INTRODUCTION

Some common problems encountered in a urological practice are discussed using case-based presentations. The material is arranged in a manner to make it more accessible to medical students and educators. Each of the conditions discussed is introduced by a letter from the referring physician outlining the issues of concern followed by my response.

Many diagnostic and therapeutic measures have attendant risks which may actually be more damaging than the underlying medical problem itself. Indeed, not all problems require active therapy. The risk/benefit ratio of any proposed study or therapy must be weighed against the natural course of the disease and the patient must be actively involved in any planning process.

The material presented herein is not intended to provide a thorough analysis of the issues since details of diagnostic and therapeutic modalities can be found in other medical publications. It is important, however, that the medical student be very aware that all options must be made available to the patient and be sensitive to the patient’s responses. Close observance of the patient’s verbal and body language is critical. There should be an interactive discourse between the patient and physician, conducted in a relaxed environment as free from time constraints as possible.

PSYCHOSOMATIC ILLNESS:

PSYCHOSOMATIC ILLNESS:

Dear Sumner,

I am sending you Jocelyn Brent, a 42 year old woman with complaints of lower abdominal pains for the past 5 years. She has been a vice president of an advertising firm for about 10 years and is under constant pressure in her job. While she recognizes that her symptoms are more severe while at work, she, nonetheless, is certain that there is something seriously wrong with her kidneys. She has already been evaluated by a gynecologist, gastroenterologist, endocrinologist, general surgeon as well as an urologist, and no obvious cause for her symptoms has been found thus far. I have advised a psychological evaluation but she resents any suggestion that her problems are based in her head. Quite frankly, I am at my wit’s end in dealing with her. I would be most grateful if you would see her, and, hopefully, if not render a cure, at least calm her down.

Dear Brenda,

As I know you are well aware, Jocelyn is convinced that she has a real problem. The bulk of my time with her (about an hour) involved a rather extended discussion re the anatomy, physiology and psychology of the genitourinary tract. We went over in some detail the “negative” results from her previous evaluations, as well as those from my exam. We spoke quite openly about the fact that the body can definitely be influenced by emotional factors and even if her symptoms are caused, or exacerbated, by her mental state, the symptoms themselves are still very real for her. I mentioned to her that although we (the physicians) did not come up with a diagnosis, in the process of the evaluation, no serious underlying problem was revealed. (REASSURANCE IS A POWERFUL THERAPEUTIC MODALITY.) I felt that, apropos of your last request in your referral letter, Jocelyn left my office in a much calmer state than when she arrived!

HYDROCELE

HYDROCELE

Dear Sumner:

A very tense young man just left my office, convinced that he has a testicular cancer. Bob is 26 years of age and has been aware of a scrotal swelling since “as long as he can remember.” He states the mass causes him no pain, although it seems to be getting progressively tenderer to touch (his girlfriend expresses her concern every time they are having sex). It was interesting that Bob commented that the swelling sometimes gets larger after he exercises, but soon reverts to its previous size. I believe we are dealing with a hydrocele given the history and the consistency of the mass. And assuming that the underlying diagnosis is, indeed, a hydrocele, is interventional therapy indicated? If it gets larger, can’t you just remove the fluid with a syringe or inject a chemical to destroy the sac?

Dear Craig:

I had a good talk with Bob and his girlfriend re his situation. Most likely we are, indeed, dealing with a hydrocele, since the mass did transilluminate on my physical examination. The cystic nature of the lesion was confirmed on ultrasound study. I believe that the progressive tenderness of the testis is likely secondary to the multiple self-examinations along with a bit of Bob’s “fixation” on this part of his anatomy. Ordinarily unless a hydrocele is sufficiently large as to cause local distress (either physically or psychologically), surgical intervention is not necessary. To answer your question about possible therapy, a hydrocele can be aspirated, but since the lining of the hydrocele sac secretes the fluid, the sac will likely refill within a few weeks, and, therefore, if surgery were to be done, it is best to remove the entire sac. Besides which, sticking a needle into the closed space of the hydrocele runs a risk of secondary infection.

However, in Bob’s case, these points are probably moot. Since the swelling has apparently been present since early childhood and is variable in size, there is very likely a persistent connection between the scrotal and peritoneal cavities: a patent processus vaginalis. (Ordinarily the processus vaginalis, which is the channel through which the testis descends from the abdominal cavity through the inguinal canal into the scrotum, closes spontaneously prior to birth). For practical purposes, I would treat this as a hernia (congenital) and I would advise its repair along with removal of the hydrocele sac (as an encore).

SPERMATOCELE (AKA EPIDIDYMAL CYST):

SPERMATOCELE (AKA EPIDIDYMAL CYST):

Dear Sumner:

George, a 23 year old man, called me last week in a panic that he had found an extra testicle in his scrotum. When I examined him, I found a mass above and separate from his left testicle which seemed to be softer than the testis. I think that the mass represents a spermatocele although George would like to be certain that he doesn’t have a tumor. Assuming that it is, indeed, a spermatocele, can the fluid within it be aspirated and its lining destroyed with some type of chemical solution, or must the entire mass be removed. If nothing is done, might it affect his fertility? He will be calling you for an appointment in the near future.

Dear Felicia:

George was still quite anxious about the mass in his scrotum when I saw him in the office today. The fact that the mass transilluminated and was separate from the testis itself is consistent with the diagnosis of a spermatocele. A spermatocele is usually thought to arise from obstruction of an epididymal duct, with the secondary dilatation forming a cystic structure. Smaller spermatoceles are sometimes referred to as epididymal cysts. However, we did discuss what procedures might be considered if there was associated discomfort due to a significant increase in its size, as well as the potential risks of invasive therapy. In the case of a spermatocele, my own feeling is that active treatment may cause more problems than surveillance only. For example, not only might reaccumulation of the fluid occur after needle aspiration of a spermatocele, but the procedure itself runs a risk of infection. Even more importantly, epididymal obstruction can result from both the surgery as well as from the chemical destruction of its lining (sclerotherapy)--which obviously could adversely affect his fertility.

At this time, being reasonably certain of the diagnosis and being assured that there is no life threatening process present and that it should not interfere with his fertility or sexual function, George expressed his desire to avoid any invasive procedures. In fact, said he (with a sheepish grin), he really enjoys the comments he receives about his “profile” in his tight Speedo bathing suit!

VARICOCELE:

VARICOCELE:

Dear Sumner:

I’d like your opinion on Ralph, a 16 year old, who came to my office today complaining of a large cluster of wormy- like structures in his scrotum. From my examination, I believe this is a varicocele. It was on the left side, and I thought that the left testicle was slightly smaller than its mate. Does this need any medical attention? It does not seem to bother Ralph.

Dear Marv:

I had a good discussion with Ralph and his Dad about varicoceles and their possible significance. They were surprised to learn that about 15% of all men have varicoceles. As is the case with Ralph, most occur on the left side. This is influenced by hydraulics. The vein from the left testicle drains into the left renal vein at a right angle, whereas the vein from the right testicle has a more gradual insertion, draining directly into the vena cava. This may result in reversed flow of blood in the left testicular vein stretching and enlarging the tiny veins above the testicle. This is referred to as a varicocele.

The question you pose is, of course, the critical one: “Does Ralph’s varicocele need any medical attention?”

Ralph’s varicocele is, indeed, quite prominent, especially when he is in the standing position. As expected, when he lay down on the examining table, the varicocele was barely detectable. (This demonstration was most reassuring to Ralph.) Ralph’s left testicle is somewhat smaller than its mate. It is certainly possible that this is secondary to the varicocele, or perhaps just a variation of his anatomy. I explained that the function of the scrotum is to regulate the temperature of the testes; added heat from the varicocele can impair sperm production. (This is one of the reasons for bringing an undescended testicle into the scrotum at an early age: the other main reason being its increased potential for malignant changes. Marv, you may have noticed that the testes of many mammals are usually up in their abdomen most of the year, descending into the scrotum during mating season in the spring. Now won’t that little tid-bit of information make for good conversation at your next cocktail party?)

The main purpose of surgical intervention is to interrupt or remove the varicose veins in the scrotum in order to detour the flow of blood into normal veins. Surgery would be advisable only if there were evidence that the varicocele is causing a problem with Ralph’s fertility and the most direct way to check his fertility status is to check a semen analysis. However, since Ralph has no immediate plans for fatherhood, both he and his Dad preferred to hold off on a sperm count for now.

It is difficult to know whether early surgery will reverse the effect of the varicocele on spermatogenic activity. In a significant number of men who have undergone varicocele surgery, there has been improvement of sperm count and motility. Unfortunately it has not been definitely established whether early interruption of the varicocele is indicated.

TESTICULAR TUMOR:

TESTICULAR TUMOR:

Dear Sumner:

I need your help with Joe, a 32 year old man, whose wife noticed a firm area on the bottom of his right testicle about one week ago. The mass appears to be localized and. palpation of the testis does not elicit pain. I found no other abnormalities on physical examination. The family’s anxiety level is increased by the fact that one of Joe’s cousins was recently diagnosed with testicular cancer. (I have known his family for many years and they have been “surfing the net” for any information about testicular tumors). What diagnostic and therapeutic steps should be taken at this time? What about doing a biopsy of the testicle to see if we are, indeed, dealing with a cancer and if no cancer were found, the testis could be saved? It does not seem right to remove the testis on the basis of suspicion alone.

Dear Harry:

Except for the finding of the distinct area of firmness at the base of Joe’s right testicle, I found nothing unusual on exam. For “starters,” I am obtaining a testicular ultrasound study to ascertain if the firm area that we feel is within the testis itself and if it is solid or cystic. I feel that any solid mass within the testis itself is highly suspicious for malignancy. However, since testicular tumors usually spread via the retroperitoneal lymph nodes, I will be ordering staging procedures to include abdominal/pelvic and chest CT scans.

One of the most challenging of your inquiries was about doing a biopsy on the testis prior to possible removal. This point is controversial. The standard approach for the surgery is via an inguinal approach, exposing the spermatic cord and putting some type of tourniquet around the entire cord prior to delivering the testis into view. If the mass in question is confirmed to be within the testis itself, given the high probability that there is a cancer within, along with the chance of causing spread of the tumor by cutting into it, most urologists (including myself) would be to proceed with its removal, with analysis of the tissue being done in the laboratory. However, in the event we were dealing with a solitary testicle and/or the patient stated that even though he realized the risk of possible spread if there was a cancer present, he wanted that testis saved if at all possible, then I would go ahead with a biopsy, obtain a frozen section, but leave the tourniquet in place until I got the results of the biopsy and proceed with removal of the testis only if the pathologist finds a definite cancer therein.

I will be proceeding with a radical orchiectomy (via an inguinal approach) in the near future. Statistically the tumor, if present, is most likely to be a seminoma, in which case the cure rate is very high. Since an elevation of the tumor markers, beta sub-unit human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP), could occur from other testicular tumors such as embryonal cell carcinoma or choriocarcinoma, I will be getting these studies prior to any surgery. It is interesting that his cousin also had a testicular carcinoma, suggesting the possibility of a genetic (or maybe even an infectious or immunological) component with this tumor; studies are currently going on re these possibilities

I will let you know the findings and further plans. Hopefully, this will turn out to be a pure seminoma, and all of the staging studies will reveal no evidence of spread. However, if there were evidence of current metastases or if there were subsequent recurrence, for most testicular tumors, adjunctive therapy is quite effective. Needless to say, we will follow Joe closely over the years to come. I appreciate your permitting me to be involved in Joe’s care.

TENDER TESTICLE:

TENDER TESTICLE:

Dear Sumner:

I am sending you a 45 year old Silicone Valley executive for a second opinion. He has been bothered by a painful right testicle for about 4 months. Craig did see another urologist a few weeks ago, who reputedly rushed him through an abbreviated exam and failed to address all of his concerns. No obvious abnormalities were found on either physical exam or urinalysis. However, he is still worried that he has a serious underlying condition. I would be most grateful if you would see him.

Dear Ken:

You were certainly correct in your appraisal of Craig’s degree of anxiety. I spent the bulk of our time together trying to address his concerns. Craig admitted he was worried about an unrecognized infection--or even a tumor! We discussed the differential diagnosis of tender scrotal contents, namely inflammatory or infectious processes of the testis, epididymis or spermatic cord structures, as well as testicular torsion. Other entities, which could, though do not ordinarily, produce discomfort include inguinal hernia, hydrocele, varicocele, spermatocele (AKA epididymal cyst) or a testicular tumor. Primary disorders of the back, or pressure secondary to a ureteral stone, can also cause radiating pain to the testicle.

I went ahead with Doppler testicular ultrasonography which showed good blood flow to the testes and no testicular masses. An abdominal ultrasound revealed no gross obstruction of the renal collecting system. Given these findings, I was able to assure Craig that we had ruled out any obvious condition that required interventional therapy. We discussed the fact that the genital structures have more nerves than many other parts of the body, and may, therefore, be more sensitive to any underlying irritative or inflammatory processes (which can cause secondary spasm of the perineal muscles, with resultant pressure on the surrounding nerves, causing more muscle spasms, etc., etc.) I am hoping (and I’m actually optimistic) that a trial of anti-inflammatory meds (e.g. ibuprofen) along with relaxing in warm tub baths (possibly with a friend), combined with a good dose of reassurance, will result in a cure!