Seminoperitoneum in a Dog with a History of a Vasectomy: Case Report.

An 8 yr old male German shorthaired pointer was presented on July 4, 2022, for acute abdominal and testicular pain. The dog was vasectomized at an unknown age under the care of his previous owners. The dog had an enlarged, painful left testis, scrotal edema, and an enlarged, nonpainful prostate. Abdominal ultrasound revealed mild peritoneal and retroperitoneal effusion, orchiepididymitis, enlarged ductus deferentes and testicles, and suspected benign prostatic hyperplasia versus prostatitis. Peritoneal effusion cytology revealed seminoperitoneum with marked neutrophilic inflammation. Peritoneal effusion aerobic culture and Brucella canis rapid slide agglutination test were negative. The dog was hospitalized overnight with IV antibiotic therapy and analgesics. The following day, the dog's abdominal pain, testicular pain, and scrotal edema were resolved. The dog was discharged and castrated after completion of antibiotic therapy and complete resolution of clinical signs. Testicular histopathology results were not available. Seminoperitoneum is uncommon in dogs and is a rare diagnosis for dogs with acute abdominal pain. This is the second known reported case of a seminoperitoneum in a vasectomized dog.

High risk and low prevalence diseases: Testicular torsion.

INTRODUCTION: Testicular torsion is a serious condition that carries with it a high rate of morbidity. OBJECTIVE: This review highlights the pearls and pitfalls of testicular torsion, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: Testicular torsion is a urological emergency that occurs with rotation of the testicle along its supporting ligaments leading to obstruction of vascular flow. A key risk factor is the presence of a bell-clapper deformity. The most common population affected includes children in a bimodal distribution with the most cases occurring in the first year of life and between 12 and 18 years, although cases do occur in adults. Acute, severe, unilateral scrotal pain is the most common presenting symptom. Nausea and vomiting are common, but the presence or absence of a cremasteric reflex is not a reliable indicator of disease. The TWIST score may assist with clinical decision making in patients presenting with acute testicular pain but should not be used in isolation. If torsion is suspected or confirmed, consultation with the urology specialist should not be delayed, as outcomes are time sensitive. Ultrasound can be used for diagnosis, but a normal ultrasound examination cannot exclude the diagnosis. Treatment includes emergent urology consultation for surgical exploration and detorsion, as well as symptomatic therapy in the ED. Manual detorsion can be attempted in the ED while awaiting transfer or consultation. CONCLUSIONS: An understanding of testicular torsion can assist emergency clinicians in diagnosing and managing this disease.

Testicular Pain - Not Always What it Seems: A Cross-Sectional Assessment of Patients Presenting for Chronic Scrotal Content Pain at a Tertiary Care Center.

OBJECTIVE: To review historical and examination findings in patients presenting to a tertiary care center for evaluation of Chronic Scrotal Content Pain (CSCP) defined by persistent/bothersome pain present for > 3-months. METHODS: We performed a retrospective chart review of all patients presenting to our medical center for evaluation of CSCP. Pertinent information collected included historical data, physical examination findings, laboratory and imaging results, and treatments recommended by the assessing physician. The data was summarized to present a cross-sectional representation of patients presenting for CSCP. RESULTS: 110 patients were identified. 80 patients (73%) had seen at least one prior urologist. 26 patients (24%) had undergone a prior unsuccessful surgical intervention for CSCP. Reproducible tenderness was present in 67% of patients including testicular tenderness in 50 (45%), epididymal tenderness in 60 (55%), and spermatic cord tenderness in 31 patients (28%). 33% of patients did not have any reproductible scrotal content tenderness on physical examination. Surgery was recommended in 57/110 patients (52%), including microdenervation in 22%. Musculoskeletal etiologies were suspected based on specific aspects of the history and physical examination in 43 patients (39%), prompting additional evaluation and/or referrals. CONCLUSION: CSCP presents with a wide array of symptoms and many patients do not have reproducible findings on examination, suggesting alternative sources of pain such as referred pain from musculoskeletal causes. The history and physical examination should include assessments for concurrent abdominal, back, hip, and other genital/pelvic pain that may suggest alternative diagnoses and referrals for appropriate treatment.

Splenogonadal fusion misdiagnosed as spermatic cord cyst: a case report.

INTRODUCTION: Splenogonadal fusion is a rare congenital anomaly. The aim of this study was to report a case of splenogonadal fusion mimicking a spermatic cord cyst, and discuss therapeutic management of this rare congenital malformation. OBSERVATION: An eight-years old patient was presented with an asymptomatic three-centimeter oval scrotal mass mistaken for a spermatic cord cyst. Surgical exploration has revealed tow purple-red, firm encapsulated masses. The first mass was two cm long and adherent to the upper pole of the left testis with a cleavage plane. The second mass was four cm long, attached to the first by a fibrous cord and drawn on its superior pole by a serpiginous vascular structure that extended inside the abdomen. The spermatic cord was individualized. Extemporaneous anatomopathological examination of the first mass, totally excised, has concluded to benign lesion. Therefore, the peritoneum was opened, and the superior mass was excised as high as it could be reached without orchiectomy. Definitive Anatomopathological examination concluded to an ectopic splenic tissue. The final diagnosis was a continuous splenogonadal fusion. CONCLUSION: This case highlights the clinical characteristics of this condition, with a special focus on the signs and findings that might help prevent unnecessary orchiectomy. Consequently, it is essential to include this malformation in the differential diagnosis of scrotal masses in children.

Testicular schistosomiasis: a systematic review of the literature.

INTRODUCTION: To consolidate reported information on presentation, diagnosis, and treatment modalities in testicular schistosomiasis (TS) to provide a reference tool for this rare disease. MATERIALS AND METHODS: A comprehensive PubMed search was performed using PRISMA guidelines, which yielded 21 articles detailing 22 cases of TS. RESULTS: Testicular schistosomiasis remains a rare disease, presenting at a variety of ages (median age 27). All reports of this condition are associated with exposure to an endemic area. The most common presenting symptoms include nonspecific testicular swelling (54.5%) followed by a testicular mass/nodule (18.4%). Diagnosis relies upon clinical suspicion due to low specificity on laboratory and imaging evaluation, with only 18% of urine evaluations positive for parasitic infection. Final diagnosis was made on biopsy (38.1%), radical orchiectomy (47.6%) or frozen section during partial orchiectomy (14.3%). Treatment included anthelmintic mediation (37%), radical/partial orchiectomy (31%), or some combination of the above. CONCLUSIONS: This systematic review of individual patient data reveals that while urine tests and imaging may aid in diagnosis, all patients require definitive histologic diagnosis. It is important to obtain a thorough history to elucidate exposure to endemic areas and inform whether biopsy, and subsequent testicular preservation, may be appropriate.

The importance of genetic research in cases of severe male factor infertility: A case of 46,XX testicular disorder of sex development.

46,XX testicular disorder of sex development is a rare syndrome characterized by an inconsistency between genotype and phenotype. Affected individuals present variant genitalia between male and ambiguous, non-functional testicles, non-obstructive azoospermia, generally accompanied by hypergonadotropic hypogonadism, a condition known for high levels of gonadotrophic hormones. In some cases, disorders of sexual development are diagnosed during puberty. However, a significant number of individuals show physical characteristics common to males that are not clinically suspicious. As a result, patients with the condition may remain undiagnosed. Many individuals with the condition are diagnosed as adults, due to infertility. The present study discusses the case of an individual who underwent karyotyping for sterility and was found to be a 46,XX male. Despite having a female karyotype, the presence of the sex-determining region Y gene explains the manifestation of masculine secondary sex characteristics. This report highlights the importance of genetic evaluation, considering that carriers may present significant complications resulting from the disorder. Based on correct diagnosis, it is possible to improve a carrier's quality of life through multidisciplinary approaches and help them achieve pregnancy through assisted reproductive technology treatments.

Management of Testicular Microlithiasis.

Until molecular diagnostics become available, individualized risk assessment for men with testicular microlithiasis, counseling on the current evidence base regarding the benefit of testicular biopsy or testicular self-examination, and a patient-centered approach provide the framework for the best quality of care for the individual patient.

The prognostic value of testicular microlithiasis as an incidental finding for the risk of testicular malignancy in children and the adult population: A systematic review. On behalf of the EAU pediatric urology guidelines panel.

INTRODUCTION: The exact correlation of testicular microlithiasis (TM) with benign and malignant conditions remains unknown, especially in the paediatric population. The potential association of TM with testicular malignancy in adulthood has led to controversy regarding management and follow-up. OBJECTIVE: To determine the prognostic importance of TM in children in correlation to the risk of testicular malignancy or infertility and compare the differences between the paediatric and adult population. STUDY DESIGN: We performed a literature review of the Medline, Embase and Cochrane controlled trials databases until November 2020 according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) Statement. Twenty-six publications were included in the analysis. RESULTS: During the follow-up of 595 children with TM only one patient with TM developed a testicular malignancy during puberty. In the other 594 no testicular malignancy was found, even in the presence of risk factors. In the adult population, an increased risk for testicular malignancy in the presence of TM was found in patients with history of cryptorchidism (6% vs 0%), testicular malignancy (22% vs 2%) or sub/infertility (11-23% vs 1.7%) compared to TM-free. The difference between paediatric and adult population might be explained by the short duration of follow-up, varying between six months and three years. With an average age at inclusion of 10 years and testicular malignancies are expected to develop from puberty on, testicular malignancies might not yet have developed. CONCLUSION: TM is a common incidental finding that does not seem to be associated with testicular malignancy during childhood, but in the presence of risk factors is associated with testicular malignancy in the adult population. Routine monthly self-examination of the testes is recommended in children with contributing risk factors from puberty onwards. When TM is still present during transition to adulthood a more intensive follow-up could be considered.

Clinical Challenge: A Rare Testicular Tumor.

We present the case of a 22-year-old male that comes to the Urology clinic with the incidental finding of a testicular mass. Typical findings in echography will guide us towards the diagnosis of an epidermoid cyst.1,2 This type of infrequent benign tumor is responsible for only around 2% of all testicular tumors.1 Because of this low incidence literature regarding epidermoid cysts is scarce. Treatment has been susceptible to change throughout the years.6 In this clinical case we challenge readers to review a rare tumor and to choose the most appropriate treatment for our patient.

Spermatic Cord Block Series as a Minimally Invasive Therapy for Chronic Scrotal Content Pain.

PURPOSE: The primary aim of our study was to evaluate relief of chronic scrotal content pain after a series of spermatic cord blocks with a combination of local anesthetic and a steroid. Secondary aims were to assess factors associated with a positive response and complications. MATERIALS AND METHODS: We performed a retrospective chart review of patients who underwent spermatic cord block series for chronic scrotal content pain at our practice between 2012 and 2019. Pain scores were compared before and after treatment using an 11-point numerical pain rating scale. We performed univariate analysis to assess differences between responders and nonresponders, and the relationship between symptom duration and response was analyzed by rank-order correlation. RESULTS: We included 44 men with chronic scrotal content pain present for a median duration of 24 months who underwent a spermatic cord block series. At a median followup of 16 months, 31 patients (70.5%) experienced sustained relief, including 9 patients (20.5%) with complete resolution of pain. There were no differences between responders and nonresponders in terms of symptom duration, perceived etiology, or previous treatments, and there was no association between response and duration of pain. Minor complications occurred in 5 cases (11.4%). CONCLUSIONS: Spermatic cord block series is a safe, minimally invasive treatment for men with refractory chronic scrotal content pain. Response to cord block series appears to be independent of symptom duration, perceived etiology or prior medical and surgical treatments. Future studies should be conducted to evaluate long-term durability and predictors of success.

A rare case of 46, XX (SRY positive) testicular disorder of sex development with growth hormone deficiency: Case report.

RATIONALE: Chromosome karyotype analysis and SRY (sex determined region of Y chromosome) gene detection are routines for the diagnosis of growth hormone deficiency (GHD), but further whole exome gene sequencing occasionally leads to subversive results and unexpected conclusions. PATIENT CONCERNS: We report a single case of a 7-year-old Chinese boy who had stunted growth since he was 1 year old. He was short in height (height Standard Deviation Score (SDS) was less than 2.9), bilateral scrotal dysplasia and delayed bone age. DIAGNOSIS: His growth hormone (GH) stimulation tests showed GHD. His karyotype analysis and polymerase chain reaction (PCR) analyses indicated a 46, XX disorder of sex development (DSD) without the presence of the SRY gene. Nevertheless, considering that female gonad was not observed in the chest and abdominal magnetic resonance imaging, the whole exome gene sequencing was performed. Sequencing data confirmed the presence of SRY gene sequence and two copies of chromosome X. Later, using different primer sequences for PCR, it showed that the SRY gene was positive. The final diagnosis was a rare case of "46, XX (SRY positive) testicular DSD with GHD". INTERVENTIONS: The boy's parents agreed to use recombinant human growth hormone (rhGH) for GHD treatment, the starting dose was 0.035 mg / kg / day. But they disagreed with molecular diagnostics and genomic analysis of the Y chromosome. OUTCOMES: The boy was treated with rhGH for 3 months and his height increased by 2.2 cm. The patient will be followed-up until the end of his puberty. LESSONS: In summary, whole exome gene sequencing overturned the preliminary diagnosis results of karyotype analysis and SRY gene detection, and found that there may be a certain correlation between testicular DSD and GHD.

Chronic Scrotal Content Pain: a Review of the Literature and Management Schemes.

PURPOSE OF REVIEW: Chronic scrotal content pain (CSCP) is a complex condition with multiple etiologies that requires a thorough understanding of its pathophysiology, workup, and treatment options. We performed a comprehensive and contemporary review to augment our current understanding of CSCP. RECENT FINDINGS: We discuss new advances in CSCP-specific pain questionnaires, modern studies of microscopic spermatic cord denervation and its variations, and novel techniques including electric nerve stimulation and cryoablation in addition to randomized control trials with significant negative findings. We also present literature focusing on the prevention of CSCP secondary to surgical iatrogenic causes. The constantly evolving literature of CSCP has led to the significant evolution in its diagnosis and treatment, from oral medications to salvage options after microscopic spermatic cord denervation. With each advance, we come closer to developing a more thorough, evidence-based algorithm to guide urologists in treatment of CSCP.

Why adolescents delay with presentation to hospital with acute testicular pain: A qualitative study.

BACKGROUND/PURPOSE: Adolescents have poor outcomes following testicular torsion directly attributable to delay from onset of symptoms to presentation to hospital. The aim of this study was to investigate the barriers to urgent presentation in young men. METHODS: Semistructured interviews were undertaken with young men (11-19 years), using a topic guide exploring issues surrounding testicular pain and health. Thematic analysis was undertaken using a framework approach. RESULTS: Twenty-seven adolescents were recruited, data saturation was reached at sixteen participants, and median age was 13.5 years (range 11-18). The process by which an adolescent gets to hospital with testicular pain is slow. They must recognize the problem and alert their parents, who then use a 'watch and wait' policy to assess need for medical review, often leaving it 'a day' or overnight. Adolescent males do not engage with healthcare services independently of their parents. Additional factors preventing early presentation include: absence of knowledge about testicular pathology from adolescents and their parents; concern from the young people about raising a false alarm and family concerns about burdening healthcare services. CONCLUSIONS: Recommendations include designing a testicular health education campaign for young men and educating parents regarding the medical conditions where a 'watch and wait' policy may be harmful to their child. LEVEL OF EVIDENCE: VI.

Male infertility due to testicular disorders.

CONTEXT: Male infertility is defined as the inability to conceive following 1 year of regular unprotected intercourse. It is the causative factor in 50% of couples and a leading indication for assisted reproductive techniques (ART). Testicular failure is the most common cause of male infertility, yet the least studied to date. EVIDENCE ACQUISITION: The review is an evidence-based summary of male infertility due to testicular failure with a focus on etiology, clinical assessment, and current management approaches. PubMed-searched articles and relevant clinical guidelines were reviewed in detail. EVIDENCE SYNTHESIS/RESULTS: Spermatogenesis is under multiple levels of regulation and novel molecular diagnostic tests of sperm function (reactive oxidative species and DNA fragmentation) have since been developed, and albeit currently remain as research tools. Several genetic, environmental, and lifestyle factors provoking testicular failure have been elucidated during the last decade; nevertheless, 40% of cases are idiopathic, with novel monogenic genes linked in the etiopathogenesis. Microsurgical testicular sperm extraction (micro-TESE) and hormonal stimulation with gonadotropins, selective estrogen receptor modulators, and aromatase inhibitors are recently developed therapeutic approaches for men with the most severe form of testicular failure, nonobstructive azoospermia. However, high-quality clinical trials data is currently lacking. CONCLUSIONS: Male infertility due to testicular failure has traditionally been viewed as unmodifiable. In the absence of effective pharmacological therapies, delivery of lifestyle advice is a potentially important treatment option. Future research efforts are needed to determine unidentified factors causative in "idiopathic" male infertility and long-term follow-up studies of babies conceived through ART.