Common scrotal and testicular problems

Surgical Management of Extravaginal Testicular Torsion in a 16-Year-Old Male: A Case Report

Extravaginal torsion (EVT) is a rare type of testicular torsion that usually occurs in neonates. The primary type of testicular torsion that occurs in adolescents is intravaginal torsion. In this case report, we describe the first case of EVT reported in a 16-year-old male with a contralateral bell clapper deformity and subsequent surgical management using a tunica vaginalis flap and bilateral orchiopexy. In discussion of this case, we examine possible anatomical causes of EVT and suggestions for appropriate surgical management.

Codesign and Launch of 'On the Ball': An Inclusive Community-Based 'Testicular Awareness' Campaign

INTRODUCTION

Increased awareness of testicular diseases can lead to early diagnosis. Evidence suggests that men's awareness of testicular diseases is low, with many expressing their willingness to delay help-seeking for symptoms of concern. The risk of testicular diseases is higher in gender and sexual minority groups. In this study, we discuss the codesign, refinement and launch of 'On the Ball', an inclusive community-based 'testicular awareness' campaign.

METHODS

The World Café participatory research methodology was used. Individuals from Lesbian, Gay, Bisexual, Transgender and Queer+ friendly organisations, testicular cancer survivors, policymakers, media/marketing experts and graphic designers were recruited. Participants were handed a brief for 'On the Ball', which was designed based on feedback from a previous World Café workshop. They were assigned to three tables. Participants rotated tables at random for three 20-min rounds of conversations. Each table had a facilitator who focussed on one element of the campaign brief. Data were collected using audio recorders and in writing and were analysed thematically.

RESULTS

Thirteen individuals participated in the workshop. The following themes emerged from the data: (i) campaign identity, (ii) campaign delivery and (iii) campaign impact. Participants recommended enhancements to the campaign logo, slogan, social media posts and poster. They suggested delivering the campaign online via social media and offline using various print and broadcast media. Participants recommended targeting areas with a large number of men such as workplaces. To help measure the impact of the campaign, participants proposed capturing social media analytics and tracking statistics relating to testicular diseases. Recommendations were used to refine the 'On the Ball' campaign and launch it in a university. In total, 411 students engaged with the various elements of the campaign during the soft launch.

CONCLUSIONS

'On the Ball' campaign visuals ought to be inclusive. Online and offline campaign delivery is warranted to reach out to a wider cohort. Campaign impact can be captured using social media analytics as well as measuring clinical outcomes relating to testicular diseases. Future research is needed to implement the campaign online and offline, explore its impact and evaluate its feasibility, acceptability, cost and effect on promoting testicular awareness.

PATIENT OR PUBLIC CONTRIBUTION

The 'On the Ball' campaign was codesigned and refined with members of Lesbian, Gay, Bisexual, Transgender and Queer+ friendly organisations, testicular cancer survivors, health policymakers, media and marketing experts and graphic designers using the World Café participatory research methodology.

Sclerotherapy in the Treatment of Hydroceles: A Comprehensive Review of the Efficacy, Types of Sclerosants, and Comparative Outcomes Against Hydrocelectomy

While hydrocelectomy is the gold-standard for treating hydroceles, it poses an increased risk to patients and a greater burden to the healthcare system. Sclerotherapy is an alternative treatment for hydroceles that involves injecting a sclerosant into the hydrocele under ultrasound guidance. This literature review aimed to assess the types of sclerosants used and how sclerotherapy compares to hydrocelectomy. A literature search was conducted of MEDLINE and EMBASE using the terms "sclerotherapy" and "hydrocelectomy," which yielded 1058 studies, of which 29 met the inclusion criteria. Only studies published after 2000 were included to ensure the most recent information was reviewed. The results showed hydrocele sclerotherapy is done using a variety of sclerosants. The most used agents are polidocanol, phenol, and STS. Of these, phenol had the highest clinical success rate of 96.5%. There was evidence for the use of atypical agents, such as tetracycline antibiotics, which yielded cure rates up to 93%, and alcohol, which was found to be especially useful for treating multiseptated hydroceles. The results comparing sclerotherapy to hydrocelectomy indicated hydrocelectomy to be a more effective method in completely curing hydroceles. However, this came at the cost of more complications. Additionally, sclerotherapy was found to be more advantageous for secondary outcomes, such as healthcare costs and burden to patients. In conclusion, this review shows that while hydrocelectomy is more effective, sclerotherapy is a valuable alternative for treating hydroceles. Due to the lack of standardization among studies, a definitive conclusion cannot be made regarding which sclerosant is best to use.

Promoting men's awareness, self-examination, and help-seeking for testicular disorders: a systematic review of interventions

Background: Testicular cancer (TC) is among the most commonly diagnosed cancers in men aged 15-40 years. The incidence of TC is on the rise. Benign testicular disorders, such as testicular torsion and epididymitis, can lead to testicular ischemia, sepsis, and infertility if left untreated. This updated systematic review aims to evaluate the effectiveness of studies promoting men's knowledge and awareness of testicular disorders and/or self-examination, behaviours and/or intentions to examine their testes, and help-seeking behaviours and/or intentions for testicular disorder symptoms. Methods: Academic Search Complete, Medline, CINAHL, PsycINFO, ERIC, the Cochrane Library, the World Health Organisation International Clinical Trials Registry Platform, and Clinicaltrials.gov were searched for studies published between April 2018 and August 2023. Methodological quality was assessed and results were synthesised meta-narratively. Results: Five studies were included. The majority of the reviewed interventions were successful in increasing men's awareness of TC and self-examination, including a PowerPoint presentation, an online educational brochure, video-assisted teaching, a motivational video, and a virtual reality game. Only one study addressed help-seeking for testicular symptoms and promoted men's awareness of benign as well as malignant testicular diseases. Conclusions: This review highlights the importance of evaluating innovative educational interventions aimed at younger men, whilst raising their awareness of testicular disorders and increasing their help-seeking intentions for testicular disorder symptoms. Given the lack of consensus around scheduled testicular self-examination among younger men, clinicians are encouraged to instruct men to familiarise themselves with the look and feel of their own testes and to seek timely medical attention for abnormalities. Registration: The protocol of the previous version of this review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42018093671.

Saab M. Enhancing men's awareness of testicular diseases (E-MAT) feasibility trial: Protocol for a mixed method process evaluation

Background: Testicular cancer (TC) is the most common malignancy in men under 50 years. Athletes are particularly at risk of testicular trauma and diseases. Experiencing negative testicular symptoms does not necessarily imply that men seek help. Men's awareness of testicular diseases is often lacking and their intention to seek help for testicular symptoms is sub-optimal. The use of virtual reality (VR) may be effective in promoting men's awareness of testicular diseases. The Enhancing Men's Awareness of Testicular diseases (E-MAT) feasibility trial aims to test the effect of E-MAT VR (intervention; interactive experience using virtual reality [VR]) compared to information delivered Electronically E-MAT E (control; same information as E-MAT VR delivered as plain text and images) on testicular knowledge, and testicular self-examination among male athletes affiliated with a national sports organisation. The overall aim of this mixed method process evaluation will be to describe (i) the experiences of participants and key stakeholders (e.g., researchers); (ii) the perceived effectiveness of intervention components; (iii) acceptability of the feasibility trial and intervention procedures; (iv) the relationship between implementation, mechanisms, and context; and (v) the barriers and facilitators to support effective conduct of a future definitive trial.   Methods: This mixed method process evaluation will use a descriptive realist evaluation. Quantitative data will be gathered using a usability and satisfaction survey, in addition to fidelity checks during intervention delivery. Quantitative data will be analysed using descriptive and inferential statistics. Qualitative data will be gathered from semi-structured interviews and focus groups with participants and key stakeholders to investigate their experiences of E-MAT VR and E-MAT E, and explore areas for improvement. Thematic analysis of transcripts will be conducted. Conclusions: This process evaluation will provide an in-depth understanding of how the interventions worked within this cohort and lessons for a future definitive trial.

Effect of ferulic acid on testicular damage caused by torsion-detorsion in rats

Testicular torsion is twisting of the spermatic cord around its axis, which impairs blood flow and causes ischemia and formation of free radicals. Ferulic acid is a phenolic acid of the hydroxycinnamic family that is found in the seeds and leaves of plants; it is present in substantial amounts in fruits and vegetables. We investigated the protective effect of ferulic acid on experimental testicular torsion in rats. Animals were divided randomly into five groups: control, ethyl alcohol, torsion, torsion-detorsion, and torsion-detorsion + ferulic acid. Histopathology was assessed using hematoxylin and eosin, and periodic acid-Schiff staining. Tissues were assessed using TUNEL, active caspase-3, myeloperoxidase and inducible nitric oxide synthase immunostaining. Biochemical changes were assessed using assays for superoxide dismutase, malondialdehyde, glutathione peroxidase and glutathione. Ferulic acid reduced the levels of free radicals and increased the levels of antioxidants. Ferulic acid also reduced histopathological changes and germ cell differentiation in the testis following torsion-detorsion. Ferulic acid should be investigated further as a potential treatment for sequelae of torsion-detorsion injury.

Cysteamine mitigates torsion/detorsion-induced reperfusion injury via inhibition of apoptosis, oxidative stress and inflammatory responses in experimental rat model

Oxidative stress, inflammation and apoptosis are major pathways in pathophysiology of testicular torsion/detorsion (TTDT) reperfusion injury. This study evaluated the antioxidant, anti-inflammatory and anti-apoptotic role of cysteamine in TTDT-induced injury. Male Wistar rats (n = 32) were grouped into four (n = 8): sham, ischaemia-reperfusion injury (IRI), cysteamine (100 mg/kg and 200 mg/kg) for in vivo study. Samples were taken for biomolecular and histological evaluation 48 hr after detorsion. Tissue SOD, GPx, GSH, GST activity, total thiol, H₂ O₂ and MDA were assessed. Serum levels of NO, MPO, TNF-alpha and IL-6 and sperm motility, count and viability were assessed. Caspase-3 and bax were evaluated by immunohistochemistry. Significant difference was set as p < .05. Significant increase in H₂ O_2, MDA and nitrite but reduction in SOD, GPx, GSH, GST and total thiol in the testicular tissue of IRI rats was reversed by cysteamine. Serum MPO and TNF-α were significantly elevated in RI, while treated-RI rats showed decrease (p < .05) in tissue level of the inflammation markers. Reduced sperm motility in RI was significantly reversed by cysteamine. Increased tissue expression of bax and caspase-3 was reversed by cysteamine. Cysteamine protected the testis against reperfusion injury through anti-inflammatory, antioxidant effects and inhibition of apoptosis in rats.

Atypical presentation of testicular torsion: a case series

Background

Testicular torsion is a urological emergency and needs urgent intervention to prevent testicular loss and impaired future fertility. It is commonly seen in the neonatal and adolescent age groups. Testicular torsion can also present outside these common age groups with uncommon symptoms and signs. We report case series of patients managed at Lily Hospitals Limited, Warri, Delta State, Nigeria with atypical presentation of testicular torsion.

Case Presentation

The first patient was a 35-year-old male that presented with recurrent right testicular pain of 1-year duration, described as dull aching with no constitutional symptoms, physical examination findings were not pathognomonic of testicular torsion, he had scrotal exploration with right orchidectomy and left orchidopexy. The second patient was a 39-year-old male who presented with recurrent right testicular pain of 4-days duration, described as dull aching with no constitutional symptoms. Physical examination findings were not classical for testicular torsion, he had scrotal exploration with bilateral orchidopexy.

Conclusion

Testicular torsion although common in neonatal and adolescent age groups can also present outside these age groups with uncommon symptoms and signs, a high index of suspicion is thus invaluable in any patient presenting with testicular pain despite the age and severity to avoid missing the diagnosis as this can lead to testicular loss.

Testicular torsion induced by epididymo-orchitis: A case report

Introduction and importance

Acute scrotum is considered a urological emergency requiring early intervention depending on the cause. There are multiple causes of acute scrotum with testicular torsion being the most feared as delayed treatment leads to testicular loss. However, differentiating between epididymo-orchitis and torsion can be very difficult.

Case presentation

We present a case of an 18-year old male patient with 2 separate episodes of acute scrotum. He had epididymo-orchitis as the first presentation followed by testicular torsion 5 days later. To our knowledge this is the first case of testicular torsion secondary to epididymo-orchitis.

Clinical discussion

Differentiating between epididymo-orchitis and torsion is challenging but important due to risk of loss of testis with a wrong diagnosis. Once you establish epididymo-orchitis the suspicion for subsequent torsion should be high with close follow up and adequate counselling.

Conclusion

He ultimately had orchiectomy, although a rare presentation, enlarged testis due to epididymo-orchitis can predispose an individual to developing testicular torsion thus adequate counselling on warning signs to patients with epididymo-orchitis is of particular importance so as to intervene early and ultimately save the testis.

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18-year old male presenting with 2 separate episodes of acute scrotum.

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Initially diagnosed to have epididymo-orchitis with confirmation of color doppler ultrasound

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Second acute scrotum 5 days after and diagnosed to have torsion

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Unsalvageable testis due to delay in second presentation

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Epididymo-orchitis as a preceding risk factor to develop torsion

Protective effects of curcumin on chromatin quality, sperm parameters, and apoptosis following testicular torsion-detorsion in mice

Objective

The chief outcome of testicular torsion in clinical and experimental contexts is testicular ischemia. Curcumin, a compound with anti-inflammatory and antioxidant properties, has fascinated researchers and clinicians for its promise in the treatment of fertility diseases.

Methods

Thirty-five fully grown male mice were randomly classified into five groups: control, sham, testicular torsion, treatment group 1 (testicular torsion+short-term curcumin), and treatment group 2 (testicular torsion+long-term curcumin). Thirty-five days later, spermatozoa from the right cauda epididymis were analyzed with regard to count and motility. Toluidine blue (TB), aniline blue (AB), and chromomycin A3 (CMA3) staining assays were used to evaluate the sperm chromatin integrity. In addition, the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling (TUNEL) test was used to assess apoptosis.

Result

Treatment group 1 exhibited a remarkably elevated sperm count compared to the testicular torsion group. Additionally, notably lower sperm motility was found in the testicular torsion group compared to the control, treatment 1, and treatment 2 groups. Staining (CMA3, AB, and TB) and the TUNEL test indicated significantly greater testicular torsion in the torsion group compared to the control group (p<0.05). The data also revealed notably lower results of all sperm chromatin assays and lower apoptosis in both treatment groups relative to the testicular torsion group (p<0.05). Significantly elevated (p<0.05) AB and TB results were noted in treatment group 1 compared to treatment group 2.

Conclusion

Curcumin can compensate for the harmful effects of testicular ischemia and improve sperm chromatin quality in mice.

Remote ischemic conditioning in a rat model of testicular torsion: does it offer testicular protection?

BACKGROUND

Testicular torsion is a surgical emergency mainly affecting adolescent boys, with a relatively high rate of missed torsion and testicular loss secondary to delay in prompt diagnosis and surgical intervention. With ischemic reperfusion injury as its underlying culprit, testicular torsion may respond favorably to remote ischemic conditioning (RIC) where a non-privileged site (e.g. limb) is concurrently rendered ischemic to divert the cascade of reperfusion injury from the privileged organ (e.g. testicle), thus offering a protective effect in improving salvage. This mechanism is established for other organs, whereas it has not been evaluated for testis.

AIM

It was aimed to evaluate RIC in a rat model of testicular torsion as a proof of principle that, similar to what has been demonstrated in other organs, RIC does offer testicular protection.

STUDY DESIGN

This is an animal experimental study. Thirty Sprague-Dawley male rats were divided into control group (n = 15) and experimental group (n = 15). Non-survival surgeries of right-sided spermatic cord torsion (720° counter-clockwise twist) were performed for both the groups (45 min) followed by detorsion and reperfusion (5 min) and then orchiectomy. For the experiment group, an intervention of tail clamping to create RIC was applied 5 min after torsion, then unclamping 5 min before detorsion, followed by detorsion and reperfusion for 5 min and then orchiectomy. The testicles were histologically and immunologically examined using a hypoxia inducible factor (HIF-1α) ELISA Kit. The histological findings on ischemic changes, vascular congestion, and immunohistochemistry were quantified using previously described, validated grading systems.

RESULTS

DISCUSSION: This is the first study to demonstrate the concept of RIC in an animal model of testicular torsion. It is limited by the non-availability of similar studies to compare outcomes and by the caution of extrapolating animal studies on humans. It does lay grounds, however, to subsequent studies to further elaborate on this concept and its clinical applicability.

CONCLUSION

When RIC is applied in the experimental setting of testicular torsion, there is less evidence of hypoxic injury by histology and immunohistochemistry.

Sodium nitrite-derived nitric oxide protects rat testes against ischemia/reperfusion injury

Testicular torsion, a common urologic emergency, is primarily caused by ischemia/reperfusion (I/R) injury of the testis. Nitric oxide (NO)-derived from nitrite (NO2-) has been reported to have prominent therapeutic effects on I/R injury in the heart, liver, and brain; however, its effects on testicular I/R injury have not been evaluated. This study, therefore, investigated whether NO from NO2- is beneficial in a rat model of testicular I/R injury which eventually results in impaired spermatogenesis. Male Sprague-Dawley rats were assigned to the following seven groups: group A, sham-operated control group; Group B, I/R with no treatment; Groups C, D, and E, I/R followed by treatment with three different doses of NO2-; Group F, I/R followed by administration of NO2- and NO scavenger (2-(4-carboxyphenyl)-4,4,5,5-tetramethylimidazoline-1-oxyl-3-oxide potassium salt [C-PTIO]); and Group G, I/R followed by administration of nitrate (NO3-). NO2-, NO3-, and C-PTIO were intravenously administered. Histological examination of the testes and the western blot analysis of caspase-3 were performed. Levels of antioxidant enzymes and lipid peroxidation were measured. Germ cell apoptosis, oxidative stress, antioxidant enzymatic function, and lipid peroxidation in Group B were significantly higher than those in Group A. Group B exhibited an abnormal testicular morphology and impaired spermatogenesis. In contrast, testicular damages were attenuated in the NO2- treatment groups, which were caused by reduction in superoxide and peroxynitrite levels and an inhibition of caspase-3-dependent apoptosis. The results of this study suggest NO2- to be a promising therapeutic agent with anti-oxidant and anti-apoptotic properties in testicular I/R injury.

Dorsal Root Ganglion Stimulation for Chronic Pelvic Pain: A Case Series and Technical Report on a Novel Lead Configuration

INTRODUCTION

Chronic pelvic pain (CPP) is an elusive and complex neuropathic condition that is notoriously recalcitrant to treatment. The term "CPP" encompasses a number of treatment-resistant conditions like pudendal neuralgia, interstitial cystitis, coccygodynia, vulvodynia. CPP has been presented neuromodulators attempting to utilize conventional spinal cord stimulation (SCS), with constant frustration and high explant rates. Contrary to SCS, dorsal root ganglion stimulation (DRGS) delivers targeted target to focal areas, does not rely on paresthesias, and is able to reliably capture body parts like the pelvis making it an ideal modality for the treatment of CPP. We present seven patients with intractable CPP, resistant to conventional treatment methods, all successfully treated with DRGS.

METHODS

The case series includes seven patients with severe, CPP who failed to respond to a variety interventional treatments, and in some cases SCS. All seven patients were successfully trialed with DRGS utilizing leads placed over the bilateral L1 and S2 DRG's-to our knowledge, no publications describing either this particular lead configuration, or utilizing DRG stimulation on CPP, exist.

RESULTS

Following treatment, all seven patients experienced significant pain relief as well as reduction in opioid consumption and some cases improvement with sexual function and urination. Four of these patients have been implanted and continue to self-report sustained pain relief with high-satisfaction and functional improvement. To date no explants or instances of loss of efficacy have occurred (>1 year since implant).

CONCLUSION

Like most neuropathic pain states, CPP is resilient, difficult to manage, and typically unresponsive to the traditional therapeutics and SCS. Our case series demonstrates no only that DRGS is potentially effective, long-term treatment modality for CPP, but that the L1/S2 lead placement is the configuration of choice despite distinct differences in etiologies of pain and location.

Is genetic drift to blame for testicular dysgenesis syndrome in Semliki chimpanzees (Pan troglodytes schweinfurthii)?

BACKGROUND

We present 3 likely cases of testicular dysgenesis syndrome (TDS) within a community of chimpanzees (Pan troglodytes schweinfurthii). We tested whether genetic drift may be the culprit, as a genetic cause has been suspected to account for TDS among other wildlife.

METHODS

We successfully sequenced a 367-bp segment spanning the first hypervariable region within the D-loop of the mitochondrial genome for 78 DNA samples.

RESULTS

We found 24 polymorphic sequence sites consisting of 7 singletons and 17 parsimony informative sites. This sample contained 9 haplotypes with a diversity index of 0.78 (SD = 0.03). All tests against the null hypothesis of neutral polymorphisms were non-significant (P > .10). The mismatch distribution of pairwise differences does not fit a Poisson's curve (raggedness index = 0.166; SSD = 0.12; P = 1).

CONCLUSIONS

Thus, we found no significant signs of genetic isolation, population expansion, or genetic bottleneck. Alternative causes of TDS and how they might pertain to this population are discussed.

Promoting men's awareness, self-examination, and help-seeking for testicular disorders: a systematic review of interventions

Background: Testicular cancer (TC) is commonly diagnosed among men aged 15-40 years. The incidence of TC is on the rise. Benign testicular disorders such as testicular torsion and epididymitis can lead to testicular ischemia, sepsis, and infertility if left untreated. This systematic review aims to evaluate the effectiveness of studies promoting men's knowledge and awareness of testicular disorders and/or self-examination, behaviours and/or intentions to examine their testes, and help-seeking behaviours and/or intentions for testicular symptoms. Methods: Academic Search Complete, Medline, CINAHL, PsychINFO, ERIC, the Cochrane Library, the World Health Organisation International Clinical Trials Registry Platform, Clinicaltrials.gov, Grey Literature Report, and Open Grey were searched for studies published between November 2014 and April 2018. The methodological quality and level of evidence per outcome were assessed.  Results: There were five papers included: two were experimental studies, two were systematic reviews, and one was an integrative review. The majority of the reviewed interventions were successful in increasing men's awareness of TC and self-examination. Examples include a television show featuring a celebrity with TC, a university campaign, and interactive educational sessions. The impact of the reviewed interventions on health beliefs (i.e. perceived susceptibility, severity, benefits, barriers, and self-efficacy) varied across the reviewed literature. Studies promoting help-seeking for testicular symptoms and awareness of benign testicular disorders were lacking. Conclusions: This review highlights the importance of evaluating educational interventions aimed at younger men, whilst raising their awareness of testicular disorders and increasing their help-seeking intentions for testicular symptoms. Given the lack of consensus around scheduled testicular self-examination among younger men, clinicians are encouraged to instruct men to familiarise themselves with the look and feel of their own testes and to seek timely medical attention for abnormalities. Registration: The review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42018093671.

Promoting men's awareness, self-examination, and help-seeking for testicular disorders: a systematic review of interventions

Background: Testicular cancer (TC) is commonly diagnosed among men aged 15-40 years. The incidence of TC is on the rise. Benign testicular disorders such as testicular torsion and epididymitis can lead to testicular ischemia, sepsis, and infertility if left untreated. This systematic review aims to evaluate the effectiveness of studies promoting men's knowledge and awareness of testicular disorders and/or self-examination, behaviours and/or intentions to examine their testes, and help-seeking behaviours and/or intentions for testicular symptoms. Methods: Academic Search Complete, Medline, CINAHL, PsychINFO, ERIC, the Cochrane Library, the World Health Organisation International Clinical Trials Registry Platform, Clinicaltrials.gov, Grey Literature Report, and Open Grey were searched for studies published between November 2014 and April 2018. The methodological quality and level of evidence per outcome were assessed.  Results: There were five papers included: two were experimental studies, two were systematic reviews, and one was an integrative review. The majority of the reviewed interventions were successful in increasing men's awareness of TC and self-examination. Examples include a television show featuring a celebrity with TC, a university campaign, and interactive educational sessions. The impact of the reviewed interventions on health beliefs (i.e. perceived susceptibility, severity, benefits, barriers, and self-efficacy) varied across the reviewed literature. Studies promoting help-seeking for testicular symptoms and awareness of benign testicular disorders were lacking. Conclusions: This review highlights the importance of evaluating educational interventions aimed at younger men, whilst raising their awareness of testicular disorders and increasing their help-seeking intentions for testicular symptoms. Given the lack of consensus around scheduled testicular self-examination among younger men, clinicians are encouraged to instruct men to familiarise themselves with the look and feel of their own testes and to seek timely medical attention for abnormalities. Registration: The review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42018093671.

Sexually Transmitted Infection Review for the Acute Care Pharmacist

PURPOSE

Review selected sexually transmitted infections (STIs) and treatment recommendations for pharmacists and providers practicing in the acute care setting.

SUMMARY

In 2015, the Centers for Disease Control and Prevention (CDC) published an updated guideline on the treatment of STIs with an emphasis on prevention and new diagnostic strategies to combat the growing problem of STIs in the United States. Despite this guidance, the incidence of infection has continued to grow. In October 2016, an in-depth analysis reported that 20 million new infections occur annually in the United States. With this growing burden of disease, it is pertinent that health-care providers optimize their treatment strategies to improve upon the management of STIs. Focusing on identification of asymptomatic- and symptomatic-infected persons, treatment, education, effective follow-up, and counseling for patients and sexual partners, emergency medicine pharmacists and providers can help minimize the negative long-term health consequences of STIs.

CONCLUSION

In the emergency department setting, clinical pharmacists and providers can play a crucial role in preventing and treating STIs and should continue to expand and keep current their knowledge of this topic.

Psychological perspectives in the patient with chronic orchialgia

Chronic orchialgia is a challenging problem to both the practitioner and unhappy patient and may be a poorly understood manifestation of a potential variety of different discrete causes. Treatment options can be wide ranging and include conservative measures, medical therapy, in office treatments and surgical procedures. Research has primarily focused on these more concrete treatment options with little focus on the either co-morbid or causative psychological issues. By at least considering the potential psychological co-morbidities and stressors that may be associated with chronic orchialgia, physicians can better utilize a multi-modal approach to this vexing problem.

Hydrocele with a surprise: Malignant mesothelioma of the tunica vaginalis - Case report and review of literature

Hydrocele is a very common condition that is simple to evaluate and treat. Management of hydrocele is usually delegated to the junior members of the surgical team. Sometimes this simple condition can spring huge surprises. A 20-year-old man presented with acute onset large, painless fluctuant left hemi-scrotal swelling. Scrotal ultrasonography showed thickened tunica vaginalis. A diagnosis of left hydrocele was made and repair by excision of sac was planned. During the procedure, the sac was found studded with red nodular growths; histopathology reported malignant mesothelioma of tunica vaginalis. Metastatic evaluation showed extensive retroperitoneal lymph nodal involvement. Despite receiving adjuvant chemotherapy with radiotherapy patient died due to extensive metastasis within 16 months. This case is presented for rarity of diagnosis, young age of presentation, absence of etiological factor and rapidly progressive clinical course.

Evaluation of Adult Acute Scrotum in the Emergency Room: Clinical Characteristics, Diagnosis, Management, and Costs

OBJECTIVE

To evaluate the clinic characteristics, diagnosis, management, and costs of the adult acute scrotum in the emergency room (ER). Acute scrotum is a syndrome characterized by intense, acute scrotal pain that may be accompanied by other symptoms. It is usual in children and commonly found as well in adults, with different causal pathologies between these groups.

METHODS

Between November 2013 and September 2014, 669 cases of adult acute scrotum who presented to our ER were prospectively analyzed. Patients under 15 years of age were excluded. Patient age, reason for consultation, investigations performed, final diagnosis, management, and costs were evaluated. For the statistical analysis, the Mann-Whitney, Kruskal-Wallis U, and chi-square tests were used.

RESULTS

A total of 669 cases of acute scrotum were analyzed. The mean age at presentation was 40.2 ± 17.3 years. The most presented diagnoses were orchiepididymitis (28.7%), epididymitis (28.4%), symptoms of uncertain etiology (25.1%), and orchitis (10.3%). Diagnostic tests were carried out in 57.8% of cases. Most cases were treated as outpatients (94.2%), with 5.83% admitted and 1% undergoing surgical treatment. Overall, 13.3% of patients represented to the ER. Abnormal results in blood and urine tests were more common among older patients and infectious pathologies. The average cost generated by an acute scrotum ER consult was 195.03€.

CONCLUSION

Infectious pathologies are the most common causes of acute scrotum at ER. Abnormal blood and urine tests are unusual and are more common in older patients and infectious pathologies.

Alteration of spermatogenesis following spermatogonial stem cells transplantation in testicular torsion-detorsion mice

PURPOSE

Testicular ischemia is the main consequence of testicular torsion, in both clinical and experimental aspects. Preservation and auto-transplantation of spermatogonial stem cells (SSCs) could be a new treatment for infertility in testicular ischemia following testicular torsion.

METHODS

To apply the idea in this study, animals were randomly divided into four groups of control, sham, with torsion, and with torsion followed by transplantation (TT). Isolated SSCs from neonatal mice were cultured and identified by flow cytometry (C-KIT(-), INTEGRIN β1 (+)) and RT-PCR (Reverse transcription polymerase chain reaction) for specific spermatogonial cell markers (Oct4, Gfrα-1, Plzf, Vasa, Itgα 6 , and Itgβ 1 ). SSCs were transplanted upon a 2-h testicular torsion in the TT group. Cultured cells were transplanted into ischemia reperfusion testicle 2 weeks post-testicular torsion. Eight weeks after SSCs transplantation, the SSCs-transplanted testes and epididymis were removed for sperm analysis, weight and histopathological evaluation, and pre- and post-meiotic gene expression assessment by qRT-PCR.

RESULTS

Our findings indicated that all evaluated parameters (epididymal sperm profile, Johnsen score, Plzf, Gfrα-1, Scp-1, Tekt-1 expressions, and histopathological profile) were significantly decreased following testicular torsion (group 3) when compared to the control group (p ≤ 0.05). However, all abovementioned parameters showed a significant increase/improvement in torsion-transplantation group compared to torsion group. However, these parameters in the TT group were significantly lower in the sham and control groups (p ≤ 0.05).

CONCLUSION

SSCs transplantation could up-regulate the expression of pre- and post-meiotic genes in testicular ischemia, which resulted in improvement of both testicular function and structure after testicular torsion.

Males' Awareness of Benign Testicular Disorders: An Integrative Review

Disorders that affect the testes can range from painless and benign to debilitating and life threatening. Despite the availability of literature on the etiology, diagnosis, and treatment of benign testicular disorders (BTD), very little is known about men's awareness of these conditions. The aim of this review was to extract and analyze evidence from studies that explored males' awareness of BTD. Four e-databases (CINAHL, MEDLINE, PsychINFO, and PubMed) were thoroughly searched and four articles met the review inclusion criteria. The quality of the included studies was appraised and data were extracted and cross-checked using a standardized data extraction table. It was determined that participants lacked education about testicular self-examination and scrotal signs and symptoms which contributed to their lack of awareness of BTD. Help seeking in the event of scrotal abnormalities was suboptimal which is alarming given the acuteness of some BTD such as testicular torsion. Individuals who are at risk for health disparities were underrepresented in the reviewed literature. Findings from this review highlight the need to address barriers to BTD knowledge and help seeking. This could be achieved through making use of past interventions that succeeded in increasing men's awareness of testicular cancer such as university campaigns and mass media. From a practical standpoint, clinicians must be encouraged to educate young men about BTD. This could be attained through tailoring creative educational interventions that are sensitive to the needs of individuals who are at risk for health disparities.

Outcomes of Second Look Exploration in Testicular Torsion of Children

Background:

Testicular torsion (TT), or twisting of the testicle resulting in a strangulation of the blood supply, occurs in men whose tissue surrounding the testicle is not well attached to the scrotum. It is important to emphasize that testicular torsion is a medical emergency.

Objectives:

The aim of this study is to evaluate the second look exploration and outcomes in TT.

Patients and Methods:

Seventy boys out of 124 patients underwent early exploration and 48 hours later second look exploration due to TT. All patients were checked with preoperative color-doppler ultrasonography (CDU) and intraoperative bleeding test. Data included age at admission, side of pathology, relation of TT with season of year, duration of preoperative history, degree of testicular torsion, CDU findings, and degree of bleeding; results of second look exploration, follow-up, and outcomes were analyzed.

Results:

Totally 70 patients were included in this study within five years, of which mean age was 28.6 ± 32.9 months (range 1 to 144), 48% of our patients had nausea and vomiting. Preoperative CDU showed absent/weak flow in 50 (71%) cases. Winter showed most frequently (44%) referred cases of testicular torsion. Orchidopexy was performed in 44 (63%) and orchidectomy in 26 (37%) cases after second look exploration. Mean follow-up duration was 3.1 ± 1.4 years. 4 (9%) cases in orchidopexy group developed testicular atrophy during follow-up, all four cases had a history of longer than 12 hours and grade II testicular bleeding test intra-operatively. Other orchidopexy patients salvaged. 26 patients, who were in grade III, underwent orchidectomy in second look exploration.

Conclusions:

TT requires emergency attention. The ischemia time of the testis is traditionally after 6 hours, and imaging or other diagnostic modality should not be a cause of delay. Early surgical exploration is modality of choice, and second look exploration after 48 hours can be more effective and salvageable in these patients.

Diagnosis of cardiac tamponade with transesophageal echocardiography following the induction of anesthesia for suspected testicular torsion

Transesophageal echocardiography (TEE) is a valuable tool for evaluating hemodynamic instability in patients under general anesthesia. We present the case of a 28-year-old man who presented with complaints of testicular pain concerning for testicular torsion. After induction of general anesthesia for scrotal exploration and possible orchiopexy, the patient developed severe and persistent hypotension. Using intraoperative TEE, the diagnosis of pericardial tamponade was made, and an emergent pericardial window was performed.

Liposarcoma of the spermatic cord masquerading as an inguinal hernia

This is a case of a 70-year-old male who presented with a mass in his right testicle. He was treated with antibiotics for epididymitis while undergoing serial ultrasounds for one year due to testicular swelling and pain. His fourth ultrasound revealed a mild hydrocele with a large paratesticular mass of undescribed size, superior to the right testicle, thought to be an inguinal hernia. Preoperative CT scan demonstrated a large fat-containing inguinal hernia extending into the scrotal sac. An inguinal hernia repair was complicated by fatty tissue surrounding the testicle requiring a right orchiectomy. Pathology review of the tissue demonstrated well-differentiated liposarcoma with a small focus of dedifferentiation grade 2 tumor. Tumor was identified at the inked margins indicating an incomplete resection. It was decided that no further surgical intervention was needed and the patient would undergo surveillance for local tumor recurrence. Six-month follow-up MRI scan was negative for any recurrence of disease. A liposarcoma presenting as a paratesticular mass with spermatic cord involvement is rare, and imaging studies may fail to distinguish a liposarcoma from normal adipose tissue.

Prevalence and risk factors for scrotal lesions/anomalies in a cohort of Brazilian men ≥ 40 years of age

OBJECTIVE

To estimate the prevalence of and risk factors for cutaneous lesions of the scrotum and intrascrotal lesions/anomalies among men included in a prostatic cancer screening program in a Brazilian metropolitan city.

DESIGN AND SETTING

Cross-sectional study, private outpatient healthcare service.

METHODS

1731 men aged 40 years or over, participating in a prostate cancer screening program conducted by the municipal public employees' healthcare system, underwent systematic urological assessment by a single examiner.

RESULTS

The prevalence of scrotal diseases in our sample was 44.7% (773/1731). Tinea cruris occurred in 203 (11.7%) of the participants, with higher risk among diabetics and lower prevalence among nonwhite individuals; scrotal tinea in eight (0.5%), with higher risk among hypertensive men; subcutaneous nodules in 12 (0.7%), especially in individuals with low schooling level; hydrocele in 283 (16.4%), with higher frequency among participants over the age of 60 years, diabetics or individuals with previous histories of nonspecific urethritis; spermatoceles in 174 (10.1%), with greater prevalence among individuals over the age of 60 years or diabetics, and lower frequency among individuals who underwent vasectomy; unilateral testicular hypotrophy/atrophy in 167 (9.7%) and bilateral hypotrophy/atrophy in 93 (5.4%), both occurring more frequently in individuals over the age of 60 years; absence of palpable testicles due to cryptorchidism in 7 (0.4%); and epididymitis/orchitis in 5 (0.3%), with higher prevalence among diabetics. No cases of cancer were identified in this sample.

CONCLUSIONS

Scrotal diseases were highly prevalent in this population of Brazilian men.

Large Retroperitoneal Liposarcoma Diagnosed upon Radiological Evaluation of Mild Right-Sided Inguinal Hernia

While inguinal hernia is common in the primary care office, the differential diagnosis is extensive and includes infectious, inflammatory and neoplastic processes. Varicocele is another frequent, generally benign condition which occasionally reflects serious disease entities. Left-sided or bilateral varicoceles account for the overwhelming majority of varicoceles because the left gonadal vein drains into the left renal vein in contrast to the right gonadal vein, which drains directly into the inferior vena cava, thus making left-sided or bilateral venous congestion more likely. Presence of an uncommon unilateral right-sided varicocele thus warrants further radiological workup, in particular CT abdomen and pelvis, to evaluate for retroperitoneal pathology. We describe a case in which appropriate use of a variety of imaging modalities including testicular ultrasound and CT led to an important diagnosis of a large, well-differentiated liposarcoma in the right retroperitoneum of a patient with a right-sided groin mass.