Empty scrotum In adults

Abstract

Background: Testicular maldescent is a common urological problem, the aetiology of which is not well understood. Though it can easily be detected and diagnosed at birth or during early childhood, still some patients present late. A reasonable number of patients presents for the first time with complications like infertility or malignant changes. The diagnosis is mainly clinical. The role of ultrasonography is not yet established. Methods: this is a prospective hospital-based study of 96 patients with 104 impalpable testes. In addition to clinical history and examination, all patients had semenalysis, ultrasound scan and surgical exploration. Results: Prevalence of empty scrotum was 1%. Fertility from the history was detected in 28 out of 40 married people while semenalysis was normal in 76 (79%) of the total. Testes were found to be intraabdominal in 60 (58%). Most of the testes were atrophied. Malignancy was detected in 2 cases (2%). Conclusions: Empty scrotum in adults is more prevalent than expected. Ultrasonography in this study was not a sensitive diagnostic tool in cases of impalpable testes.

Full text

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Empty scrotum in adults
Mohamed T Musa* and Randa Z A/Rahman
Department of Surgery, Faculty of Medicine, University of Khartoum, Sudan
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Abstract
Background: Testicularmaldescent is acommonurological problem, theaetiologyof which isnotwell understood.
Thoughitcaneasilybedetectedanddiagnosedatbirthorduringearlychildhood,stillsomepatientspresentlate.A
reasonablenumberofpatientspresentsforthersttimewithcomplicationslikeinfertilityormalignantchanges.The
diagnosisismainlyclinical.Theroleofultrasonographyisnotyetestablished.
Methods:this is aprospectivehospital-basedstudyof96patientswith 104 impalpable testes.Inadditiontoclinical
historyandexamination,allpatientshadsemenalysis,ultrasoundscanandsurgicalexploration.
Results:Prevalenceofemptyscrotumwas1%.Fertilityfromthehistorywasdetectedin28outof40marriedpeople
whilesemenalysiswasnormalin76(79%)ofthetotal.Testeswerefoundtobeintraabdominalin60(58%).Mostofthe
testeswereatrophied.Malignancywasdetectedin2cases(2%).
Conclusions:Emptyscrotuminadultsismoreprevalentthanexpected. Ultrasonographyinthisstudywasnotasensitive
diagnostictoolincasesofimpalpabletestes.
Introduction
Testicular maldescent is one of the most common clinical
entities encountered in paediatric urology; it affects
approximately5%ofallfulltermmaleinfants(1).InTurkey,
inareviewof6381primaryschoolboys,theincidenceof
undescendedtestiswasfoundtobe1.43%(2). The overall
incidenceinthegeneralpopulationisabout0.8%dueto
thespontaneous descentbetweenbirthandoneyearof
age.
The aetiology of testicular maldescent is not fully
understood;butatheorythatashortperiodofandrogen
blockade leads to inhibition of descent is suggested. The
mechanismisnotyetknown(3).
Testiculardescentisbelievedtobeimportantfornormal
spermatogenesis at a temperature below the body
temperaturein the scrotum.Infertility(4,5) and testicular
neoplasm(6-9) are complications of cryptorchism. Many
facts of cryptorchism are poorly understood despite
extensive literature review concerning this problem.
Impaired fertility was found to complicate unilateral
as well as bilateral undescended testes (UDT)(5).
Seminomaalso occurred inipsilateral and contralateral
cryptorchism(8)andthepositionofthetestiswasrelated
to the carcinogenses i.e. intraabdominal testis has the
highestmalignantpotential(9).InastudyfromSouthAfrica,
cryptorchismwasfoundtobeassociatedwithseminoma
mainlyinblackracesatameanageof40years(10).
The effectiveness of orchiopexy, one of the most
frequently performed operations in childhood, has yet
to be determined. Some studies showed that seminoma
complicates both corrected and uncorrected inguinal
cryptorchism(11), while others proved that orchiopexy
decreases the risk of cancer(12,13)ormarginallyreducesthe
symptomaticinterval of cancer butdoes not affect the
stageofpresentationortheprognosis(13).
Having one side or both sides of the empty scrotum is
aproblemwhichcaneasilybedetectedatbirthbythe
midwifeordoctor.Inastudy fromTurkey,58.7%ofthe
familiesoftheaffectedboyswereawareoftheproblem
andin 78% ofthose the motherwas the rstperson to
*Corresponding author: Faculty of Medicine, University
of Khartoum, PO Box 102, Khartoum, Sudan.
Email: mohtoum@hotmail.com
KharoumMedicalJournal(2008)Vol. 01, No. 02 pp.69-71

70
detect it(2). School doctors also have a role to detect an
emptyscrotum(14).Theaimsofthisstudyaretodetermine
theprevalence andthecomplicationsofempty scrotum
inadults(ESA)inahospitalbasedstudyinKhartoum.
Patients and Methods
Thisisaprospective analytical study conductedinthe
Police University Hospital in Khartoum, Sudan in the
periodbetweenJanuary1996andJanuary1999.Alladult
patientswithempty scrota wereincludedin this study.
Patients who had orchidectomy or testicular atrophy
were excluded. A questionnaire containing general
information,fullmedicalhistoryandphysicalexamination
was lled for each patient. Laboratory investigations
(Haemoglobin level and urinalysis), semenalysis and
scrotal and abdominal ultrasound scan were performed
forallpatients.
Surgery was performed on all patients and histological
studieswereperformedonalltestes(eitheronthewhole
testisincasesoforchidectomy,oronanincisionalbiopsy
incasesoforchiopexy).
Results
Patientswithemptyscrotumconstituted96outof10000
(1%) male patients, 8 of them had bilaterally empty
scrotum.Theagerangedbetween17-75yearswithamean
+SD of26+11years.Noneofthepatientswasilliterate,
and those who received high education (high school or
university)werethemajorityrepresenting67%.
The side of impalpable testis was the left in 48 (50%),
andtherightin40(42%)whileonly8(8%)hadbilaterally
impalpabletestes.Fiftysixpatients(58%)wereunmarried
andtherest were marriedfor2 years ormore.Twenty
eightoutofthe40marriedpatientswerehavingchildren.
Semenalysiswasnormal in 76(79%)ofthe patients.All
patients underwent ultrasound scanning, which showed
positiveresultsin82(79%)and negativeinthe22(21%)
testes.
All96patientsunderwentsurgicalexplorationforthe104
impalpabletestes.Thisstartedbyinguinalexploration.If
the testis was not found then another abdominal incision
wasmade.Orchiectomywasthemostfrequentoperation;
itwasdonein76patients.Thetesteswerefoundintra-
abdominally in 60 patients. Histopathology showed
benign atrophic testicular tissue in the majority (98
testes representing 94%) while seminoma was detected
in2testes(2%).
Discussion
Patients with empty scrotum constituted nearly 1% of
adult male patients which is a higher rate than that
reportedinthe literature. This maybe due to thefact
thatitisahospital-basedstudy.AstudyfromSaudiArabia
reportedaveryhighprevalenceofcryptorchidismin114
(43%) patients presenting with uni- or bilateral UDT(12).
Most patients in the study were educated, yet they
presentedratherlate.
Bothsideswereequallyaffected,afactwhichisnoticedin
otherstudies.Bothimpalpableandvanishingtesteswere
common in the left side but the likelihood of vanishing
testis was similar in both sides(15).
Fortypatients (42%)were married for at least 2 years.
Theotherswereunmarriedanddidnotpracticesexdue
to social and religious limitations. Twelve (30%) of the
married group had no children and their wives had no
historyofconceptioninspiteofthenormalregularsexual
intercourseandthattheirwiveswerenormalbyclinical
examinationandlaboratory investigations. Semenalysis-
wasnormal in 76 (79%) ofthe study population and all
belonged to the unilateral empty scrotum (ES) group.
In another study performed in 48 men who underwent
orchiopexy,semenanalysiswasnormalin18(86%)ofthe
23whohadunilateralimpalpabletestis(4). Ultrasound of
thescrotum,inguinalregionandabdomenwasperformed
inallpatients.Outofthe 22negativeresults,18testes
(representing 82%) were found intra-abdominally at
operation. Ultrasound scan is a good tool to detect
intrascrotal lesions though it does not suggest whether
they are benign or malignant(16). However, this method
isnot very sensitive in detecting intraabdominal testes
possibly because the retained testes were markedly
hypoplastic and had low elasticity((17). However a study
from Israel showed 75% sensitivity of ultrasound in the
detection of impalpable testis and recommended it as
the initial investigation(18).Laparoscopy(19,20)andMagnetic
Resonance Imaging (MRI) showed good results and the
latterhas90%diagnosticaccuracy(21).
All patients underwent surgery and only 4 testes were
not detected. Orchiectomy was performed in 76 (79%)
while orchiopexy and testicular biopsy was performed
in the remaining 24 patients. Some studies had higher
rateoforchiopexyinpostpubertalUDTperformedmainly
forcosmeticandpsychologicalpurposesandfortunately
theseshowedlowincidenceofcanceronfollowup(12). In
thisstudy,thesiteofthetestiswasmainlyintraabdominal
in60(58%),inguinalcanal in 40(38%) and thetestiswas
notdetected in only 4 patients(4%). Vaysse performed
laparoscopyfor201boyswith232impalpabletestis.He
reported36%intraabdominaltestesand14%blindending
abdominal structure (50% total) while the testis was
absentinonly1%(19).Thisreectsthatcompleteabsence
of testis is rare.
In the present study, testicular cancer was conrmed
inonly 2 patients (2%).Thisincidence is lowcompared
tothe literature reportsin whichthe incidence ranged
between20-34%(6,7,8,10,11).Theriskofmalignancyis there
evenafterorchiopexy(11)andthelattermaydecreasethe
risk but not the prognosis(13). One study reported that
postpubertalpresentationhas low risk ofcancer(12). The
risk of testicular cancer in blacks with maldescended
testeshasbeenreportedtobehighattheageof40years
Mohamed T Musa and Randa Z A/Rahman

71
butlateronitbecomescomparabletoothers(10).
Conclusion
TheconditionofESAisnotinfrequent.Infertilityoccurred
in20%ofpatientswithunilateralemptyscrotumandinall
patientswithbilateralemptyscrotum.Testicularcancer
wasseenin2%ofourpatientswhichislowincomparison
to other studies.
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Emptyscrotuminadults