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Syphilis of the Epididymis1
SYPHILIS OF THE EPIDIDYMIS 1 H. C. ROLNJCK Chicago, Illinois
Received for publication May 1, 1924
Syphilis of the epididymis occurs more frequently than a review of the literature would indicate, reports of cases having appeared only at infrequent intervals. Although very little has been written in English or German, the French have developed quite a literature on this subject. Occurring more ·o ften as part of the secondary manifestatations, it is as temporary as the eruption. During this stage the involvement usually is not very marked, is associated with very little or no symptoms, and having no particular clinical or diagnostic significance at this time, escapes the notice of both patient and physician. However, it is also seen as a late secondary or tertiary manifestation and it is in these cases that it may be mistaken for tuberculosis or tumor. Sypilitic epididymitis is usually secondary to or associated with syphilitic orchitis. Primary syphilitic epididymitis without involvement of the testicles is rare, but does occur. The possibility of such was doubted by most English and German writers until recent times. Four cases of syphilis of the epididymis have come under my observation, one of which can be considered a primary epididymitis. Three of these can be reported; the fourth case was seen only once. Case 1. H. W. D., white, aged thirty-two, private patient first seen in August, 1920. _Complained of discomfort, slight pain and a feeling 1
Read before the Chicago Urological Society, Oct. 26, 1922 147
148
H. C. ROLNICK
of heaviness in right testicle. Examination E
My experience with this case led me to examine the scrotal contents of all cases of syphilis that have since come under my observation, also those presenting an acute or sub-acute hydrocele, many of which are syphilitic. The other cases reported here would have been overlooked had not a routine examination of the scrotal contents been made, for there were no subjective symptoms referable to the scrotum. The following cases were seen in the Genito-Urinary Dispensary of the Northwestern University Medical School. Case 2. J. H. R ., colored, aged twenty-six, first seen in October, 1920. Had no urethral discharge, urine clear and no recent history of gonorrhea. Complained of back ache and pain in lower abdomen, but no symptons referable to the scrotum. Left scrotal sac was considerably larger than the right and under tension. Transillumination showed hydrocele present which was aspirated. Testicle was found to be hard, irregular and nodular in upper pole. The epididymis was thickened to the size of a pencil for almost its entire length. The globus minor was not involved. The epididymis was uniformily hard, no nodules could be felt, and was detached from the testicle except at the head. There was a white scar on dorsum of penis of a lesion that
SYPHILIS OF EPIDIDYMIS
149
had been present five years previously. . He had never had any internal medication. His Wassermann was strongly positive. Patient was under observation and specific treatment for a period of three months during which time testicle and epididymis returned to normal size and consistency. He was seen again about one year later. There had been no recurrence.
The next case I believe can be considered one of primary epididymitis. Case 3. F . S., aged thirty-six, white, first seen in April, 1921, presented a most marked case of secondary syphilitic manifestations with cachexia, chancre on upper lip. Although patient did not complain of it swelling of the right scrotum ~as marked two and a half to three times the size of the left. He had no urethral discharge, no urinary symptoms, urine was clear, and there was no recent history of gonorrhea. Particular care was taken to exclude gonorrhea for the condition resembled that usually seen in gonorrheal epididymitis. The entire epididymis was diffusely involved, large, hard and painless, and matted down to the testicle. The testicle itself was normal in size and consistency. It could be distinctly felt and there was no difference between it and the testicle on the left side. Patient stated that he had noticed the enlargement of the scrotum for the previous four weeks; that it had developed gradually and had been growing larger, but had not given him any trouble. Under anti-syphilitic treatment all manifestations, together with the epididymitis, disappeared in about eight weeks. Case 4. This case was seen only once but this undoubtedly was also a case of syphilis of the epididymis. Patient gave a history of primary lesion eight months previous, a rash appearing later and a positive Wassermann. Had a left hydrocele which was aspirated. The left epididymis was nodular almost in its entire extent, felt beady and was detached from contact with testicle. The right felt the same. The right testicle appeared normal, but the left was irregular and hard.
Bell in 1793 first described syphilis of the testicle. In making a diagnosis, gonorrhea and tuberculosis were excluded in a patient known to be syphilitic. In 1863 Dron of Lifons first described syphilis of the epididymis and reported 15 cases, most of which occurred one to five months
150
H. C. ROLNICK
after the beginning of the secondaries. Following his report a number of cases were reported by various French writers. Lisser and Hinman in reporting a case of syphilis of the epididy~ mis without involvement of the testicle presented a fairly complete review of the literature on this subject. German writers were slow in coming to the conclusion that syphilis can attack the epididymis without involvement of the testicle. In 1884 Pinner reported 1 case. He stated there is distinct separation between testicle and epididymis, condition is chronic and painless, also can be acute, occurring commonly during the first year of infection and earlier than testicle involvement. A review of American literature disclosed very little, most text-books merely mentioning the subject in passing or neglecting it entirely. It is generally agreed that the epididymitis occurs early during the first or second years of disease before the time the testicles are commonly affected. As a primary manifestation without involvement of the testicle it resembles tuberculosis, must be differentiated from tuberculosis and malignancy and is usually associated with hydrocele. The head of the epididymis is always affected, the body also at times and very infrequently the entire epididymis and part of the vas are involved in the syphilitic process. Michelson in reporting a series of 7 cases gave a summary of the literature. He divides them into three types. 1. An acute, diffuse interstitial type, at first diffuse, becoming nodular later. Nodules most often in upper pole. The two epididymes rarely becoming involved at the same time. It may occur as early as the second month of infection and appears during first and second years of disease. 2. Chronic, diffuse interstitial type similar to the acute, except slower in development and practically always associated with hydrocele. Occurs later in the disease from two to seven years after appearance of initial lesion. 3. Gummatous type. McDonough says that the affected pole feels as a bunch of grapes would through a soft bag. Cooper states that the
SYPHILIS OF EPIDIDYMIS
151
involvement is in the fibrous tissue and not in the lumen of the epididymis and that its function is not inter£ered with. The earlier the appearance of the epididymitis the less likelihood of the testicle being involved, for syphilitic orchitis is usually a tertiary manifestation. The internal spermatic artery as it enters the testicle gives off a branch to the globus major. As this is the most direct blood supply, it is readily seen why the head of the epididymis is always affected in these cases. The testicle is more commonly involved in syphilis than the epididymis because of its more direct blood supply and also because of the particular affinity the spirochete has for it. The testicle also has a selective action, being a favorite place for typhoid, syphilis and mumps and very seldom for gonorrhea or tuberculosis. It is thus seen that syphilis of the epididymis alone, without extension from the testicle, is truly a rare condition. Syphilis of the epididymis alone, without involvement of the testicle, can be due to the fact that the spirochete is carried directly to it and not to the testicle. It may also be possibly explained as follows: Belfield states that the testicle has an excretory function and that the vas and epididymis are excretory tubules of the testicle, the same as the old urinary duct of the frog. It is well known that organisms of various types circulate in the blood stream and are excreted by the kidney, without damage to the epithelium. The organisms may also be carried to the testicle and excreted by it through the epididymis and vas without any injury to its epithelium. The spirochete if thrown off may lodge in the epididymis and not injure the testicle, so that it may be possible for an epididymitis to occur with the testicle apparently normal. Because the condition is usually painless and occurs most commonly early in the disease, it is overlooked by both patient and physician. A routine examination of all cases of early syphilis and all those presenting an acute or sub-acute hydrocele, many of which are syphilitic, will sometimes disclose an epididymitis which would have been otherwise overlooked.
152
H. C. ROLNICK
REFERENCES (1) BELL: Q·uoted by D'ARCY PowER AND KEOGH J. MURPHY: System of Syphilis, London, 1908, ii, 146. (2) DRON: Archives Gen. de Med., 1863, 513; 724. (3) HUTCHINSON: Syphilis, 1875, Philadelphia, 267-268. (4) LANCEREAux: Treatise on Syphilis, New Sydenham Society, 192. (5) FULLER: Diseases of Genito-Urinary System, London, 1900, 106-108. (6) THOMAS: Journ . Cutan. Dis., New York, 1891, 292; 294. (7) DAvrs: Weekly Med. Rev., 1889, 679; 680. (8) COOPER: Brit . Med. Jour., 1883, 1094; 1095. (9) TAYLOR: Genito-Urinary and Venereal Diseases, New York, 1904, 654; 655 . (10) KEYES: Syphilis, New York and London, 1908, 479; 480. (11) McDONOUGH: Venereal Diseases, London, 1915, 154. (12) FINGER, ERNEST: Syphilis, 1901. (13) MAX, JOSEPH: Venereal Diseases, 1901. (14) MATZENAUER, RUDOLPH: Venereal Diseases, 1904. (15) WRIGHT: Ural., and Cutan. Rev., 1916, 661 : 663. (16) HINMAN AND LISSER: Amer. Jour. Syph., 1918, 446; 471. (17) HAZEN: Syphilis, St. Louis, 1919, 298; 299. (18) BELFIELD: Quoted by BARNEY: Cabot's Modern Urology. (19) MICHELSON : Amer . Med. Assoc. Jour., 1919, 1431; 1433.
Received for publication May 1, 1924
Syphilis of the epididymis occurs more frequently than a review of the literature would indicate, reports of cases having appeared only at infrequent intervals. Although very little has been written in English or German, the French have developed quite a literature on this subject. Occurring more ·o ften as part of the secondary manifestatations, it is as temporary as the eruption. During this stage the involvement usually is not very marked, is associated with very little or no symptoms, and having no particular clinical or diagnostic significance at this time, escapes the notice of both patient and physician. However, it is also seen as a late secondary or tertiary manifestation and it is in these cases that it may be mistaken for tuberculosis or tumor. Sypilitic epididymitis is usually secondary to or associated with syphilitic orchitis. Primary syphilitic epididymitis without involvement of the testicles is rare, but does occur. The possibility of such was doubted by most English and German writers until recent times. Four cases of syphilis of the epididymis have come under my observation, one of which can be considered a primary epididymitis. Three of these can be reported; the fourth case was seen only once. Case 1. H. W. D., white, aged thirty-two, private patient first seen in August, 1920. _Complained of discomfort, slight pain and a feeling 1
Read before the Chicago Urological Society, Oct. 26, 1922 147
148
H. C. ROLNICK
of heaviness in right testicle. Examination E
My experience with this case led me to examine the scrotal contents of all cases of syphilis that have since come under my observation, also those presenting an acute or sub-acute hydrocele, many of which are syphilitic. The other cases reported here would have been overlooked had not a routine examination of the scrotal contents been made, for there were no subjective symptoms referable to the scrotum. The following cases were seen in the Genito-Urinary Dispensary of the Northwestern University Medical School. Case 2. J. H. R ., colored, aged twenty-six, first seen in October, 1920. Had no urethral discharge, urine clear and no recent history of gonorrhea. Complained of back ache and pain in lower abdomen, but no symptons referable to the scrotum. Left scrotal sac was considerably larger than the right and under tension. Transillumination showed hydrocele present which was aspirated. Testicle was found to be hard, irregular and nodular in upper pole. The epididymis was thickened to the size of a pencil for almost its entire length. The globus minor was not involved. The epididymis was uniformily hard, no nodules could be felt, and was detached from the testicle except at the head. There was a white scar on dorsum of penis of a lesion that
SYPHILIS OF EPIDIDYMIS
149
had been present five years previously. . He had never had any internal medication. His Wassermann was strongly positive. Patient was under observation and specific treatment for a period of three months during which time testicle and epididymis returned to normal size and consistency. He was seen again about one year later. There had been no recurrence.
The next case I believe can be considered one of primary epididymitis. Case 3. F . S., aged thirty-six, white, first seen in April, 1921, presented a most marked case of secondary syphilitic manifestations with cachexia, chancre on upper lip. Although patient did not complain of it swelling of the right scrotum ~as marked two and a half to three times the size of the left. He had no urethral discharge, no urinary symptoms, urine was clear, and there was no recent history of gonorrhea. Particular care was taken to exclude gonorrhea for the condition resembled that usually seen in gonorrheal epididymitis. The entire epididymis was diffusely involved, large, hard and painless, and matted down to the testicle. The testicle itself was normal in size and consistency. It could be distinctly felt and there was no difference between it and the testicle on the left side. Patient stated that he had noticed the enlargement of the scrotum for the previous four weeks; that it had developed gradually and had been growing larger, but had not given him any trouble. Under anti-syphilitic treatment all manifestations, together with the epididymitis, disappeared in about eight weeks. Case 4. This case was seen only once but this undoubtedly was also a case of syphilis of the epididymis. Patient gave a history of primary lesion eight months previous, a rash appearing later and a positive Wassermann. Had a left hydrocele which was aspirated. The left epididymis was nodular almost in its entire extent, felt beady and was detached from contact with testicle. The right felt the same. The right testicle appeared normal, but the left was irregular and hard.
Bell in 1793 first described syphilis of the testicle. In making a diagnosis, gonorrhea and tuberculosis were excluded in a patient known to be syphilitic. In 1863 Dron of Lifons first described syphilis of the epididymis and reported 15 cases, most of which occurred one to five months
150
H. C. ROLNICK
after the beginning of the secondaries. Following his report a number of cases were reported by various French writers. Lisser and Hinman in reporting a case of syphilis of the epididy~ mis without involvement of the testicle presented a fairly complete review of the literature on this subject. German writers were slow in coming to the conclusion that syphilis can attack the epididymis without involvement of the testicle. In 1884 Pinner reported 1 case. He stated there is distinct separation between testicle and epididymis, condition is chronic and painless, also can be acute, occurring commonly during the first year of infection and earlier than testicle involvement. A review of American literature disclosed very little, most text-books merely mentioning the subject in passing or neglecting it entirely. It is generally agreed that the epididymitis occurs early during the first or second years of disease before the time the testicles are commonly affected. As a primary manifestation without involvement of the testicle it resembles tuberculosis, must be differentiated from tuberculosis and malignancy and is usually associated with hydrocele. The head of the epididymis is always affected, the body also at times and very infrequently the entire epididymis and part of the vas are involved in the syphilitic process. Michelson in reporting a series of 7 cases gave a summary of the literature. He divides them into three types. 1. An acute, diffuse interstitial type, at first diffuse, becoming nodular later. Nodules most often in upper pole. The two epididymes rarely becoming involved at the same time. It may occur as early as the second month of infection and appears during first and second years of disease. 2. Chronic, diffuse interstitial type similar to the acute, except slower in development and practically always associated with hydrocele. Occurs later in the disease from two to seven years after appearance of initial lesion. 3. Gummatous type. McDonough says that the affected pole feels as a bunch of grapes would through a soft bag. Cooper states that the
SYPHILIS OF EPIDIDYMIS
151
involvement is in the fibrous tissue and not in the lumen of the epididymis and that its function is not inter£ered with. The earlier the appearance of the epididymitis the less likelihood of the testicle being involved, for syphilitic orchitis is usually a tertiary manifestation. The internal spermatic artery as it enters the testicle gives off a branch to the globus major. As this is the most direct blood supply, it is readily seen why the head of the epididymis is always affected in these cases. The testicle is more commonly involved in syphilis than the epididymis because of its more direct blood supply and also because of the particular affinity the spirochete has for it. The testicle also has a selective action, being a favorite place for typhoid, syphilis and mumps and very seldom for gonorrhea or tuberculosis. It is thus seen that syphilis of the epididymis alone, without extension from the testicle, is truly a rare condition. Syphilis of the epididymis alone, without involvement of the testicle, can be due to the fact that the spirochete is carried directly to it and not to the testicle. It may also be possibly explained as follows: Belfield states that the testicle has an excretory function and that the vas and epididymis are excretory tubules of the testicle, the same as the old urinary duct of the frog. It is well known that organisms of various types circulate in the blood stream and are excreted by the kidney, without damage to the epithelium. The organisms may also be carried to the testicle and excreted by it through the epididymis and vas without any injury to its epithelium. The spirochete if thrown off may lodge in the epididymis and not injure the testicle, so that it may be possible for an epididymitis to occur with the testicle apparently normal. Because the condition is usually painless and occurs most commonly early in the disease, it is overlooked by both patient and physician. A routine examination of all cases of early syphilis and all those presenting an acute or sub-acute hydrocele, many of which are syphilitic, will sometimes disclose an epididymitis which would have been otherwise overlooked.
152
H. C. ROLNICK
REFERENCES (1) BELL: Q·uoted by D'ARCY PowER AND KEOGH J. MURPHY: System of Syphilis, London, 1908, ii, 146. (2) DRON: Archives Gen. de Med., 1863, 513; 724. (3) HUTCHINSON: Syphilis, 1875, Philadelphia, 267-268. (4) LANCEREAux: Treatise on Syphilis, New Sydenham Society, 192. (5) FULLER: Diseases of Genito-Urinary System, London, 1900, 106-108. (6) THOMAS: Journ . Cutan. Dis., New York, 1891, 292; 294. (7) DAvrs: Weekly Med. Rev., 1889, 679; 680. (8) COOPER: Brit . Med. Jour., 1883, 1094; 1095. (9) TAYLOR: Genito-Urinary and Venereal Diseases, New York, 1904, 654; 655 . (10) KEYES: Syphilis, New York and London, 1908, 479; 480. (11) McDONOUGH: Venereal Diseases, London, 1915, 154. (12) FINGER, ERNEST: Syphilis, 1901. (13) MAX, JOSEPH: Venereal Diseases, 1901. (14) MATZENAUER, RUDOLPH: Venereal Diseases, 1904. (15) WRIGHT: Ural., and Cutan. Rev., 1916, 661 : 663. (16) HINMAN AND LISSER: Amer. Jour. Syph., 1918, 446; 471. (17) HAZEN: Syphilis, St. Louis, 1919, 298; 299. (18) BELFIELD: Quoted by BARNEY: Cabot's Modern Urology. (19) MICHELSON : Amer . Med. Assoc. Jour., 1919, 1431; 1433.