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Abscess of the Testicle1
ABSCESS OF THE TESTICLE 1 WILLIAM ROSENBERG From the Department of Urology, Mt. Sinai Hospital, Cleveland, Ohio
Abscess of the testicle, although not a rarity, is infrequently reported in the literature. It occurs as a result of many causative factors and is observed as a complication in a variety of conditions: (1) Orchitis associated with certain systemic infections, such as typhoid fever, influenza, variola, parotitis, scarlet fever, chicken pox, osteomyelitis, etc. These are undoubtedly hematogenous in character. (2) Abscess of the testicle associated with epididymitis and gonorrheal urethritis. (3) Abscess of the testicle associated with chronic urinary tract infection. (4) Abscess of the testicle associated with torsion of the spermatic cord. Many writers stress particularly, as sources of testicular abscess, the seminal ducts, the vas deferens, and the epididymis. Others ascribe an important place to the lymphatics. After a careful histological examination, Dalous (3) concluded that the process in a great measure extends along the natural channels, the vas deferens and the epididymis, but that the lymphatics play an important role. Generally, a small abscess having formed in the testicle, it may become encysted and undergo caseous degeneration. It may spread beneath the tunica albuginea, involve the entire testicle and cause complete sloughing. Again, the abscess may rupture into the tunica vaginalis, which usually contains some · free fluid, causing suppuration of this sac and eventually pointing externally, or, the abscess may reach the surface without rupturing into the cavity of the tunica vaginalis. Fortunately, abscess of the testicle is probably not so common due to the fact that it is so well protected from bacterial invasion by its rich vascular and lymphatic supply, as well as the tunica albuginea. Due to the firmness of the tunica albuginea, most testicular abscesses do not increase the size of the testicle to any considerable extent. I. Suppurative conditions of the testicle are infrequent in typhoid fever, parotitis, scarlet fever, etc., although orchitis occurs in about 0.2 per cent of the cases of typhoid fever and one-fourth of these go on to abscess formation. Durnin (5) reports a case of bilateral abscess of the testicles due to Bacillus typhosus with trauma as a predisposing factor. 1
Received for publication February 15, 1935.
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His patient sustained an injury to the left testicle while climbing over a wire fence. Immediate pain and swelling occurred. For one month he consulted no physician. With acute swelling of the right side, a physician was called in and conservative treatment instituted. Two months after the injury, the testicles were greatly swollen and there was a moderate amount of free fluid in each tunica vaginalis and considerable swelling of the testicles and epididymes. The urine in this case showed pus cells and bacteria. Operation revealed abscesses involving both testicles, no growth being obtained from one side and the Bacillus typhosus from the other. It is interesting to note that this patient never presented symptoms of typh~id fever but was known to have used drinking water from a well which later was found to be a source of typhoid fever. The Bacillus typhosus was also found in the urine. Landifer (13) reports a case of multiple abscesses of both testicle and epididymis, due to the pneumococcus. His patient developed sudden pain in the region of the right scapula. Two weeks later, incision revealed much pus from which the pneumococcus was cultured. One month after the onset of his illness, there was marked swelling of the left testicle and epididymis. At operation, both testicle and epididymis were found to be riddled with pneumococcic abscesses. II. Abscess of the testicle is a comparatively rare termination of gonorrheal epididymitis although it has been maintained by Ricord, Kocher and others, that gonorrheal involvement of the testicles is more frequent than is supposed. Fournier and Kocher state that abscess of the testicle may occur without demonstrable participation of the epididymis. They hold that the parenchyma is first involved, the process then spreads to the adjoining connective tissue and finally spreads to the tunica albuginea. Ricord, on the contrary, believes that orchitis can develop only in those cases in which the epididymis is primarily involved. It is the belief of Langer (9) that in a comparatively large percentage of cases of gonorrheal epididymitis, there is concomitant involvement of the tunica vaginalis and that the parenchyma of the testis is secondarily involved. Generally, no abscess results in the testicle proper except in a few cases where the process does not recede but continues to advance until partial or total necrosis and abscess formation results. According to Christeller and Jacoby, the etiological connection and the mechanism of the genesis of such abscess formation has never yet been clearly determined on the basis of the published cases. Mulzer believes that such cases of gangrene of the testicles may develop in connection with acute
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or chronic gonorrhea and he distinguishes two classes, the benign type in which simple gangrene of the testis occl,lrs, and the malignant type in which there may be abscesses with perforation into the cavity of the testis towards the outside. In one case described by Buschke and in two reported by Mulzer, there was acute necrosis of the testicle with suppuration so severe that the entire testicle was destroyed and orchidectomy resorted to. All three of these cases developed in the course of a specific urethritis. Neither of these authors could determine gonococci in the pus, either culturally or histologically, so that the affection was designated by Mulzer as a "secondary complication" of gonorrhea. Metarasso, however, did find gonococci in the greenish-yellow pus in a testicular abscess in a boy aged 14, suffering with an acute gonorrhea. Delling also reports a case in which, 2 months after his patient had been operated upon for abscess of the testicle, gonococci were found in the pus which drained from the fistula. Langer (9) reported 3 cases of abscess of the testicle associated with gonorrhea. Gonococci could not be demonstrated in the pus obtained at operation. He made particular note of the fact that all 3 cases were associated with funiculitis and advanced the theory that severe edema of the spermatic cord exerts such severe pressure on the blood vessels that the blood supply of the testicle is disturbed, thus creating excellent soil for bacterial growth. Buschke states that it is his belief that the funiculitis causes thrombosis of the blood vessels with resultant necrosis of the testicle. Solomon (6) reported a case of abscess of the testicle due to gonorrhea but which followed trauma superimposed on a receding epididymitis. His patient was a very famous football player who insisted on playing while suffering from an acute posterior urethritis. It is interesting to note that gonococci were easily demonstrated in the pus evacuated at operation. This case, together with those reported by Metarasso and Delling, are the only ones reported in the literature where gonococci were found in a testicular abscess. Salutsky (11) reported 2 cases of abscess of the testicle, the first being associated with gonorrhea and the second following massage for chronic prostatitis. Fleischman (12) reports an unusual case of suppuration of the testicle occurring as a result of gonorrhea. In his case, multiple abscesses were present and there was a spontaneous separation of the testicle from its vascular supply.
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Case 1. J. L., aged 26, admitted to Mt. Sinai Hospital October 17, 1922, complaining of swelling of the right testicle of 3 days duration. He had had an acute specific urethritis for which he had been under treatment for 2 weeks prior to admission. Epididymotomy was done on the following day in the usual manner. The patient was discharged from the hospital on November 7, apparently in good condition. He was re-admitted on January 22, 1923, complaining of marked atrophy of the testicle. He stated that shortly after being discharged from the hospital, there appeared a discharge of purulent material in the line of incision of the epididymotomy. He had not reported for treatment following drainage of the epididymis. Orchidectomy was done on January 23. The testicle was markedly necrotic and measured 4 x 2.5 cm. Section showed a great deal of purulent material and microscopically no tubules were demonstrable. Case 2. I. C., aged 20, admitted to the hospital August 27, 1931, complaining of pain in the left testicle. The patient had been treated for acute gonorrhea for the previous 3 weeks and the epididymitis occurred several days prior to admission. Epididymotomy was performed on August 28 and the patient discharged September 2, temperature normal and apparently in good condition. On September 7, the epididymis was slightly tender on palpation and some tenderness was noted over the body of the testicle proper. There was a moderate amount of drainage from the epididymotomy incision. It was noted during the next several weeks that there was considerable sloughing of purulent testicular tissue and within about 6 weeks the sinus closed and the entire testicle had sloughed away. This patient was again seen during January, 1933, at which time there was no testicle palpable. The epididymis could be felt as a small, fi.brotic structure. Case 3.2 J. F. 0., aged 26, admitted to the hospital November 4, 1932, with a history of having been treated for gonorrhea since July, 1932. Both urines had been clear for some time when patient failed to continue treatment. He returned November 2, complaining of pain in the left testicle and presented symptoms of acute urethritis. Epididymotomy was done on November 5, in the usual manner. The patient was discharged from the hospital on Nov,ember 15 without the usual recovery. There was some tenderness still present, a moderate degree of swelling but the temperature was normal. On November 26, :fluctuation was noted on the anterior scrotal surface. Incision and drainage disclosed a great deal of pus and testicular slough. Subsequently, the entire testicle sloughed away and the epididymis could be palpated as a small indurated mass. 2
Case 3-Courtesy of Dr. P. A. Jacobs.
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Case 4. L. C., aged 24, was first seen July 27, 1934, with a specific urethritis. There was nothing of note in the progress of his infection until September 10, when patient appeared with profuse hematuria following exposure. On September 29, patient developed right epididymitis for which operation was refused at the time. Epididymotomy was performed in the usual manner on October 4. Subseq~ently, the urethritis cleared up, but on October 19, there was marked edema of the penis. The following day, the right testicle became markedly swollen and incision and drainage were done on October 23. Half of the testicle was necrotic and sloughed away, leaving some testicular tissue present.
III. In 1914, Barney (1) presented a paper dealing with abscess of the testicle and called attention to a very rare type of abscess in which no associated inflammatory condition could be determined. He concluded that the infection in the testicle was hematogenous since there was no demonstrable lesion in the urinary or genital tracts. The abscess which he studied was in the lower pole of the testicle, and the epididymis appeared to be free from pathological change. Analysis of his case, however, shows conclusively that there must have been some infection either in the prostate or the seminal vesicles. It is doubtful if abscess of the testicle can develop without involvement of the urinary or genital tracts. According to Barney, no associated inflammatory condition could be demonstrated in his case. The urine was clear and sparkling . on admission and he assumed that the abscess was the result of a hematogenous infection. Caulk (7) also found abscesses of the testicles in which the patient's urine was perfectly clear. However, his patients had been treated for prostatitis and vesiculitis. The fact that Barney's case promptly developed a urethral discharge and pyuria following orchidectomy would tend to prove that there must have been an infection in the genital tract although not demonstrable at the time of examination. It is not at all uncommon to find clear urine in involvement of the genital tract and epididymitis is not an unusual occurrence following treatment of this condition. Caulk (7) reported 15 cases of testicular abscess in which 13 showed urogenital infections and two resul,t ed from surgical injury with consequent interference with the circulation. In the 3 cases of orchidectomy which were performed in this series, 2 showed changes in the epididymes, the other marked perivascular involvement at the site of the lymphatics and clinically epididymitis was present in 13 of the 15 cases. Gron, Fredrik and Thjotta describe a case of purulent orchitis and
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epididymitis in a man aged 44. This patient became acutely ill with painful micturition and severe pain in the scrotum with marked swelling of the testicle. Ultimately, the entire testicle and epididymis were destroyed. B. coli communis was found in pure culture. This patient had a long-standing history of "spermatocystitis." Nash (4)~irported 2 cases of abscess of the testicle due to the colon bacillus. Ifoth' were associated with pyuria and epididymitis. He assumed that involvement of the testicle occurred by way of the vas deferens. Bonrier cites a case of testicular abscess following heavy muscular effort: his patient, however, also had evidence of chronic infection of the urinary tract. Case 5. H. I., aged 55, first seen April, 1931, complaining of frequency and nocturia, voiding every 15 to 30 minutes during the day and 3 to 4 times every night. In 1927, he had been operated for multiple vesical calculi by another surgeon. For 2 years following this cystotomy, he had been fairly comfortable. Fre_quency recurred and he was given bladder lavage by his family physician for several months. When first seen, the urine was grossly cloudy and co1:tained much pus. Cystoscopy disclosed multiple vesical calculi. Cystotomy was done on April 22 and 5 calculi removed. On May 23, the patient was seen at home because of an epididymitis which had been present for one week. This subsided with rest in bed, hot applications, etc. However, in July, the epididymis again became markedly swollen and tender and drainage was instituted July 20. A moderate amount of pus was obtained and within 10 days, the patient was apparently cured of his epididymitis. Two months later, the testicle suddenly became swollen and tender. Fluctuation was apparent and aspiration resulted in obtaining greenish purulent material. Orchidectomy was done in the usual manner. frior to orchidectomy, left vasectomy was done to obviate possible occurrence on this side. Pathological report. 3 S. P. No. 19,383. Gross description (fig. 1): Specimen consists of the testicle and epididymis forming a mass measuring approximately 10 x 5 x 5 cm. On section, a striking picture presents itself. There is a large abscess present in the testicle measuring approximately 5.5 cm. in long diameter. The abscess cavity is filled with greenish yellow viscid exudate, culture of which shows Staphylococcus aureus. On removing the exudate the abscess wall is seen to be irregular and there are strands of fixed tissue forming irregular septa in the cavity. There is only a small amount of testicular tissue recognizable at the periphery of the abscess. The epididymis is considerably thickened by edema, is grayish white with areas of yellow flecking. There is also considerable thickening of the tunica, the layers of which are firmly adherent 3
Pathological reports by Drs. B. S. Kline and A. M. Young.
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to each other. ::\1:icroscopic description: Section 1 (fig. 2) shows a portion of the abscess wall which is lined by a layer of granulation tissue made up of fibroblasts and young capillaries. The cavity is filled with polymorphonuclear
FIG. I. Abscess of testicle (grcss).
Surgical Path. No. 19383
FIG. 2 FIG. 3 FIG. 2. Low power. Abscess wall. Testis. S. P. No. 19383 FrG. 3. High power. Epididymis. S. P. :!'\o. 19383
cells and there is moderate infiltration of the wall by polymorphonuclears, plasma cells and endotheliocytes. Section 2 (fig. 3) shows a portion of the epididymis with tubules of average size and no spermatozoa present in the tubules. There is some edema of the
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stroma throughout with the tubules separated more widely than average. There is slight infiltration of the stroma throughout by round cells and a few polymorphonuclears. Case 6. A. P., colored, aged 28, was admitted to Mount Sinai Hospital April 20, 1934, complaining of a painful swelling of the left testicle of 7 days duration. This was of sudden onset and patient had had no recent treatment for any urinary tract infection. Temperature on admission was 103.2°. Patient had a specific urethritis 8 years ago. Family history and physical examination entirely negative except for marked swelling of the left epididymis. Epididymotomy was done on April 21 and the epididymis found to be almost entirely destroyed and much purulent material was obtained. A direct smear showed numerous Gram-negative bacilli and diplococci. There were also many Gram-positive cocci and diplococci and a few Gram-positive bacilli. Culture showed a slight growth of Staphylococcus aureus. Broth culture showed an abundant growth of B. coli and many Gram-positive and negative organisms which suggested intestinal bacteria. Patient was discharged on April 28, temperature normal and with slight drainage. Patient was re-admitted on May 6, 1934, with a history that the testicle has become larger and very painful on May 4. Temperature on admission was 101.8°. No urethral discharge was present either upon this or the previous admission although urinalysis disclosed numerous pus cells on both occasions. The testicle was markedly swollen and painful upon palpation and there was a draining sinus at the site of the former incision. Operation was performed on May 7, the testicle incised and much greenish yellow pus obtained. Practically the entire testicle was destroyed. Culture at this t.ime was the same as before. Subsequently, the remaining portion of the testicle sloughed out completely.
IV. An important cause for abscess of the testicle is the suppuration which occurs following torsion of the spermatic cord. Scudder (2) reported 32 such cases. Ombredanne (quoted by E. Olry (10)) operated a child of 6 weeks old with an abscess of the testicle of unknown origin. Torsion of the spermatic cord was suspected but not found at operation. Case 7. R. M., aged 18. Patient was colored and first seen March, 1932, complaining of swelling of the left testicle of 4 weeks duration. He was on the track team of one of the local high schools and while taking a high hurdle, suddenly experienced a sharp pain in the left testicle. He was advised to remain in bed for 2 weeks with scrotal support and the customary ice bag. Examination disclosed the left testicle to be moderately enlarged, slightly tender upon palpation but extremely hard and firm, so much so that it was impossible to differentiate the testicle from the epididymis. Malignancy was
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considered and operation advised. Orchidectomy was done on March 31. The epididymis was found to be densely adherent to the testicle .. · Biopsy was done but no evidence of malignancy found. In view of the general appearance of the mass, it was deemed advisable to perform orchidectomy.
FIG. 4. Necrosis of testis (gross).
S. P. No. 20,274
FIG. 5 FIG. 6 FIG. 5. High power. Necrosis of testicle FIG. 6. Varicocele with regional hemorrhage. S. P. No. 20,272
Pathological report. S. P. No. 20,274. Gross description (fig. 4): Specimen consists of the testicle and epididymis which together measure 4.5 x 4.5 x 3.5 cm. The epididymis is firmly adherent to the testicle, the tunica albuginea is considerably thickened, measuring approximately 3 mm. in width. On section portions of the testicle and 'epididymis show the normal architecture to be
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obliterated, the tissue here is friable, dark reddish brown, suggesting areas of necrosis and hemorrhage. Elsewhere, normal testicular tissue is still recognizable, the tubules strip with difficulty, however. The blood vessels of the rete appear dilated considerably. The portion of the spermatic cord present shows the veins dilated and tortuous with areas of regional hemorrhage. Microscopic description (fig. 5): Sections of the testicle and epididymis show the tissue in great part necrotic with only phantoms of tubules and intervening stroma remaining. The nuclei are for the most part unstained. There is no appreciable infiltration by wandering cells. There is considerable hemorrhage throughout, the red cells being laked. One section (fig. 6) shows a portion of a variococele with the blood vessels dilated and tortuous and with considerable hemorrhage into the regional stroma. The capsule which is intact with well stained nuclei is considerably thickened and shows considerable infiltration throughout by fibroblasts and round cells. Sections of the spermatic cord and regional voluntary muscle show considerable scarring and round cell infiltration of stroma. SUMMARY
1. Six cases of abscess of the testicle and 1 case of necrosis of the testicle are reported. Four testicular abscesses were associated with gonorrhea and a complicating epididymitis; 2 cases were due to chronic urinary tract infection with non-specific epididymitis, and 1 case of necrosis of the testicle probably due to torsion of the spermatic cord following violent muscular effort. 2. Abscess of the testicle can be traced directly, in almost every instance, to some infection either in the urinary or genital tracts, excluding testicular abscess associated with typhoid fever, influenza, cellulitis, osteomyelitis, etc. In the latter, involvement of the testicle is probably hematogenous in origin. 3. Generally, four types of abscess of the testicle occur: a. Associated with gonorrhea and a complicating epididymitis. This type of abscess is usually small in size and the testicle generally sloughs out in its entirety. b. Associated with chronic infection of the urinary tract or the genital tract. This type occurs in such conditions as prostatic obstruction, where catheter drainage has been instituted, urethral instrumentation employed, etc. This type of abscess is usually large and causes complete destruction of the testicle, as noted in Barney's case and case 5 reported by the author.
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c. Associated with torsion of the spermatic cord. d. Associated with systemic infections such as typhoid fever, variola,
influenza, cellulitis, etc. This is usually a true orchitis and rarely leads to suppuration. When testicular abscesses occur here, they are probably due to phlebitis of the spermatic vessels. e. Abscess of the testicle associated with tuberculosis or malignancy is not considered. 4. Abscess of the testicle usually results in complete destruction of the organ, whether or not drainage be instituted. Early diagnosis 1s important in order to conserve as much testicular tissue as possible. 1558 Hanna Building, Cleveland, Ohio. REFERENCES (1) BARNEY, J . D. : Abscess of the testicle. Surg., Gynec. and Obst., March, 1914, xviii, 307. (2) SCUDDER: Ann. Surg., 1901. (3) DALOus : Ann. des mal org. Genito-Urinaires, 1905. (4) NASH, W . G. : Brit. Med. Jour., February 2, 1918, 149- 150. (5) DURNIN, G. A.: Lancet, 1923, xliii, 624-5. (6) SOLOMON, 0 .: Munch. med. Wschr., January 3, 1930, lxxvii, 18- 19. (7) CAULK, J. R .: Trans. Amer. Assoc. Genito-Urin. Surg., 1927, xx, 333- 347. (8) GRON, FREDRIK AND TuJOTTA: Norsk Mag. f. Laegevidensk., Oslo, 1925, lxxxvi, 33-40. (9) LANGER, E.: Munch. med. Wschr., 1929, lxxvi, 2051, 2053, (10) OLRY, E. : Arch. de med. d. enf., 1926, xxix, 329-340. (11) SALUTSKY, H .: Arch. f. Dermat. u . Syph. Berl., 1926, cl, 300-303. (12) FLEISCHMAN, A. G.: Jour. Ural., 1933, xxix, 4, 413-423. (13) LANDIFER, R.: J . de Chir., August, 1931, 436.
Abscess of the testicle, although not a rarity, is infrequently reported in the literature. It occurs as a result of many causative factors and is observed as a complication in a variety of conditions: (1) Orchitis associated with certain systemic infections, such as typhoid fever, influenza, variola, parotitis, scarlet fever, chicken pox, osteomyelitis, etc. These are undoubtedly hematogenous in character. (2) Abscess of the testicle associated with epididymitis and gonorrheal urethritis. (3) Abscess of the testicle associated with chronic urinary tract infection. (4) Abscess of the testicle associated with torsion of the spermatic cord. Many writers stress particularly, as sources of testicular abscess, the seminal ducts, the vas deferens, and the epididymis. Others ascribe an important place to the lymphatics. After a careful histological examination, Dalous (3) concluded that the process in a great measure extends along the natural channels, the vas deferens and the epididymis, but that the lymphatics play an important role. Generally, a small abscess having formed in the testicle, it may become encysted and undergo caseous degeneration. It may spread beneath the tunica albuginea, involve the entire testicle and cause complete sloughing. Again, the abscess may rupture into the tunica vaginalis, which usually contains some · free fluid, causing suppuration of this sac and eventually pointing externally, or, the abscess may reach the surface without rupturing into the cavity of the tunica vaginalis. Fortunately, abscess of the testicle is probably not so common due to the fact that it is so well protected from bacterial invasion by its rich vascular and lymphatic supply, as well as the tunica albuginea. Due to the firmness of the tunica albuginea, most testicular abscesses do not increase the size of the testicle to any considerable extent. I. Suppurative conditions of the testicle are infrequent in typhoid fever, parotitis, scarlet fever, etc., although orchitis occurs in about 0.2 per cent of the cases of typhoid fever and one-fourth of these go on to abscess formation. Durnin (5) reports a case of bilateral abscess of the testicles due to Bacillus typhosus with trauma as a predisposing factor. 1
Received for publication February 15, 1935.
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His patient sustained an injury to the left testicle while climbing over a wire fence. Immediate pain and swelling occurred. For one month he consulted no physician. With acute swelling of the right side, a physician was called in and conservative treatment instituted. Two months after the injury, the testicles were greatly swollen and there was a moderate amount of free fluid in each tunica vaginalis and considerable swelling of the testicles and epididymes. The urine in this case showed pus cells and bacteria. Operation revealed abscesses involving both testicles, no growth being obtained from one side and the Bacillus typhosus from the other. It is interesting to note that this patient never presented symptoms of typh~id fever but was known to have used drinking water from a well which later was found to be a source of typhoid fever. The Bacillus typhosus was also found in the urine. Landifer (13) reports a case of multiple abscesses of both testicle and epididymis, due to the pneumococcus. His patient developed sudden pain in the region of the right scapula. Two weeks later, incision revealed much pus from which the pneumococcus was cultured. One month after the onset of his illness, there was marked swelling of the left testicle and epididymis. At operation, both testicle and epididymis were found to be riddled with pneumococcic abscesses. II. Abscess of the testicle is a comparatively rare termination of gonorrheal epididymitis although it has been maintained by Ricord, Kocher and others, that gonorrheal involvement of the testicles is more frequent than is supposed. Fournier and Kocher state that abscess of the testicle may occur without demonstrable participation of the epididymis. They hold that the parenchyma is first involved, the process then spreads to the adjoining connective tissue and finally spreads to the tunica albuginea. Ricord, on the contrary, believes that orchitis can develop only in those cases in which the epididymis is primarily involved. It is the belief of Langer (9) that in a comparatively large percentage of cases of gonorrheal epididymitis, there is concomitant involvement of the tunica vaginalis and that the parenchyma of the testis is secondarily involved. Generally, no abscess results in the testicle proper except in a few cases where the process does not recede but continues to advance until partial or total necrosis and abscess formation results. According to Christeller and Jacoby, the etiological connection and the mechanism of the genesis of such abscess formation has never yet been clearly determined on the basis of the published cases. Mulzer believes that such cases of gangrene of the testicles may develop in connection with acute
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or chronic gonorrhea and he distinguishes two classes, the benign type in which simple gangrene of the testis occl,lrs, and the malignant type in which there may be abscesses with perforation into the cavity of the testis towards the outside. In one case described by Buschke and in two reported by Mulzer, there was acute necrosis of the testicle with suppuration so severe that the entire testicle was destroyed and orchidectomy resorted to. All three of these cases developed in the course of a specific urethritis. Neither of these authors could determine gonococci in the pus, either culturally or histologically, so that the affection was designated by Mulzer as a "secondary complication" of gonorrhea. Metarasso, however, did find gonococci in the greenish-yellow pus in a testicular abscess in a boy aged 14, suffering with an acute gonorrhea. Delling also reports a case in which, 2 months after his patient had been operated upon for abscess of the testicle, gonococci were found in the pus which drained from the fistula. Langer (9) reported 3 cases of abscess of the testicle associated with gonorrhea. Gonococci could not be demonstrated in the pus obtained at operation. He made particular note of the fact that all 3 cases were associated with funiculitis and advanced the theory that severe edema of the spermatic cord exerts such severe pressure on the blood vessels that the blood supply of the testicle is disturbed, thus creating excellent soil for bacterial growth. Buschke states that it is his belief that the funiculitis causes thrombosis of the blood vessels with resultant necrosis of the testicle. Solomon (6) reported a case of abscess of the testicle due to gonorrhea but which followed trauma superimposed on a receding epididymitis. His patient was a very famous football player who insisted on playing while suffering from an acute posterior urethritis. It is interesting to note that gonococci were easily demonstrated in the pus evacuated at operation. This case, together with those reported by Metarasso and Delling, are the only ones reported in the literature where gonococci were found in a testicular abscess. Salutsky (11) reported 2 cases of abscess of the testicle, the first being associated with gonorrhea and the second following massage for chronic prostatitis. Fleischman (12) reports an unusual case of suppuration of the testicle occurring as a result of gonorrhea. In his case, multiple abscesses were present and there was a spontaneous separation of the testicle from its vascular supply.
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Case 1. J. L., aged 26, admitted to Mt. Sinai Hospital October 17, 1922, complaining of swelling of the right testicle of 3 days duration. He had had an acute specific urethritis for which he had been under treatment for 2 weeks prior to admission. Epididymotomy was done on the following day in the usual manner. The patient was discharged from the hospital on November 7, apparently in good condition. He was re-admitted on January 22, 1923, complaining of marked atrophy of the testicle. He stated that shortly after being discharged from the hospital, there appeared a discharge of purulent material in the line of incision of the epididymotomy. He had not reported for treatment following drainage of the epididymis. Orchidectomy was done on January 23. The testicle was markedly necrotic and measured 4 x 2.5 cm. Section showed a great deal of purulent material and microscopically no tubules were demonstrable. Case 2. I. C., aged 20, admitted to the hospital August 27, 1931, complaining of pain in the left testicle. The patient had been treated for acute gonorrhea for the previous 3 weeks and the epididymitis occurred several days prior to admission. Epididymotomy was performed on August 28 and the patient discharged September 2, temperature normal and apparently in good condition. On September 7, the epididymis was slightly tender on palpation and some tenderness was noted over the body of the testicle proper. There was a moderate amount of drainage from the epididymotomy incision. It was noted during the next several weeks that there was considerable sloughing of purulent testicular tissue and within about 6 weeks the sinus closed and the entire testicle had sloughed away. This patient was again seen during January, 1933, at which time there was no testicle palpable. The epididymis could be felt as a small, fi.brotic structure. Case 3.2 J. F. 0., aged 26, admitted to the hospital November 4, 1932, with a history of having been treated for gonorrhea since July, 1932. Both urines had been clear for some time when patient failed to continue treatment. He returned November 2, complaining of pain in the left testicle and presented symptoms of acute urethritis. Epididymotomy was done on November 5, in the usual manner. The patient was discharged from the hospital on Nov,ember 15 without the usual recovery. There was some tenderness still present, a moderate degree of swelling but the temperature was normal. On November 26, :fluctuation was noted on the anterior scrotal surface. Incision and drainage disclosed a great deal of pus and testicular slough. Subsequently, the entire testicle sloughed away and the epididymis could be palpated as a small indurated mass. 2
Case 3-Courtesy of Dr. P. A. Jacobs.
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Case 4. L. C., aged 24, was first seen July 27, 1934, with a specific urethritis. There was nothing of note in the progress of his infection until September 10, when patient appeared with profuse hematuria following exposure. On September 29, patient developed right epididymitis for which operation was refused at the time. Epididymotomy was performed in the usual manner on October 4. Subseq~ently, the urethritis cleared up, but on October 19, there was marked edema of the penis. The following day, the right testicle became markedly swollen and incision and drainage were done on October 23. Half of the testicle was necrotic and sloughed away, leaving some testicular tissue present.
III. In 1914, Barney (1) presented a paper dealing with abscess of the testicle and called attention to a very rare type of abscess in which no associated inflammatory condition could be determined. He concluded that the infection in the testicle was hematogenous since there was no demonstrable lesion in the urinary or genital tracts. The abscess which he studied was in the lower pole of the testicle, and the epididymis appeared to be free from pathological change. Analysis of his case, however, shows conclusively that there must have been some infection either in the prostate or the seminal vesicles. It is doubtful if abscess of the testicle can develop without involvement of the urinary or genital tracts. According to Barney, no associated inflammatory condition could be demonstrated in his case. The urine was clear and sparkling . on admission and he assumed that the abscess was the result of a hematogenous infection. Caulk (7) also found abscesses of the testicles in which the patient's urine was perfectly clear. However, his patients had been treated for prostatitis and vesiculitis. The fact that Barney's case promptly developed a urethral discharge and pyuria following orchidectomy would tend to prove that there must have been an infection in the genital tract although not demonstrable at the time of examination. It is not at all uncommon to find clear urine in involvement of the genital tract and epididymitis is not an unusual occurrence following treatment of this condition. Caulk (7) reported 15 cases of testicular abscess in which 13 showed urogenital infections and two resul,t ed from surgical injury with consequent interference with the circulation. In the 3 cases of orchidectomy which were performed in this series, 2 showed changes in the epididymes, the other marked perivascular involvement at the site of the lymphatics and clinically epididymitis was present in 13 of the 15 cases. Gron, Fredrik and Thjotta describe a case of purulent orchitis and
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epididymitis in a man aged 44. This patient became acutely ill with painful micturition and severe pain in the scrotum with marked swelling of the testicle. Ultimately, the entire testicle and epididymis were destroyed. B. coli communis was found in pure culture. This patient had a long-standing history of "spermatocystitis." Nash (4)~irported 2 cases of abscess of the testicle due to the colon bacillus. Ifoth' were associated with pyuria and epididymitis. He assumed that involvement of the testicle occurred by way of the vas deferens. Bonrier cites a case of testicular abscess following heavy muscular effort: his patient, however, also had evidence of chronic infection of the urinary tract. Case 5. H. I., aged 55, first seen April, 1931, complaining of frequency and nocturia, voiding every 15 to 30 minutes during the day and 3 to 4 times every night. In 1927, he had been operated for multiple vesical calculi by another surgeon. For 2 years following this cystotomy, he had been fairly comfortable. Fre_quency recurred and he was given bladder lavage by his family physician for several months. When first seen, the urine was grossly cloudy and co1:tained much pus. Cystoscopy disclosed multiple vesical calculi. Cystotomy was done on April 22 and 5 calculi removed. On May 23, the patient was seen at home because of an epididymitis which had been present for one week. This subsided with rest in bed, hot applications, etc. However, in July, the epididymis again became markedly swollen and tender and drainage was instituted July 20. A moderate amount of pus was obtained and within 10 days, the patient was apparently cured of his epididymitis. Two months later, the testicle suddenly became swollen and tender. Fluctuation was apparent and aspiration resulted in obtaining greenish purulent material. Orchidectomy was done in the usual manner. frior to orchidectomy, left vasectomy was done to obviate possible occurrence on this side. Pathological report. 3 S. P. No. 19,383. Gross description (fig. 1): Specimen consists of the testicle and epididymis forming a mass measuring approximately 10 x 5 x 5 cm. On section, a striking picture presents itself. There is a large abscess present in the testicle measuring approximately 5.5 cm. in long diameter. The abscess cavity is filled with greenish yellow viscid exudate, culture of which shows Staphylococcus aureus. On removing the exudate the abscess wall is seen to be irregular and there are strands of fixed tissue forming irregular septa in the cavity. There is only a small amount of testicular tissue recognizable at the periphery of the abscess. The epididymis is considerably thickened by edema, is grayish white with areas of yellow flecking. There is also considerable thickening of the tunica, the layers of which are firmly adherent 3
Pathological reports by Drs. B. S. Kline and A. M. Young.
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WILLIAM ROSENBERG
to each other. ::\1:icroscopic description: Section 1 (fig. 2) shows a portion of the abscess wall which is lined by a layer of granulation tissue made up of fibroblasts and young capillaries. The cavity is filled with polymorphonuclear
FIG. I. Abscess of testicle (grcss).
Surgical Path. No. 19383
FIG. 2 FIG. 3 FIG. 2. Low power. Abscess wall. Testis. S. P. No. 19383 FrG. 3. High power. Epididymis. S. P. :!'\o. 19383
cells and there is moderate infiltration of the wall by polymorphonuclears, plasma cells and endotheliocytes. Section 2 (fig. 3) shows a portion of the epididymis with tubules of average size and no spermatozoa present in the tubules. There is some edema of the
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stroma throughout with the tubules separated more widely than average. There is slight infiltration of the stroma throughout by round cells and a few polymorphonuclears. Case 6. A. P., colored, aged 28, was admitted to Mount Sinai Hospital April 20, 1934, complaining of a painful swelling of the left testicle of 7 days duration. This was of sudden onset and patient had had no recent treatment for any urinary tract infection. Temperature on admission was 103.2°. Patient had a specific urethritis 8 years ago. Family history and physical examination entirely negative except for marked swelling of the left epididymis. Epididymotomy was done on April 21 and the epididymis found to be almost entirely destroyed and much purulent material was obtained. A direct smear showed numerous Gram-negative bacilli and diplococci. There were also many Gram-positive cocci and diplococci and a few Gram-positive bacilli. Culture showed a slight growth of Staphylococcus aureus. Broth culture showed an abundant growth of B. coli and many Gram-positive and negative organisms which suggested intestinal bacteria. Patient was discharged on April 28, temperature normal and with slight drainage. Patient was re-admitted on May 6, 1934, with a history that the testicle has become larger and very painful on May 4. Temperature on admission was 101.8°. No urethral discharge was present either upon this or the previous admission although urinalysis disclosed numerous pus cells on both occasions. The testicle was markedly swollen and painful upon palpation and there was a draining sinus at the site of the former incision. Operation was performed on May 7, the testicle incised and much greenish yellow pus obtained. Practically the entire testicle was destroyed. Culture at this t.ime was the same as before. Subsequently, the remaining portion of the testicle sloughed out completely.
IV. An important cause for abscess of the testicle is the suppuration which occurs following torsion of the spermatic cord. Scudder (2) reported 32 such cases. Ombredanne (quoted by E. Olry (10)) operated a child of 6 weeks old with an abscess of the testicle of unknown origin. Torsion of the spermatic cord was suspected but not found at operation. Case 7. R. M., aged 18. Patient was colored and first seen March, 1932, complaining of swelling of the left testicle of 4 weeks duration. He was on the track team of one of the local high schools and while taking a high hurdle, suddenly experienced a sharp pain in the left testicle. He was advised to remain in bed for 2 weeks with scrotal support and the customary ice bag. Examination disclosed the left testicle to be moderately enlarged, slightly tender upon palpation but extremely hard and firm, so much so that it was impossible to differentiate the testicle from the epididymis. Malignancy was
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WILLIAM ROSENBERG
considered and operation advised. Orchidectomy was done on March 31. The epididymis was found to be densely adherent to the testicle .. · Biopsy was done but no evidence of malignancy found. In view of the general appearance of the mass, it was deemed advisable to perform orchidectomy.
FIG. 4. Necrosis of testis (gross).
S. P. No. 20,274
FIG. 5 FIG. 6 FIG. 5. High power. Necrosis of testicle FIG. 6. Varicocele with regional hemorrhage. S. P. No. 20,272
Pathological report. S. P. No. 20,274. Gross description (fig. 4): Specimen consists of the testicle and epididymis which together measure 4.5 x 4.5 x 3.5 cm. The epididymis is firmly adherent to the testicle, the tunica albuginea is considerably thickened, measuring approximately 3 mm. in width. On section portions of the testicle and 'epididymis show the normal architecture to be
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obliterated, the tissue here is friable, dark reddish brown, suggesting areas of necrosis and hemorrhage. Elsewhere, normal testicular tissue is still recognizable, the tubules strip with difficulty, however. The blood vessels of the rete appear dilated considerably. The portion of the spermatic cord present shows the veins dilated and tortuous with areas of regional hemorrhage. Microscopic description (fig. 5): Sections of the testicle and epididymis show the tissue in great part necrotic with only phantoms of tubules and intervening stroma remaining. The nuclei are for the most part unstained. There is no appreciable infiltration by wandering cells. There is considerable hemorrhage throughout, the red cells being laked. One section (fig. 6) shows a portion of a variococele with the blood vessels dilated and tortuous and with considerable hemorrhage into the regional stroma. The capsule which is intact with well stained nuclei is considerably thickened and shows considerable infiltration throughout by fibroblasts and round cells. Sections of the spermatic cord and regional voluntary muscle show considerable scarring and round cell infiltration of stroma. SUMMARY
1. Six cases of abscess of the testicle and 1 case of necrosis of the testicle are reported. Four testicular abscesses were associated with gonorrhea and a complicating epididymitis; 2 cases were due to chronic urinary tract infection with non-specific epididymitis, and 1 case of necrosis of the testicle probably due to torsion of the spermatic cord following violent muscular effort. 2. Abscess of the testicle can be traced directly, in almost every instance, to some infection either in the urinary or genital tracts, excluding testicular abscess associated with typhoid fever, influenza, cellulitis, osteomyelitis, etc. In the latter, involvement of the testicle is probably hematogenous in origin. 3. Generally, four types of abscess of the testicle occur: a. Associated with gonorrhea and a complicating epididymitis. This type of abscess is usually small in size and the testicle generally sloughs out in its entirety. b. Associated with chronic infection of the urinary tract or the genital tract. This type occurs in such conditions as prostatic obstruction, where catheter drainage has been instituted, urethral instrumentation employed, etc. This type of abscess is usually large and causes complete destruction of the testicle, as noted in Barney's case and case 5 reported by the author.
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WILLIAM ROSENBERG
c. Associated with torsion of the spermatic cord. d. Associated with systemic infections such as typhoid fever, variola,
influenza, cellulitis, etc. This is usually a true orchitis and rarely leads to suppuration. When testicular abscesses occur here, they are probably due to phlebitis of the spermatic vessels. e. Abscess of the testicle associated with tuberculosis or malignancy is not considered. 4. Abscess of the testicle usually results in complete destruction of the organ, whether or not drainage be instituted. Early diagnosis 1s important in order to conserve as much testicular tissue as possible. 1558 Hanna Building, Cleveland, Ohio. REFERENCES (1) BARNEY, J . D. : Abscess of the testicle. Surg., Gynec. and Obst., March, 1914, xviii, 307. (2) SCUDDER: Ann. Surg., 1901. (3) DALOus : Ann. des mal org. Genito-Urinaires, 1905. (4) NASH, W . G. : Brit. Med. Jour., February 2, 1918, 149- 150. (5) DURNIN, G. A.: Lancet, 1923, xliii, 624-5. (6) SOLOMON, 0 .: Munch. med. Wschr., January 3, 1930, lxxvii, 18- 19. (7) CAULK, J. R .: Trans. Amer. Assoc. Genito-Urin. Surg., 1927, xx, 333- 347. (8) GRON, FREDRIK AND TuJOTTA: Norsk Mag. f. Laegevidensk., Oslo, 1925, lxxxvi, 33-40. (9) LANGER, E.: Munch. med. Wschr., 1929, lxxvi, 2051, 2053, (10) OLRY, E. : Arch. de med. d. enf., 1926, xxix, 329-340. (11) SALUTSKY, H .: Arch. f. Dermat. u . Syph. Berl., 1926, cl, 300-303. (12) FLEISCHMAN, A. G.: Jour. Ural., 1933, xxix, 4, 413-423. (13) LANDIFER, R.: J . de Chir., August, 1931, 436.