Mumps Orchitis: Surgical Treatment

MUMPS ORCHITIS: SURGICAL TREATMENT NORMAN NIXON, MAJOR, MC, AKD DONALD B. LEWIS, CAPT. MC

From the A.AF Regional Hospital, Santa Ana Army Air Base, California

Mumps is an important disease from the standpoint of military medicine because of the difficulty in controlling its spread and because of the large number of man-days lost by soldiers with this ailment. Once mumps becomes established in epidemic proportions during late fall, it is likely to persist in a military establishment throughout the ',rinter and spring months. So far in World War II, the incidence has been some,Yhat lower 11 among American troops than it ·was during ,;y orld VV ar I when it ,ms exceeded only by influenza and venereal disease as a cause for the loss of man-days1.1 2 However, the incidence of complications in patients \Yith mumps has remained the same. 6 Epididymo-orchitis, especially, is responsible for long periods of hospitalization. Important to the patient is the possibility of atrophy of the involved testicle with subsequent sterility and impotence. Most authors have reported an incidence of testicular atrophy between 40 and 60 per cent.1.1° The term atrophy is loosely used, however, and usually includes patients with only a slight softening of the testis as well as those in ,Yhom the organ is markedly reduced in size. Even in patients (usually 1 in 4) in whom both testicles are involved, bilateral atrophy does not mean necessarily the loss of procreative powers. While sterility is a possibility, pathologic studies in some reported cases 13 have revealed that sufficient normal testicular tissue remains to prevent aspermia. Mild degrees of testicular atrophy may produce sufficient psychologic trauma to cause diminution of sexual power in some patients, resulting in maladjustment and unhappiness. SYMPTOMS AND SIGNS OF MUMPS ORCHITIS

Orchitis usually occurs before the complete subsidence of mumps parotitis. In rare instances it may precede the parotitis by a number of days 16 and in other cases may be the only manifestation of mumps. 8 Occasionally orchitis will occur 3 to 6 weeks after the onset of parotid swelling. The patient's temperature curve is helpful in diagnosis, both in the early stage 1 Ballenger, E.G., and Elder, 0. F.: Orchitis from mumps; need of conserving testes by incision of the tunica albuginea. J. A. M.A., 75: 1257, 1920. 2 Barenberg, L. H. and Ostroff, J.: Use of human blood in protection against mumps. Am. J. Dis. Child., 42: 1109-1113, 1931. 3 Bieberbach, W. D. and Vibber, F.: Orchitis due to mumps without involvement of parotid glands. J. A. M.A., 100: 1092-1093, 1933. 4 Dukes, C.: The orchitis of mumps. Lancet, 1: 25, 1900. 5 Macleod,G.: Mumpsinadults. Brit.M.J.,2: 742,1919. 6 McGuinness, A. C. and Gall, E. A.: Mumps at Army camps in 1943. War Med. 5: 95104, 1944. 7 Regan, J.C.: Serum prophylaxis of epidemic parotitis. J. A. M.A., 84: 279-280, 1925. 8 Robinson, W. J.: Prostatic atrophy and mumps. Med. Rec., 187: 404, 1915. 9 Schottmuller, H.: Parotitis Epidemica. In H. K othnagel's Specielle Pathologie and Therapie. vol. 3, pt. 2, sec. 3 Vienna, Alfred Holder, 1904, p. 49. 10 Servier, M.: Rec. de mem. de med. de cher et de pharm. milit., 34: 529, 1878. 554

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555

and in the subsequent course of testicular involvement. The temperature usually rises shortly before the patient begins to complain of testicular tenderness. As swelling occurs, the fever goes higher, sometimes to 105° F., and the patient complains of chilliness, backache, malaise, nausea, and vomiting. The testicle becomes hard, smooth, exquisitely tender, and remains so for at least 4 or 5 days. The fever then drops by lysis, and swelling subsides, the usual course of the orchitis taking about 10 days. In some patients, especially those in whom orchitis develops more than 14 days after the onset of parotitis, there are few general symptoms. PATHOLOGY

The mumps virus produces edema in the glandular tissue which it invades. In the testicle the firm, fibrous tunica albuginea offers resistance to the swelling. In fulminating cas~s the testicle becomes hard and markedly enlarged owing to accumulation of hydrocele fluid between the tunica vaginalis and the tunica albuginea. This rE]sults in pressure necrosis of the seminiferous tubules, with subsequent partial atrophy of the testicles. The shift in the blood picture from leukopenia and lymphocytosis to polymorphonuclear leukocytosis is further evidence of pressure necrosis. This change is rarely seen in parotitis or any other complication of mumps. Except for the prostate, which may show atrophy in some instances, the testicle is the only gland in which mumps will cause atrophy. 2 II

TREATMENT

Prophylaxis. Convalescent serum, when administered to contacts shortly .after exposure, is of value in the prevention of mumps, 5• 7• 18 but is ineffective when used to prevent orchitis in a patient with parotitis. Although some observers believe 3•4•14 that physical activity does not increase the incidence of mumps orchitis, rest in bed is usually advocated 8•15 for the duration of parotid swelling. This may be supplemented by use of a suspensory for the testes during the acute stage to avoid trauma, a possible predisposing factor to the development of orchitis. Medical. The medical treatment of orchitis is symptomatic. Convalescent serum, hot and cold applications, and drugs are useless. Surgical. The first report of successful treatment of mumps orchitis by Simmons, J. S.: Present state of the Army's health. J. A. M.A., 122: 916-923, 1943. Sinclair, C. G.: Mumps: epidemiology and influence of the disease on non-effective-rate in the Army. Mil. Surg., 50: 626-647, 1922. 1 a Smith, G. G.: Two cases of orchitis due to mumps treated by operation. Boston M. & s. J., 167: 323, 1912. . . . . 14 Smith, H.: On treatment of acute orch1t1s by puncturrng the testicle. Lancet, 2: 149, 1864. 1s U.S. War Dept.: Medical Dept. of U.S. Army in the World War. Washington, Government Printing Office, 1928, Vol. IX, Communicable and Other Diseases. Chap. VIII, Mumps. 16 Wesselhoeft, C.: Orchitis in mumps. Boston M. & S. J., 183: 425,458,491,520, 1920. 11 Wesselhoeft, C. and Vose, S. N.: Surgical treatment of severe orchitis in mumps. N. Eng. J. Med., 227: 277-280, 1942. 1s Zeligs, M.: Convalescent serum in prevention of mumps. J. Pediat., 1: 727-728, 1932. 11

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NORMAN NIXON AND DONALD B. LEWIS

surgery was by Henry Smith, who, in 1864, advised multiple punctures of the tunica albuginea.1 4 In 1904, Schottmuller recommended incision through the tunica vaginalis to release the hydrocele fluid. 9 In 1912, George Smith cited 2 cases treated by incision through the tunica vaginalis followed by multiple small incisions through the tunica albuginea.1 3 Ballenger and Elder, in 1920, recommended an H-shaped incision in the tunica albuginea. 1 Recently Wesselhoeft and Vose reported 10 patients with severe orchitis who were treated successfully by a similar method17 These authors concurred in the opinion that such surgical procedures released the pressure due to edema, thereby causing rapid subsidence of the acute symptoms and preventing necrosis and atrophy of the testicle.

Fm. 1. Two centimeter incision through skin and subcutaneous tissue of scrotum PATIENTS TREATED AT SANTA ARMY AIR BASE

Since the fall of 1942, the Urologic Section has treated by surgery all patients who have had severe orchitis as a complication of mumps. Of 339 soldiers with mumps, 101 (nearly 30 per cent) developed orchitis. In 68 of these patients (nearly 67 per cent) the orchitis was of sufficient severity to warrant surgery. The preoperative temperatures in this series of 68 cases ranged between 102° F. and 106°F., rising abruptly in most instances with the onset of orchitis. The remaining 33 were treated conservatively inasmuch as there was minimum fever, pain, tenderness, and swelling. The surgical technique advocated by "\Vesselhoeft and Vose was used in the first 2 cases. The patients were relieved of their pain and general symptoms promptly, and their temperature curves returned to normal within 48 hours, but it was decided that the incision of the tunica albuginea was too radical a procedure to be done routinely and that the simple drainage of the hydrocele fluid might give equally satisfactory results. Consequently this plan was followed in treatment of the remaining 66 patients.

MUMPS ORCHITIS

557

The technique of the operation is simple. After 2 per cent procaine infiltration, a small incision, approximately 2 cm. long, is made over the anterior surface of the scrotum on the involved side. The incision is carried through the skin

Ji'IG,, 2 . . . . Then tunica vaginalis is exposed, grasped with Allis clamps, incised .. _ .

Fm. 3 .. , . A"small Penrose drain inserted beneath tunica vaginalis, wound closed

and subcutaneous tissues until the tunica vaginalis is exposed. 11 his is grasped by two Allis clamps and incised (figs. 1 and 2). Usually the hydrocele fluid drains out under considerable pressure. A small Penrose drain is inserted beneath the tunica vaginalis, and the wound is closed (fig. 3).

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After operation most patients reported immediate alleviation of extreme paill and discomfort. Others showed improvement within 2 to 4 hours, with relief not only from pain but from headache, nausea, and vomiting as well. 'Within 24 hours the local swelling was considerably reduced and the testicle could be palpated with little discomfort to the patient. Drainage was maintained for at least 24 hours during which time the dressings, and sometimes the beclclothe8, were soaked. Temperature returned to normal in an average of 2.1 days. Predominantl~·, a significant drop in temperature occurred ·within 12 hours following operation. Normal temperatures occurred as early as 24 hours (fig. 4) and as late as 5 days after orchidotomy was performed (fig. 5). In the latter patient, orchitis had been present for several days prior to admission. Surgery was delayed because of absence of fever on entry and the belief that the period had passed during which optimum results could be expeded from surgical drainage. Orchidotomy, performed on the fifth hospital day, did not produce the usual dramatic drop in temperature or relief from pain and other symptoms. In figure G are recorded the temperature and pulse of a patient with bilateral mumps orchitis. Three days after right orchidotomy this soldier developed fever and left orchitis. Satisfactory response to surgery occurred after left orchidotomy was done. Because of troop movements and changes of station during the course of the cadet training program it ,ms difficult to follmv these patients as accurately as should have been done to evaluate the results following surgery. Reports lmve b0en received covering follmY-up examinations of 27 of the 68 patients, made at irregular intervals ranging from 3 months to 2 years following surgery. Of the 27 patients reported, 2G revealed no evidem:e of testicular atrophy other than u slight degree of softening of the testicle in comparison ,Yith the firmness of its fellow. One showed definite atrophy of the involved testis G months following surgery. He had been operated on late in the course of his orchitis, and the testicle at the time of operation was found to be densely adherent to the tunic:, vaginalis. COM'\!IEN'f

The cause of testicular atrophy in mumps orchitis is undoubtedly pressure necrosis. The mechanism by which this increase in pressure develops is stilI not clear. It is believed that adhesions which form between the tunica albuginea and the tunica vaginalis tend to limit the expansion of the edematous testicular tissue. At first it ,ms thought that release of the pressure created by hydrocele fluid was mainly resp011sihle for the favorable reaction. However, seYeral patients in "·horn Yery little fluid was found in the hydrocele sac responded to drainage as did the others. Another patient had had excision of the tunica vaginalis for hydrocele some years prior to the development of mumps orchitis. He responded well after adhesions were freed and the ,rnund drained. '\'Vhcn the operation was performed la.te in the rourse of orchitis the testicle ,ms rather densely adherent to the tunica vaginahs. In these patients the usual s:rntemic response occurred more slmdy.

560

NORMAN NIXON AND DONALD B. LEWIS SUMMARY

Early surgical treatment of mumps orchitis is of value in promptly relieving pain, nausea, vomiting, backache, and fever, shortening the period of disability, and preventing subsequent atrophy of the involved testicle. vYithout operation the acute symptoms of mumps orchitis will disappear more gradually, requiring 3 to 4 additional days of hospitalization, and testicular atrophy will result in 40 to 60 per cent of the cases. Observations in this series suggest that the atrophy is not caused alone by the inflammation of the parenchyma and the resistance offered by the firm tunica albuginea but that the tunica vaginalis is also involved in the development of increased pressure with resulting necrosis. It is believed that early drainage of the hydrocele fluid is necessary to avoid subsequent atrophy of the testis and that early incision of the tunica vaginalis is sufficient to insure optimum results.

123 S. Stone Ave., Tucson, Ariz. (D. B. L.)