Chapter 51

### Manifestations of Testicular Disease

#### Infertility

Either the male, the female, or both partners may be responsible for infertility, which is defined as the failure to conceive after 1 year of regular coitus without contraception. Male infertility, usually recognized by absence of spermatozoa (azoospermia) or decreased numbers of spermatozoa in semen (oligospermia), may result from one of three categories of disease:

##### Pretesticular Causes

These consist of endocrine disorders—most commonly hypopituitarism—in which failure of production of gonadotropins leads to testicular failure. These diseases are recognized by decreased pituitary gonadotropin levels in serum.

##### Posttesticular Causes

The most common mechanism is obstruction to the outflow of spermatozoa. Bilateral obstruction results in azoospermia. Obstructive infertility is responsible for up to 50% of cases of infertility and may be corrected surgically. The diagnosis is established by vasograms, in which dye is introduced into the duct system for radiographic visualization, and by testicular biopsy, which shows normal spermatogenesis.

##### Testicular Causes

Most of these conditions are untreatable and include any disorder associated with testicular atrophy (Table 51-1) plus either of the following specific abnormalities identifiable on testicular biopsies: (1) germ cell aplasia, in which there is a total absence of spermatocytes and the seminiferous tubules are lined entirely by Sertoli cells (also called “Sertoli cell only” syndrome); and (2) spermatocytic maturation arrest.

Table 51–1. Causes of Atrophy of the Testes.

#### Testicular Masses or Enlargement

The presence of masses or enlargement of the testis represents the most common symptom of testicular disease. In general, acute inflammatory lesions are painful; chronic inflammatory lesions and neoplasms are usually painless. Scrotal swelling (Figure 51-1) should be carefully examined for evidence of an enlarged testis, and any patient with a testicular mass should be considered to have a neoplasm until proved otherwise.

###### Figure 51–1.

Principal causes of scrotal swelling, including testicular mass lesions.

#### Abnormal Production of Hormones

Hormones from functional testicular stromal tumors may produce precocious puberty in the child (androgens) or gynecomastia (estrogens).

### Assessment of Testicular Dysfunction

Physical examination should be supplemented when necessary by ultrasonography and computerized tomography in the evaluation of testicular mass lesions. Testicular biopsy is useful in the diagnosis of mass lesions and in determining whether the cause of azoospermia is testicular or posttesticular. Serum levels of gonadotropins, androgens, and ...

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