As the testes move front the abdomen to the scrotum during fetal development, they take with them a covering front the abdominal contents called the processus vaginalis. This covering produces a small amount of liquid that is normally undetectable. Sometimes, however, more fluid accumulates around one or both testes, forming a hydrocele.
A hydrocele will cause the scrotum to look larger and feel boggy to the touch, but it does not cause pain. (A flashlight beam placed directly behind the scrotum will cause the scrotum to glow red if this extra fluid is present.) A hydrocele on one or both sides of the scrotum may be present at birth, but if the genitalia are otherwise normally formed and both testes can be easily felt, no treatment is necessary. The fluid will gradually be absorbed, and in the worst of cases, the hydrocele will disappear by one year of age.
A hydrocele can also develop later in life. Trauma, infection, tumor, and other illnesses can cause fluid to collect in the scrotum, but most often the cause is unknown. If your son has never had a hydrocele and you notice swelling in his scrotum, he should be evaluated by his physician, who may refer him to a general surgeon, pediatric surgeon, or neurologist for further assessment.
A varicocele is a dilation of the veins that drains the testes. This abnormality feels like a soft “bag of worms” above the testicle and occurs more commonly on the left side. It can cause a feeling of pressure in the scrotum, but it rarely produces pain unless it becomes quite large. A varicocele associated with a difference in size between testicles might impair fertility in the future. Surgery may be recommended in such cases, or if ongoing pain is a problem.
Testes usually are firmly attached to the scrotal wall, so the testes cannot twist or rotate in-side the scrotum. In some boys, however, the testes do not have normal attachments and are free to twist or turn. (Unfortunately, this cannot be diagnosed during a routine checkup.) When this happens, the blood supply to the testes is constricted and may be cut off, causing intense pain.
Testicular torsion (or twisting) can occur at any age, but the vast majority of cases are seen in teenagers. It usually causes sudden severe pain in the scrotum, most often on one side only. Some boys may also experience nausea, vomiting, or severe right-sided abdominal pain similar to that occurring with appendicitis.
Testicular torsion is a surgical emergency because the cells of the testes cannot survive without a constant supply of blood. Boys who have testicular torsion should be treated within a few hours of the onset of pain, so the normal functions of the cells within the testes (specifically, sperm and hormone production later in life) maybe preserved. Even with appropriate and rapid treatment, it is possible that the testes may not function totally normally after torsion.
Orchitis and Epiddymitis
Orchitis is an inflammation of the testes, usually occurring in adolescents and young adults as a rare complication of a viral infection such as mumps or mononucleosis. (Mumps was the most common cause of orchitis before widespread vaccinations drastically reduced the number of cases.) Orchitis is manifested by swelling and tenderness of the testes and is sometimes accompanied by fever. A physician should confirm the diagnosis. Treatment of orchitisis usually limited to bed rest and appropriate pain medication.
Epididyrnitis is an inflammation of the epididymis, the tube that carries sperm from the testes to the urethra, and can occur at any age. Symptoms of epididymitis include pain and swelling in the scrotum, usually with marked tenderness just above the testicle. Viral and bacterial infections, as well as trauma, can cause epididymitis. In sexually active teens, infection with gonorrhea or chlamydia may cause the inflammation. Treatment for epididymitis will depend to some degree upon the cause, which is sometimes difficult to determine. Bed rest may be necessary, along with appropriate pain relief.
Testes are formed early in fetal development (beginning at six weeks gestation) and initially are located in the abdomen close to the kidneys. During the second trimester of the baby’s development, the testes gradually move lower in the abdomen. By the twenty-eighth week of gestation, they begin migrating toward the scrotum through a tube called the inguinal canal. The movement of either testicle from the abdomen into the scrotum can be obstructed anywhere along its normal path and if it fails to progress into the scrotum by the time of birth it is said to be undescended.
Three to 4 percent of normal, healthy newborn babies will have one (unilateral) or two (bilateral) undescended testes. In these infants, the scrotum may appear small and underdeveloped. Infants who are born prematurely, twin boys, and infants with spina bifida are more likely to have undescended testes. In most infants the undescended testicle(s) will move into the scrotum by the first birthday.
Sometimes a testicle that has descended normally will intermittently move into the upper end of the scrotum or even into the inguinal canal. This so-called retractile testicle may at times be difficult to feel, especially when the infant or child is cold, excited, or afraid. When the child is in warm water, which usually relaxes the muscles of the scrotal sac, the retractile testicle will usually drift (or can be gently maneuvered) downward into the scrotum, where it can be felt more easily.
If one or both testes cannot be felt by the first birthday, the child’s physician may recommend an evaluation by an urologist or pediatric surgeon. To clarify the testes location, an imaging study may be done or a laparoscopy advised. During a laparoscopy, performed under general anesthesia, a narrow scope is introduced into the abdomen through a small incision, allowing the urologist/surgeon to view the abdominal contents and locate the testes. This information can help plan future surgery, should it prove necessary.
For two reasons, evaluation and treatment are usually recommended if the testicle hasn’t descended the first birthday or (at the latest) the second birthday. First, there is a slight increase in the risk of developing cancer in a testicle that remains undescended. Second, testes remaining in the warmer environment of the abdomen may become less capable of producing healthy sperm and might contribute to infertility problems later in life.