Manhood: The Rise and Fall of the Penis (24 page)

Most patients with polyorchidy present with a painless swelling.

The most common location for the abnormality is on the left. In most men the diagnosis is made between the ages of fifteen and 25, and in 80 per cent of cases tissue examination of removed additional testicles showed a reduced or non-existent production of sperm cells.

M. Hakami and S. H. Mosavy described a man with fertile sperm in whom the third testicle was discovered only after a vasectomy on both sides.

Inguinal hernia

The testicles are formed at the spot where the kidneys are situated, high up behind the abdominal cavity. From there they descend through the inguinal canal into the scrotum. On that journey – the baby boy is still in his mother’s womb – they take the front of the abdominal membrane with them. When things proceed normally this bulge in the abdominal membrane closes, so that there is no open connection left with the abdominal cavity. The remnant of abdominal membrane in the scrotum surrounds the testicles for the rest of the individual’s life as a double-layered protective membrane.

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If that hernial sac does not close around birth, then there is a chance that the intestine of the newborn infant will descend as far as the scrotum, creating a so-called innate hernia, which sometimes manifests itself as a sizeable swelling. Of course a hernia requires surgery – in boys with a scalpel, in adults mostly by means of keyhole surgery.

Adults in whom the abdominal membrane has closed properly may suffer a hernia because of an increase in pressure due, for example, to chronic coughing or a great deal of heavy lifting. Often the intestines bulge into the groin but do not reach the scrotum. The doctor can ascertain whether there is a hernia by having the man blow against the back of his hand while standing and himself feeling the inguinal canal with his finger from the scrotum.

Torsio testis

Acute, intense pain on one side of the scrotum indicates a twisted stalk (
torsio
) of the
testis.
This seems to happen to one man in 4,000 annually. The testicles do not lie loose in the scrotum: they are attached to it by a wide band which prevents the testicle from turning vertically on its axis. There are some men, mostly aged between ten and 30, in whom the band is too long and often too narrow. One day they may have the unfortunate experience of one of their testicles starting to turn: this is impossible to mistake, since the victim feels sudden intense pain in the scrotum, spilling over into the groin. The scrotum becomes red or purple, and patient is often nauseous. In a physical examination the observant doctor will notice in a case of torsion the cremaster reflex, the retraction of the testicles in the direction of the groin when the inside of the thigh is stroked. It can happen that a torsion disappears spontaneously after a short time, and with it the pain. Even then it is advisable to consult a doctor, since the phenomenon will undoubtedly recur one day, and it’s doubtful whether expert help will be on hand.

The fact is that
torsio testis
can have unpleasant consequences. As a result of the twisting of the testicle pressure is put on the veins and the artery. The flow of blood is interrupted and, if the situation continues for more than a few hours, the tissue in the testicle will die off for want of oxygen. The speed with which that happens depends on the extent to which the testicle has turned on its own axis. Sometimes it may have turned 360 degrees, in which case the process will be very rapid. The sperm-producing cells particularly are sensitive to a lack of oxygen, while those that make testosterone, the Leydig cells, survive longer. If a twisted testicle is untwisted within about four hours there need be no further repercussions. This need not, by the way, require an operation; an expert doctor may in the first instance attempt to solve 122

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the problem manually. He or she should keep in mind the image of a heavy book, say a massive King James Bible, which has to be opened –

outwards.

Occasionally a
torsio testis
is not recognized and the pain and swelling are attributed to an inflammation of the epididymis, so subsequently a completely wrong treatment is applied, usually with anti -

biotics. This results in the completely unnecessary loss of an important organ. When in doubt, the best thing to do is to operate immediately, possibly after a duplex echograph. In this kind of operation the other testicle is immediately included, that is stabilized, to ensure that the problem will never be repeated on that side.

Inflammation of the epididymis

Pain in the scrotum with a sudden onset and which is often intense can also be caused by
epididymitis
, or inflammation of the epididymis. This kind of caused is produced by a bacterium that has spread from the urinary tracts to the seminal duct and from there to the epididymis.

Nowadays in younger people this is almost always
chlamydia tracho -

matis
, which is transmitted through sex. In the case of an inflammation of the epididymis, an extremely painful swelling develops at the back of the testicle, and soon afterwards the scrotum becomes hard and swollen. Anyone continuing to suffer in silence runs the risk of the testicle itself and hence fertility being affected. Inflammation of the epididymis is easy to treat with antibiotics, but if there is any doubt about the cause the gp will generally send his or her patient along for a urine culture to check what micro-organism has caused the inflammation of the urinary tracts. Experience shows that many men with an inflamma -

tion of the epididymis are not treated in time, or for long enough or with the wrong antibiotic, with the result that the infection may spread to the testicle itself, causing
epididymo-orchitis.
Complications include abcesses and the risk that after ‘recovery’ one is left with a ‘shrivelled testicle’.

It is also important that the patient rest as far as possible, and it is sensible to support the scrotum with a flannel containing ice, or an ice-pack.

Hydrocele

As has been said, after the closure of the hernial sac a remnant of the abdominal membrane carried along on the descent continues to surround each of the testicles as a double-layered sheet. Between those two layers there is normally a small quantity of liquid, which allows the testicle as it were to dance. Sometimes too much liquid is produced between the two layers, which can lead to a very large, uncomfortable 123

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Hydrocele.

hydrocele

swelling called a hydrocele. If such a hernia becomes troublesome, for example, when cycling or during sexual intercourse, an operation is called for.

This cabaret song by Hans Dorrestein gives a humorous slant on hydroceles and sex:

Geriatric Sex

Sex for us wrinklies shows the wear and tear,

reflects the elderly wife.

God, when will he come, the poor old sod?

His prick’s grown like a goat’s hoof with no hair.

Sex for us wrinklies shows the wear and tear,

his scrotum’s like a pouffe that’s full of air.

After forty years it isn’t odd,

growing as close as peas in a pod,

but when
this
is over I won’t care,

sex for us wrinklies shows the wear and tear.

Hydrocele may be triggered by a previous inflammation of the epididymis, a trauma, or in vary rare cases testicular cancer, though in the majority of cases the cause remains obscure. It may be removed either via the groin or via the scrotum. In the latter case an incision is made 124

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in the skin and the next layer, the
tunica dartos
. Bleeding vessels are held with a fine pincette and cauterized. If the hydrocele is very large, it is first lanced and emptied by suction. The
tunica vaginalis
is cut open lengthways, so that the testicle itself can be taken out. The redundant layer is removed and folded back behind the epididymis. Because the wall of the hydrocele is turned inside out, the chance of relapse is small.

Because of the abundant blood there is a high risk of bleeding after this operation, and partly because of this a pipe is frequently left in through which blood can drain away.

Spermatocele

The weird idea of ‘growing an extra ball’ is particularly common with spermatocele. This is because a hydrocele is as it were attached to the testicle, which as a result appears to grow bigger and bigger, while a spermatocele can be felt separately from the testicle, always at the level of the head of the epididymis. A weak spot may occur in the wall of the tubes between the testicle and the epididymis, a bulge develops and sperm cells accumulate in it. Such spermatoceles are very common: most middle-aged men have one or two. There are generally small, do not hurt and can do absolutely no harm. However, sometimes they grow to such proportions that it becomes difficult to go on walking with them. Anyone who consults a specialist and is told that an operation is proposed would be well advised to ask whether that operation is really necessary. There is a risk of damage to the artery to the tes ticle, inflammation and bleeding may occur, and moreover there is no guarantee that very shortly there will not be a recurrence of spermatocele.

In order to prevent that the whole epididymis would have to be removed: with men who still want to have children it is completely disastrous to start operating.

Varicocele

To understand how a varicose vein or varicocele emerges it is necessary to know something about the blood supply to the testicles, or rather the drainage of blood. Venal blood leaves the testicles via the left and right testicular veins (
vena spermatica interna
). The right-hand vessel discharges into the inferior vena cava, which transports low -

oxygen blood back to the heart. In the case of the left-hand testicular vein the situation is slightly different: it discharges into the left-hand renal vein, which transports blood purified in the left kidney to the vena cava. Since no organ, including a testicle, likes used blood, which contains waste matter, there are, especially in the left testicular vein, valves 125

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that prevent the blood from flowing back to the testicle. If those valves do not function properly it is possible that blood from the left renal artery will flow back, resulting in the formation of a varicose vein just above the left testicle, where there is a dense network of blood vessels (the
plexus pampiniformis
). This can lead to nagging pain, especially in men who stand up all day long. The accumulation of venal blood may cause the local temperature to rise, with possible harmful effects on fertility. But if the left testicle no longer functions properly, surely that won’t affect the right one? You’d certainly think not, but in practice in a number of cases of varicose veins venal blood flows back on the right-hand side too. This is because there are communication channels between the left and right side, but gravity undoubtedly also plays a part, since vari cose veins have never yet been observed in the scrotums of quad -

rupeds. Apart from that, varicose veins differ widely. Quite a few men, estimated at between 10 and 18 per hundred, have a varicose vein, but by no means everyone has a problem with it. Some 30 per cent of all men who consult a doctor because of involuntary childlessness have such a vein.

Making the diagnosis is generally quite simple. In half of patients the varicose vein is either visible to the naked eye or can be felt with the hand. In order to be able to assess the whole situation, the doctor will ask the patient to blow on the back of his hand briefly. A manoeuvre like this propels venal blood and causes the vein in the scrotum to swell considerably. If the doctor is not sure of his or her ground, he or she will ask for an ecograph of the scrotum. Surgery is by no means always called for in all cases of varicocele. With most men it is sufficient to advise the use of a tight-fitting pair of underpants. Only if the patient wishes to have children is treatment worthwhile. Researchers from Rotterdam showed recently in an excellent study that treating a varico -