Standardized diagnosis and treatment of cryptorchidism and prevention and treatment of orchitis, microtestis, and testicular atrophy

Cryptorchidism, also known as undescended testis, refers to the inability to palpate the testicles in one or both sides of a boy's scrotum. Whether the testicle remains in the abdominal cavity, in the groin, or above the scrotum, it is considered undescended testis, and all these conditions require treatment for testicular malformation. During the embryonic period, the two testicles are located on either side of the waist in the abdominal cavity. As the fetus develops, the testicles gradually descend. Statistics show that approximately 3% of newborns have testicles that do not descend into the scrotum, but most descend within 6 weeks of birth. Bilateral cryptorchidism, if left untreated, can have serious consequences. The temperature inside a normal scrotum is 2-3°C lower than body temperature, which is ideal for testicular development. If both testicles are constantly in the relatively warmer abdominal cavity or groin, it hinders healthy testicular development, causing atrophy of the testicular germinal epithelium and leading to infertility. Furthermore, such testicles produce very little androgen, which can impair male puberty sexual development, leading to low libido and affecting fertility. Unilateral cryptorchidism does not affect puberty sexual development or fertility. However, unilateral testicular hypoplasia can affect the contralateral testis, potentially reducing sperm count or impairing sperm cell function, thus indirectly impacting fertility. Bilateral cryptorchidism results in infertility. Most seriously, there is a high risk of testicular cancer developing in the abdominal cavity, and once cancer develops, its malignancy is extremely high. Furthermore, the inguinal testis is easily injured during childhood activities, causing severe pain and potentially affecting development.

If parents find that they cannot feel the testicles in their child's scrotum, they should promptly take the child to the hospital for an ultrasound or CT scan to determine the exact location of the testicles; testosterone levels can also be tested to assess testicular development. Treatment for cryptorchidism mainly involves two methods: surgical treatment and drug treatment. ① Surgical treatment. Surgery should be performed between 1 and 2 years of age. Generally, reproductive cell development begins to be affected at 10 months, and the impact becomes significant after age 2. If surgery is not performed before age 2 for various reasons, it should not be later than age 6. Statistics show that if cryptorchidism is treated after age 7 (called orchiopexy), there are still many cases of death due to cancer around age 30, a significant difference compared to surgery performed before age 6. Furthermore, when children start school and urinate with other children, cryptorchidism can cause significant psychological stress, and childhood trauma can have lifelong effects. Therefore, the earlier cryptorchidism surgery is performed, the better. ② Drug treatment. Treatment of cryptorchidism with gonadotropins commonly involves injecting human chorionic gonadotropin (hCG) around the age of one, or using luteinizing hormone-releasing hormone (LH-FRAG) nasal drops. While this may lower the level of cryptorchidism in milder (lower) cases, prolonged use can interfere with normal testicular and external genital development. Therefore, hormone therapy is generally only used for diagnostic testing, comparing testosterone levels before and after treatment to assess testicular development. If testosterone levels do not increase after hormone use, testicular repositioning surgery is unnecessary; instead, the affected testis should be removed. For future psychological support, implanting a prosthetic testis can be considered.

Orchitis is mainly divided into two categories, and their different characteristics and prevention and treatment are as follows: (1) Acute nonspecific orchitis: It often occurs in patients with urethritis, cystitis, prostatitis, prostatectomy, and long-term indwelling catheters. Common pathogens include Escherichia coli, Proteus, Staphylococcus, and Enterococcus. The routes of infection include hematogenous, lymphatic, or ascending infection. In most patients, the inflammation spreads from the epididymis to the testis. From the naked eye, nonspecific orchitis is characterized by varying degrees of testicular enlargement, congestion, and tension. When the testis is dissected, small abscesses can be seen. Histological observation shows numerous focal necrosis, connective tissue edema, and infiltration of segmented neutrophils. The seminiferous tubules show inflammation, hemorrhage, and necrosis. In severe cases, testicular abscess and testicular infarction may form. ① Clinical manifestations. It is mostly unilateral, often accompanied by chills and fever, testicular pain radiating to the groin, nausea and vomiting, scrotal skin congestion and edema, testicular enlargement, and hydrocele. Diagnosis is primarily based on physical examination of the testis, including signs such as redness, swelling, heat, and pain. However, it needs to be differentiated from acute epididymitis, spermatic cord torsion, and incarcerated inguinal hernia. Treatment includes local cold or hot compresses, scrotal elevation, nerve block therapy, and antibiotics. If an abscess has formed, incision and drainage are necessary. Orchiectomy is recommended when the testis is completely destroyed. For orchitis caused by long-term indwelling urethral catheters, the catheters should be removed as soon as possible.

(2) Acute mumps orchitis: This is the most common cause of orchitis caused by the mumps virus entering the testis via the bloodstream. It is more common in men in late puberty. The testis is visibly enlarged and bluish. When the testis is cut open, the testicular tubules cannot be expelled due to interstitial reaction and edema. Histological observation shows edema and vasodilation, with a large number of segmented neutrophils, lymphocytes and macrophages infiltrating, and varying degrees of degeneration of the seminiferous tubules. As the orchitis heals, the testis becomes smaller and softer. The seminiferous tubules are severely atrophied, but the interstitial cells of the testis are preserved. During the inflammatory process, the epididymis can be involved at the same time, with up to 85% of cases developing epididymitis. ① Clinical manifestations: The onset is rapid, generally appearing 3 to 4 days after the onset of mumps. The scrotum has erythema and edema, and the body temperature can reach 40°C, with significant signs of collapse. In orchitis caused by mumps, about 30% of patients experience irreversible damage to sperm, and the affected testis is severely atrophied. Bilateral orchitis can lead to male infertility, but androgen secretion function is generally normal. ② Treatment. Antibiotics are ineffective for orchitis caused by mumps. To relieve testicular swelling and pain promptly, a low spermatic cord block injection of 20 ml of 1% lidocaine can be administered, which improves testicular blood flow and protects spermatogenesis. Literature reports that diethylstilbestrol and gamma globulin can reduce fever and alleviate testicular swelling and pain. Prednisone has similar effects. Using convalescent serum from mumps patients to reduce the incidence of orchitis is worth trying. ③ Prevention. Live attenuated mumps virus vaccine is an effective preventative measure against mumps, generally administered to susceptible children under one year old. Mumps hyperimmune globulin (20 ml) can also be injected during the incubation period to reduce disease progression. Routine use of estrogen or glucocorticoids also helps prevent orchitis in children with mumps.

Many young men worry excessively about their testicular development, unaware that the normal range of testicular size can vary by more than 100%. Because they fear that small testicles will affect their future marriage and fertility, their assessment of testicular size is highly subjective and often unfounded. In fact, simply measuring the size using a testicular measuring instrument or other measuring instruments can quickly dispel these concerns. If the volume of both testicles is less than 10 ml, it is called microtestis, which can be congenital or acquired. Congenital causes include Klinefelter syndrome (47,XXY chromosome) and congenital adrenal hyperplasia. Acquired causes are due to the adrenal glands synthesizing large amounts of androgens, causing precocious puberty (the appearance of secondary sexual characteristics before the age of 10). However, the large amount of testosterone secreted by the adrenal glands inhibits the synthesis and secretion of gonadotropins from the pituitary gland, thus inhibiting testicular development, resulting in a very small testicular volume. Treatment for this type of adrenal gland disease is relatively difficult. Prednisone treatment can be considered to lower blood testosterone levels, relieve pituitary suppression, increase gonadotropin secretion, and further promote testicular development. If congenital cryptorchidism is not treated promptly, testicular atrophy may also occur. Acquired causes of testicular atrophy are numerous, including trauma, surgical injury, paraplegia; mumps complicated by orchitis or other viral infections; severe varicocele; high-dose radiation; high-dose anticancer or antitumor drugs or estrogens, chemical teratogens, environmental pollution; long-term consumption of raw cottonseed oil in cotton-producing areas; malnutrition; and various endocrine disorders. For acquired factors, prevention or treatment targeting the underlying cause is crucial. Testicular atrophy caused by these factors only damages the seminiferous epithelium and often does not affect interstitial cells. In other words, testosterone production can still maintain normal levels, therefore sexual function is usually unaffected.

Testicular enlargement can be seen in testicular tumors, epididymitis, hydrocele, testicular hematoma, etc. (1) Testicular tumors: Most are malignant and occur in young adults. They usually enlarge gradually on one side of the testicle without any clear cause, and are usually not accompanied by pain. A few may grow faster or be accompanied by tumor bleeding or necrosis, which may cause pain and discomfort. In this case, it is easy to misdiagnose as inflammation. The enlarged testicle is usually hard, heavy, inelastic, and opaque. It may not be painful when touched or squeezed. (2) Epididymitis: There are usually obvious symptoms such as redness, swelling, pain and fever. There may be a history of urethritis before. (3) Hydrocele: It develops slowly. The mass is usually soft and elastic and can be translucent. (4) Testicular hematoma: There is usually a history of trauma and the tenderness is obvious. A preliminary judgment can usually be made based on these characteristics. In any case, you should go to the hospital for treatment in time. When the mass is not too big, B-ultrasound and other examinations can usually make a preliminary diagnosis. Because testicular tumors are mostly malignant, and some types can metastasize early on, they pose a significant threat to health. Once diagnosed, radical removal of the affected testis is necessary. In cases with a longer disease course, major surgeries such as retroperitoneal lymph node dissection may be required. Depending on the condition, radiotherapy and chemotherapy may also be necessary, both of which have substantial impacts on the body. Once metastasis occurs, it becomes difficult to completely eradicate the tumor using various treatment methods, resulting in significant medical expenses, immense suffering, and potentially affecting long-term survival. The testes are located on the surface of the body, making them easy to palpate and facilitating early detection of abnormalities. If a testicular tumor is treated when it is small, a complete cure is entirely possible. Therefore, early detection, examination, and treatment are crucial.

Normally, the scrotum will contract when stimulated by cold, which is normal. Testicular atrophy refers to the testes that were originally normal but gradually shrink and become smaller due to certain factors. Testicular atrophy can cause infertility and also affect sexual function. Therefore, it is crucial to actively prevent and treat the above diseases. The causes of testicular atrophy are roughly as follows: (1) Viral infection: This is the most common cause of testicular atrophy in children and adolescents, especially the mumps virus, commonly known as "malaria". When the testes are attacked by the virus, the spermatogenic tissue in the testes is destroyed, the testes shrink in size and soften in texture. (2) Injury: Impact injury to the scrotum or testes can cause scrotal hematoma or testicular laceration, which can lead to a long-term state of insufficient blood supply to the testes, resulting in atrophy. (3) Inflammatory factors: Severe orchitis can cause testicular swelling and pain that can last for many days. Due to bacterial invasion, testicular tissue is destroyed, leading to testicular atrophy. (4) Effects of radioactive substances: Those who are exposed to radioactive substances for a long time, such as those who work with X-rays or isotopes, may develop testicular atrophy if they do not take proper precautions. (5) Endocrine diseases: The testes are an endocrine organ that mainly produces androgens. Diseases of many organs that control the endocrine system, such as the pituitary gland, adrenal glands, and hypothalamus, can interfere with testicular function and cause testicular atrophy. (6) Effects of drugs: Long-term use of certain toxic drugs, such as arsenic and mercury, or frequent use of estrogen-containing drugs, can cause testicular atrophy. (7) Varicocele: The spermatic cord is the "bridge" connecting the testes to the human body. If varicocele is present, the blood circulation of the testes will be interfered with, resulting in congestion, hypoxia, and the accumulation of harmful substances in the testes. Over time, the testes will also atrophy.