Pathology of the Testicular Tunics and Spermatic Cord
Diseases of the testicular tunics are relatively common and feature a diverse etiology.
Hydrocele represents an abnormal accumulation of fluid within the tunica vaginalis. The acquired form develops secondary to hypersecretion (e.g., in orchitis and epididymo-orchitis) or impaired lymphatic and venous drainage of the spermatic cord. In uncomplicated cases, the vaginal tunic remains smooth and glistening. With secondary infection or neoplastic processes, it thickens and undergoes sclerosis, and hemorrhages may occur. The congenital form is linked to incomplete closure of the processus vaginalis of the peritoneum, creating a potential hernial sac. If a congenital hydrocele does not regress by two years of age, surgical intervention is required.
Other lesions of the tunics include:
- Hematocele — an accumulation of blood, typically resulting from trauma or as a complication of hydrocele.
- Spermatocele — a cystic dilation of the efferent ductules or the rete testis, containing spermatozoa.
- Encysted hydrocele of the cord / Hydatid cyst — a rare pathology in men over 40 years old, presenting as a cyst filled with clear or hemorrhagic fluid, lined by a single layer of epithelium.
- Fibrous pseudotumors — nodular or plaque-like proliferations of connective tissue forming as a sequela of trauma or orchitis.
Varicocele and the Problem of Infertility
A prominent role is played by varicocele — an abnormal dilation of the pampiniform plexus veins within the spermatic cord. The vast majority of cases (80%) are left-sided, explained by the anatomical insertion of the left testicular vein into the left renal vein at a right angle.
This condition is closely associated with male infertility. The pathogenesis of infertility in varicocele is driven by two main factors: tissue hypoxia and a localized increase in scrotal temperature. These conditions impair normal spermatogenesis.
Microscopic examination of a testicular biopsy reveals:
- Foci of desquamation of necrotic spermatogenic epithelium.
- Marked peritubular sclerosis.
- Varying degrees of testicular parenchymal atrophy.
The primary treatment for this pathology is surgical ligation of the affected venous vessel.
Inflammatory Diseases of the Epididymis
Among diseases of the epididymis, inflammatory processes (epididymitis) predominate over neoplasms.
Ascending bacterial epididymitis can be acute or chronic. In younger patients, the causative agents are most frequently Neisseria gonorrhoeae and Chlamydia trachomatis, whereas in older men, Escherichia coli predominates, typically associated with urinary tract infections. Morphologically, acute cases show edema, congestion, and prominent polymorphonuclear leukocyte infiltration within the wall and lumen of the epididymis. The chronic process is characterized by the formation of encysted abscesses, diffuse infiltration by macrophages, plasma cells, and lymphocytes, alongside fibrosis with potential ductal lumen obliteration.
Tuberculous epididymitis arises via retrograde hematogenous or canalicular spread from urinary tract tuberculosis. Macroscopically, the epididymis is enlarged and firm, and the vas deferens thickens, sometimes acquiring a beaded appearance. The microscopic picture features classic epithelioid cell granulomas with central areas of caseous necrosis. Progression of the disease risks specific epididymo-orchitis.
Another entity is the sperm granuloma — an inflammatory reaction triggered by the extravasation of spermatozoa directly into the interstitial tissue of the epididymis.
Tumors of the Epididymis and Scrotum
The most significant epididymal neoplasm is the adenomatoid tumor. This is a benign, unilateral lesion forming a circumscribed nodule 1–3 cm in diameter. On cross-section, the tissue is gray-yellow, glistening, and soft to firm in consistency. Microscopically, the tumor displays a solid-tubular architecture, where tubular spaces alternate with solid cellular sheets. The cytoplasm of the cells is frequently vacuolated and oxyphilic, while the sclerotic stroma contains smooth muscle elements and lymphoid infiltrates.
Regarding scrotal pathologies, the predominant malignant tumor is squamous cell carcinoma, the morphology of which is identical to epidermoid carcinoma of other anatomical sites. Basal cell carcinoma, Paget's disease, and various benign lesions such as condylomata acuminata, hamartomas, and cysts may also occur.