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About Arthur Goldstein, M.D.
Expertise
Any problems or questions related to the field of urology; ie urinary stone disease, urinary cancers (kidney, bladder, prostate, testis, etc.), urinary infections, impotency, etc.
Experience
I am retired from the active practice of urology. My 34 years was totally in the clinical field and involved the entire gamut of genitourinary problems, with special interest in male impotence and endourology.
Organizations
American Medical Association, American Urological Association, American College of Surgeons
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You are here: Experts > Health/Fitness > Urology > Urology > Right greater than left testicular swelling.
Expert: Arthur Goldstein, M.D.
Date: 10/1/2008
Subject: Right greater than left testicular swelling.
Question
I'm a 52 y/o male who notes about a four month history of an INTERMITTENT right greater than left testicular swelling. It seems to occur in the AM upon rising, with sexual activity, and if the testis are jostled. There is mild pain that can refer to the lumbar region. The swelling invariably returns to normal after about 15 minutes. It is a firm swelling, more a change from the normal flat/ovoid to a more round shape, not a fluidy feeling. Most times it's the right, or both, and occasionally just the left. I take no meds I have been evaluated by a urologist who checked for a hernia standing and lying, urinalysis, prostate, and testicle exam, all normal. No explanation was given for my unusual symptoms. Any ideas? Thanks kindly, Bob.
Answer
Bob, as you might imagine, for this type of problem it is not possible for me to make an exact diagnosis over the internet because of the inability to do a physical examination. However, I shall try to help you.
The testicles in the fetus are actually formed just below the kidneys in a space called the retroperitoneum. As the nerve suppy of the testicles also originates at this site, it is characteristic of any testicular problem to refer pain to the lumbar area. Just before birth, they begin their descent into the scrotum. In the lower abdominal area, they force a hole in the abdominal muscles and drag some muscles fibers along the cord. This is called the cremaster muscle which allows one to pull the testes upward by contracting the abdominal muscles. The “hole” (inguinal ring) produced is the opening through which the typical hernia will bulge. The latter is really intra-abdominal contents inside a pocket of the peritoneum, the lining that contains all components of the abdomen. Typically a hernia will be present with standing as opposed to lying as gravity plays a role in causing the protrusion. Any action that causes the diaphragm to push down (termed the Valsalva maneuver) such as coughing, straining, lifting, etc.) usually accentuates the hernia bulge.
Surrounding the testicle is a thin layer of tissue folded upon itself with a potential (but empty) space between these leaves. This membrane is called the tunica vaginalis. The cells of the inner lining of this membrane have the potential to secrete fluid in response to trauma, allergies, infections, local tumors, etc. If fluid is produced, the space becomes filled as the walls of the membrane separate more from each other. This is called a hydrocele. It is a perfectly benign condition and requires no treatment. The are 2 exceptions. First, sometimes there is an associated tumor of the testicle that stimulated the hydrocele to form. It is, therefore, important to establish that the associated testicle is normal either by physical examination or ultrasound of the scrotum. The second is that sometimes a hydrocele sac can be connected to a hernial sac. In this case, fluid in the abdominal cavity can flow into and out of the hydrocele resulting in changes in size of the scrotal swelling. Again, however, this is generally accentuated by gravity and the upright position.
A third possibility is a varicocele. A varicocele is a collection of varicose veins of the spermatic cord (the rope-like structure that suspends each testicle). They occur in about 15% of the population. More than 90% occur on the left, 5% on the right and the rest are bilateral. Varicoceles are due to a defective valve in the vein that drains blood from the testicle. They fill by gravity and therefore are not detectable while recumbent but apparent when upright. On examination, the lesion feels like a bag of worms. Small varicoceles may only be detected by imaging studies such as ultrasound. A varicocele that does not disappear when lying down may indicate a tumor in the abdomen (but this is quite unusual). Varicoceles are generally painless.
All of these lesions are accentuated by gravity. There is nothing I know of that is specifically characteristic of the history that you have provided. I would suggest an ultrasound of the scrotum in both the recumbent and upright positions for further insight into your problem. If this is normal and you remain curious, examination by a second urologist is suggested. Good luck.
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