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Urology/Testie pain and shrinkage

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Question
For the past few months iv had pain in first my left nut I went to the VA and dr had me lay back and lifted up my nut it hurt like hell he said I had a infection in the tubing so have me some antibiotics and sent me on my way took the 14 day script and all felt good a few days after finishing pills pain came back in my right nut both hurt and have shrunk to the size of a grape and my right one is sucked up while the left one hangs normale I had a ultrasound done last week at the VA it came back that there was fluid around both nuts but they can't tell if its normale fluid or not I also have sharp pain when I get a erection and having sex is out of the question I just want to throw up the pain is so bad the pain is worse when laying down also along with this I have pains in my side towards the back but all my urine and blood work came back good I'm at a loss I'm waiting to set up a appointment with the urologist my pcp has yet to put in the consultation any help would be great thank you

Answer
Matt,  I think you probably have a condition called epididymitis and prostatitis but a torsion of the testicle is also a possibility.  Before discussing your problems, let me first provide you with some basic information.  During sexual arousal the prostate gland manufactures fluid that accounts for about 2/3 of the volume of ejaculate.  The seminal vesicles are paired structures located behind the prostate gland that also manufacture fluid.  Sperm from the testicles (which account for only 1-2% of the semen) travel up a series of tubes (epididymis and vas deferens) on each side to join the seminal vesicles forming the paired ejaculatory ducts.  These structures empty into the prostatic portion of the urethra.  At the time of ejaculation, prostatic fluid is discharged into the urethra (urinary canal) where it mixes with discharge from the ejaculatory ducts forming the semen.  The semen volume is in the 2-6 cc range.  

The epididymis is the tubular structure located behind the testicle that drains sperm from the testis to the vas deferens and eventually out the ejaculatory ducts.  Inflammation or infection of the prostate gland (prostatitis) often will spread down the vas and into the epididymis causing inflammation in this area (epididymitis).  This is the most common cause of epididymitis although it may also occur without prostatitis.  Typical signs of epididymitis are swelling of the scrotal skin with loss of the normal skin folds (rugae), redness of the skin, enlargement of the epididymis and testicle, and local tenderness and pain that is eased by elevation of the testicle.  I believe this is probably what you had.   The discomfort associated with prostatitis can sometimes be referred into the epididymis without actually an inflammation being present in the epididymis.  In this case, the epididymis and scrotum are normal although slightly tender.

Too frequent or too infrequent ejaculation, sexual arousal without ejaculation, withdraw at the time of ejaculation, aggressive bike or horse back riding, and excessive spicy foods, alcohol, and caffeine in the diet can predispose you to this.  Sitting for long periods of time, especially in an automotive vehicle, can put undo pressure on the prostate and aggravate the condition.  For the latter, it is best not to sit more than 2-3 hours at a time.  Stop the vehicle periodically, take a short walk and go to the bathroom to urinate.  A thick pad or piece of sponge rubber on your seat will also help to cushion the prostate.  One should avoid any of the above that apply. Epididymitis is treated with antibiotics, warm baths, scrotal supporter and mild pain relievers.  Probably the best antibiotics to use are from the fluoroquinolone group, such as Cipro and Levaquin.   Usually the pain is gone in a few days but the swelling may persist for several weeks.  Treatment should be instituted by a urologist after a proper and prompt evaluation.  The urologist should follow the patient until the inflammation has totally resolved and the testicle has returned to normal.  The reason for this is that occasionally, a tumor of the testicle may present clinically as epididymitis.  In this case, the inflammation and swelling initially obscure the true diagnosis.  A lack of response to treatment may be due to bacterial resistant to the antibiotic being used, the formation of a testicular abscess (which may be detected on ultrasound), or a misdiagnosis of torsion of the testicle. To follow is some information on this condition.

Torsion of the testicle can sometimes be confused with epididymitis.  The testicles are suspended by a rope-like structure called the spermatic cord.  This cord is composed of a number of parts including arteries, veins, nerves, lymphatics (tissue vessels) and connective tissue.  Surrounding the testicles is a membrane called the tunica vaginalis.  The testicles are further anchored to the inner scrotum by a band of tissue called the gubernaculum.    Abnormalities of any of the structures may predispose to a condition called torsion where the spermatic cord can twist on itself causing the testicle inside the tunica vaginalis to twist also.   The torsion can be partial or complete.  Usually the testicle on the affected side is drawn up toward the groin due to foreshortening of the cord.  Partial torsion testicle causes variable pain and swelling and often spontaneously corrects itself by detorsion.    If complete, the pain and swelling are quite impressive.  If prompt correction is not performed within a few hours (either manually or surgically), the testicle can be destroyed due to lack of blood supply.  This can result in a small shrunken testicle that is drawn up.  If there is suspicion of either type of torsion, you should be immediately seen by a urologist.  If an attempt at manual detorsion fails, prompt surgical detorsion and bilateral orchidopexy is performed.  This is a minor outpatient operation that involves small incisions in each side of the scrotum, untwisting the spermatic cord and tacking the testicles to the inner wall of the scrotum with sutures to prevent a future torsion.  The orchidopexy is done bilaterally as the propensity for torsion on the asymptomatic side is increased in such individuals.   Sometimes the torsion is intermittent and self-correcting.  The urologist may detect abnormal mobility of the testicles on examination but not always.  If there is uncertainty about the diagnosis, a radio-nucleotide scan of the testicles is often definitive.  However, if torsion cannot be ruled out,  the safest practice is to perform a prophylactic bilateral orchidopexy.  

At present, I suggest you see a urologist inn consultation.  A radio-nucleotide scan of the testis should be done to evaluate the blood supply if he has suspicion of torsion.  Most of your discomfort and difficulty with erection may well be due to prostatitis and he can attend to this also.  Good luck.  

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Arthur Goldstein, M.D.

Expertise

Problems or questions related to the field of urology; ie urinary stone disease, urinary cancers (kidney, bladder, prostate, testis, etc.), urinary infections, etc. I no longer answer questions related to erection problems or male sexual dysfunction.

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 endourology.

Organizations
American Medical Association, American Urological Association, American College of Surgeons

Education/Credentials
College degree - BS Medical degree - MD Master of Science - MS

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