Abstract
Background
The testes are the male reproductive glands and the homolog of the ovary in females performing critical functions. Pathologic conditions could arise from the testes and blunt or completely obliterate these functions leading to clinically overt or covert sequelae. The aim of this research is to study the pattern of histologically diagnosed testicular disease in relation to clinical features at the Jos University Teaching Hospital between January 2012 and December 31st, 2021.
Methodology
This study is a retrospective analysis of all cases of testicular biopsies. All histologically diagnosed testicular lesions were identified from the departmental records and clinical data obtained further from the patients’ folder at the Medical Records Department.
Results
Four hundred and thirty (430) biopsies were seen, of which 304 (70.7%) were orchidectomy specimens. The commonest histological diagnosis was testicular atrophy accounting for 328(76.3%) cases. Testicular torsion is followed by 42(9.8%) cases. Together, inflammatory conditions accounted for 36(8.4%) cases out of which granulomatous inflammation made up 52.3% of cases. There were 16(3.7%) neoplastic conditions all of which were malignant, out of which 6(37.5%) were seminomas. The age range, mean, median and modal age was 1-90 years, 53.4 +21.3years, 60 years and 70 years respectively. Prostatic carcinoma therapy in the form of bilateral orchidectomy was the major indication for surgery.
Conclusion
The majority of testicular lesions in our locality are atrophies and most of these lesions are obtained as orchidectomies for therapy of prostatic cancer.
Keywords: Testes, Atrophy, Torsion, Prostate, Granuloma
Introduction
The testes are the male reproductive glands, homologs of the ovary in females. These bean shaped organs are situated within the scrotal sac, a location suited for the all-important functions which are essentially reproductive.[1,2]To perform this crucial function, a regulated environment (scrotum) external to the main body with temperature (35oC) less than that of core body temperature (37oC) is mandatory.[3,4]Pathologic conditions of the testes could lead to clinically overt or covert sequalae.[5]The aim of this study is to establish the clinicopathologic pattern of testicular lesions at the Jos University Teaching Hospital.
Methodology
This study is a retrospective analysis of all cases of testicular biopsies received at the Anatomical Pathology and Forensic Medicine Department of the Jos University Teaching Hospital between 1st January 2012 and December 31st, 2022. All histologically diagnosed testicular lesions were identified from the departmental records and clinical data obtained further from patients’ folder at the Medical Records Department. Archival histological slides for each case were reviewed independently by two anatomical pathologists with further harmonization in a joint session of the few areas of variation. Cases of missing or broken slides were addressed by making new slides from archival tissue blocks. All cases with definitive histological diagnosis were included. All cases with inadequate clinical information, missing archival slides and tissue blocks were excluded. The data realized were analyzed using 2016 Microsoft Excel software and presented in tables as simple frequencies, percentages, range, and measures of central tendencies.
Result
Four hundred and thirty (430) of the 441 biopsies were included in the study. Of these, 304 (70.7%) were orchidectomy specimens. Of these orchidectomies, 250(82.2%) were bilateral. The commonest histological diagnosis was testicular atrophy accounting for 328(76.3%) cases. (Table 1). Testicular torsion followed with 42(9.8%) cases. Together, inflammatory conditions accounted for 36(8.4%) cases out of which granulomatous inflammation made up 52.3% of cases. There were 16(3.7%) neoplastic conditions all of which were malignant, out of which 6(37.5%) were seminomas. (Table 1). The age range of the distribution was 1-90years while the mean, median and modal age were 53.4 +21.3years, 60years and 70years respectively. (Table 2). There were 175(40.7%) and 255(59.3%) cases before and after age 50 years respectively. (Table 2). Prostatic carcinoma therapy in the form of bilateral orchidectomy was the indication of 249 cases. (Table 3). Testicular mass and infertility were seen in 94 and 70 cases respectively. (Table 3).
Table 1:
DIAGNOSIS | AGE (Years) | TOTAL | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
<10 | 10-19 | 20-29 | 30-39 | 40-49 | 50-59 | 60-69 | 70-79 | 80-89 | 90-99 | ||
Atrophy | 5 | 2 | 14 | 44 | 29 | 28 | 78 | 101 | 26 | 1 | 328(76.3) |
Torsion/infarction | - | 16 | 12 | 7 | 5 | - | 2 | - | - | - | 42(9.8) |
Acute inflammation | - | - | 1 | - | - | - | - | 1 | 1 | - | 3(0.7) |
Chronic inflammation | - | - | 2 | 3 | 4 | 1 | 1 | 2 | 1 | - | 14(3.3) |
Granulomatous inflammation | - | - | 6 | 3 | 2 | 1 | 2 | 3 | 2 | - | 19(4.4) |
Simple cyst | - | 1 | 3 | 2 | 1 | - | 1 | - | - | - | 8(1.8) |
Seminoma | - | - | - | 4 | 1 | 1 | - | - | - | - | 6(1.3) |
Seminomatous Seminoma | - | - | - | - | - | 1 | - | - | - | 1 (0.2) | |
Sertoli cell tumor | - | - | - | 1 | - | - | - | - | - | - | 1(0.2) |
Embryonal carcinoma | - | - | - | - | 1 | - | - | - | - | - | 1(0.2) |
Yolk sac tumor | 1 | - | - | - | - | - | - | - | - | - | 1(0.2) |
Matured teratoma | 1 | - | - | - | - | - | - | - | - | - | 1 (0.2) |
Lymphoma | 1 | - | - | - | - | - | - | - | 1 | - | 2(0.5) |
Rhabdomyosarcoma | - | 3 | - | - | - | - | - | - | - | - | 3(0.7) |
TOTAL | 8(1.8) | 22(5.1) | 38(8.8) | 64(14.9) | 43(10.0) | 31(7.2) | 85(19.8) | 107(24.9) | 31(7.2) | 1(0.2) | 430(100.0) |
Table 2:
DIAGNOSIS | MEASURES OF CENTRAL TENDENCY (AGE) | |||
---|---|---|---|---|
Range | Mean | Median | mode | |
Atrophy | 20-65 | 16.3±16.3 | 65.0 | 70.0 |
Infarction | 10-62 | 23.9± 11.8 | 20.0 | 16.0 |
Acute inflammation | 3-82 | 21.6±13.7 | 70.0 | 4.0 |
Chronic inflammation | 21-83 | 47.8±18.7 | 45.0 | 45.0 |
Granulomatous inflammation | 20-85 | 47.5±22.5 | 40.0 | 20.0 |
Simple cyst | 16-67 | 36.4±15.8 | 33.5 | 27.0 |
Seminoma | 35-55 | 40.8±7.4 | 38.5 | 35.0 |
Seminomatous Seminoma | 65 | 65 | 65 | 65 |
Sertoli cell tumor | 30 | 30 | 30 | 30 |
Embryonal carcinoma | 1.0 | 1.0 | 1.0 | 1.0 |
Yolk sac tumor | 1 | 1 | 1 | 1 |
Matured teratoma | 4 | 4 | 4 | 4 |
Lymphoma | 8-80 | 44.0±50.9 | 44.0 | NA |
Rhabdomyosarcoma | 12-17 | 14.7±2.5 | 15.0 | 12.0 |
TOTAL | 1-90 | 53.4 ±21.3 | 60 | 70 |
Table 3:
DIAGNOSIS | INDICATION FOR SURGERY/SYMPTOMS | ||||
---|---|---|---|---|---|
Prostate Cancer | Mass | Pain | Undescended | Infertility | |
Atrophy | 249 | - | - | 17 | 70 |
Torsion | - | 35 | 40 | - | - |
Acute inflammation | - | 3 | 3 | - | - |
Chronic inflammation | - | 13 | 13 | - | - |
Granulomatous inflammation | - | 19 | 4 | - | - |
Simple cyst | - | 8 | 5 | - | - |
Seminoma | - | 6 | - | - | - |
Seminomatous Seminoma | - | 1 | - | - | - |
Sertoli cell tumor | - | 1 | - | - | - |
Embryonal carcinoma | - | 1 | - | - | - |
Yolk sac tumor | - | 1 | - | - | - |
Matured teratoma | - | 1 | - | - | - |
Lymphoma | - | 2 | - | - | - |
Rhabdomyosarcoma | - | 3 | - | - | - |
TOTAL | 249(57.9%) | 94(21.9%) | 65(15.1%) | 17(4.0%) | 70(16.3%) |
Discussion
Testicular atrophy, the commonest histological diagnosis seen in this study is shown herein not to be in itself a disease. This is because the vast majority (249, 75.9%) of this histological entity are orchidectomy samples from otherwise normal patients treated with bilateral orchidectomy for prostate cancer. In Africa, hormone deprivation therapy by way of bilateral orchidectomy is the commonest modality for treatment of patients with advanced prostate cancer with or without anti-androgen drugs.[7,8]With a rising incidence of prostate cancer and a growing proportion of patients in our locality, treatment with bilateral orchidectomy is a veritable option.[8]As a consequence of harsh economic realities, this therapeutic option is expected to experience a renaissance in pockets of places in our clime where it has been substituted with other treatment modalities.[9]The advantages of bilateral orchidectomy as a therapeutic measure for prostate cancer include: persistent oncological effectiveness and disease control with low testosterone level; absent psychological perturbations; better health-related quality of life (HRQoL)and overall health status.[9,10]A study showed surgical castration for therapy of prostate cancer constituting 57.8% of all testicular biopsies.[11]
Another important entity contributing to testicular atrophy in this study is cryptorchidism. It variably differs in consequence from outright infertility arising because of testicular atrophy which is the second commonest indication for testicular biopsy with a diagnosis of atrophy in this study. Cryptorchid testis can be salvaged from damage depending on the severity of the atrophy.[12] This is possible with surgical intervention after calculating the testicular atrophy index (TAI), the ratio expressed in percentage of the difference between the volume of the normal (contralateral) testis and affected testis, to the volume of the normal (contralateral) testis.[12]A TAI value of equal or greater than 20% is an indication for surgery as it implies better outcome.[12]In a study involving 1029 infertile men, it was found inter alia that bilateral testicular atrophy translates to lowest sperm count and motility, with a significant correlation between testicular volume and spermatogenesis.[13]Also testicular volume was considered a reliable indicator of testicular function.[13]The finding in this work of undescended testes responsible for 4.% of all histologically diagnosed testicular biopsies is in agreement with several reports in which values of 3.75%-6.67% recorded.[11,14,15,16,17,18]
Testicular atrophy is graded with severity from mild, moderate to severe with consequences on fertility of the male. The process progresses in severity from the initial maturation arrest represented as partial or complete loss of spermatids within the seminiferous tubules; through hypoplasia of all maturing germ cells with vacuolation of these germ cells and presence of giant cells; to the severe stage where there is total loss of germ cells, Sertoli cell hyperplasia ('Sertoli-only' features), shrunken seminiferous tubules wall with thickened basement membrane and in advance cases complete sclerotic testicular parenchyma.[19]
Inflammatory conditions were second to testicular atrophy in this study, with granulomatous inflammation leading in frequency. Although the causes of granulomatous orchitis are rife, they could be broadly categorized into specific and non-specific (idiopathic).[20] This study however did not work towards unravelling the etiology of the granulomas. Kahn et al. reported mycobacterium tuberculosis as the commonest cause of granulomatous orchitis in a retrospective analysis of 17 cases.[20] Perimenis et al. reported 7 cases of idiopathic cases of granulomatous orchitis.[21]As at 2001 only 20 cases of granulomatous orchitis were reported in Japan giving credence to the rarity of this pathological entity.[22]Owing to the difficulty of presurgical diagnosis due to its similarity with cancer, the majority of cases of granulomatous orchitis are diagnosed histologically after orchidectomy.[21,22,23]Furthermore, orchidectomy is a preferred therapeutic option as late presentation in most cases has incurred irreparable damage that antibiotics cannot salvage at the time of clinical assessment.[16]Similar to this study, chronic granulomatous inflammation was the commonest inflammatory lesion in a study by Oranusi et al when isolated from other inflammatory conditions,[16]but second in a study by Baidya et al.[18]
Testicular torsion represented histologically as red infarct is the second commonest histological entity in this study. As seen in this study it presents symptomatically with testicular swelling and pain.[24,25] It is clinically a common, genuine time sensitive urological emergency that if not halted will slide down the slippery slope leading to coagulative necrosis (infarct), subfertility and infertility.[24,25] Several studies have put forth different red lines regarding intervention up to 24hours according to researchers’ findings, the rubicon however is widely reported as the 8-hour mark where most testicles with torsion without intervention are unsalvageable.[24,25] These unsalvageable testicles must therefore be removed as a final option.[26] The decision for orchidectomy is one that is however rife with litigations as patients probe malpractice hinged on delay in instituting treatment.[24] In this study, we found testicular torsion to constitute 9.8% of all biopsies studied. Other studies reported 6.3% (Nwafor et al),[11]10.0% (Tekumalla et al),[14]7.3% (Abdulkadir et al),[15]14.8% (Oranusi et al),[16]19.0%(Reddy et al),[27]23.2% (Albasri et al),[17]and 46.7%(Baidya et al).[18]The reason for this wide variation is likely due to sampling methods. For instance, our study was on all testicular samples while some other studies were done on orchidectomy alone.[14,27]
Neoplastic testicular diseases were all malignant cases in this study and constituted 3.7% of all cases of testicular disease. A range of 5.6% to 25% of neoplastic lesions was seen in previous studies reviewed.[11,14,16,17,18,28] Generally testicular malignancies are rare. Two previous studies in our center found that testicular malignancies were amongst the rarest cancers. In this study, seminoma was the most common malignant testicular neoplasm, a finding that is in agreement with many reports.[14,16,18,19]
References
- 1.Tiwana MS, Leslie SW. Anatomy, Abdomen and Pelvis, Testicle. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022. Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470201/ [Google Scholar]
- 2.Moore CR. Physiology of the testis. JAMA. 1941. ;116 :1638–44 [Google Scholar]
- 3.Mieusset R, Bujan L, Mansat A, Pontonnier F. Hyperthermie scrotale et infécondité masculine. Progrès en Urologie 1992. ; 2:31–6. [PubMed] [Google Scholar]
- 4.Van De Graaff, Kent M. (Kent Marshall) (1989). Concepts of human anatomy and physiology. Fox, Stuart Ira. (2nd ed.). Dubuque, Iowa: Wm. C. Brown Publishers. pp. 936. [Google Scholar]
- 5.Netto GJ, Amin MB. The lower urinary tract and male genital system. In: Kumar V Abbas AK, Aster JC (eds.) Robins and Cotran Pathologic basis of disease. 10th Ed; Philadelphia: Elsevier Saunders. 2021; 953-83. [Google Scholar]
- 6.McLachlan RI, Rajpert-De Meyts E, Hoei-Hansen CE, de Kretser DM, Skakkebaek NE. Histological evaluation of the human testis—approaches to optimizing the clinical value of the assessment: Mini Review. Human Reproduction 2007; 22:2–16. [DOI] [PubMed] [Google Scholar]
- 7.Olapade-Olaopa EO, Obamuyide HA, Yisa GT: Management of advanced prostate cancer in Africa. Can J Urol. 2008, 15:3890-8. [PubMed] [Google Scholar]
- 8.Ekeke ON, Amusan OE, Eke N. Management of prostate cancer in Port Harcourt, Nigeria: changing patterns. J West Afr Coll Surg. 2012; 2:58–77. [PMC free article] [PubMed] [Google Scholar]
- 9.Rud O, Peter J, Kheyri R, Gilfrich C, Ahmed AM, Boeckmann W. Subcapsular Orchiectomy in the Primary Therapy of Patients with Bone Metastasis in Advanced Prostate Cancer: An Anachronistic Intervention? Advances in Urology 2012. doi: 10.1155/2012/190624 [DOI] [PMC free article] [PubMed]
- 10.Atta MA, Elabbady A, Sameh W, Sharafeldeen M, Elsaqa M. Is there still a role for bilateral orchidectomy in androgen-deprivation therapy for metastatic prostate cancer? Arab J Urol. 2019;18:9-13. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Nwafor CC, Nwafor NN. Morphologic patterns of testicular lesions in Uyo: A university hospital experience. Sahel Med J 2019; 22:18-22. [Google Scholar]
- 12.Niedzielski J, Pisarska K, Przewratil P. The usefulness of testicular atrophy index in the assessment of undescended testicle--preliminary report. RoczAkad Med Bialymst. 2003; 48:112-4. [PubMed] [Google Scholar]
- 13.Bujan L, Mieusset R, Mansat A, Moatti JP, Mondinat C, Pontonnier F. Testicular size in infertile men: relationship to semen characteristics and hormonal blood levels. Br J Urol. 1989; 64:632-7 [DOI] [PubMed] [Google Scholar]
- 14.Tekumalla A, Ragi S, Thota R. Histopathological analysis of testicular lesions- a three-year experience in a tertiary care center, Telangana. Trop J Path Micro 2019; 5:260-8. [Google Scholar]
- 15.Abdulkadir A, Sanusi HM, Alhaji SA. Histopathological pattern of testicular lesions in Kano, Northwestern Nigeria. Niger J Surg 2019; 25:158-62. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Oranusi CK, Onyiaorah IV, Ukah CO. Pattern of Testicular Biopsies as Seen in a Tertiary Institution in Nnewi, Southeast Nigeria. Niger J Surg 214; 2:55-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Albasri AM, Hussainy AS. Histopathological pattern of testicular diseases in western Saudi Arabia. Saudi Med J 2018; 39:476-80. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Baidya R, Sigdel B, Baidya NL. Histopathological pattern of testicular lesion. Journal of Pathology of Nepal 2017; 7:1087-90. [Google Scholar]
- 19.Greaves P. Histopathology of preclinical toxicity studies: interpretation and relevance in drug safety evaluation. 3rd ed. Elsevier, BV; 2022:661-716.
- 20.Kahn RI, McAninch JW. Granulomatous disease of the testis. J Urol. 1980;123:868-71 [DOI] [PubMed] [Google Scholar]
- 21.Perimenis P, Athanasopoulos A, Venetsanou-Petrochilou C, Barbalias G. Idiopathic granulomatous orchitis. Eur Urol. 1991;19:118-20 [DOI] [PubMed] [Google Scholar]
- 22.Sakuma T, Den S. [A case report of granulomatous orchitis--review of 20 cases in Japan]. Nihon Hinyokika Gakkai Zasshi. 2001; 92:30-3 [DOI] [PubMed] [Google Scholar]
- 23.Wegner HE, Loy V, Dieckmann KP. Granulomatous orchitis--an analysis of clinical presentation, pathological anatomic features and possible etiologic factors. Eur Urol. 1994; 26:56-60. [DOI] [PubMed] [Google Scholar]
- 24.Laher A, Ragavan S, Mehta P, Adam A. Testicular Torsion in the Emergency Room: A Review of Detection and Management Strategies. Open Access Emerg Med. 2020; 12:237-46. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Schick MA, Sternard BT. Testicular Torsion. [Updated 2022 May 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022. Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448199/ [PubMed] [Google Scholar]
- 26.Fehér MA, Bajory Z. A review of main controversial aspects of acute testicular torsion. Journal of Acute Disease. 2016; 5: 1-8. [Google Scholar]
- 27.Reddy H, Chawda H, Dombale V D. Histomorphological analysis of testicular lesions. Indian J Pathol Oncol 2016; 3:558-63. [Google Scholar]
- 28.Mandong BM, Madaki AKJ, Mannaseh AN. Malignant diseases in Jos: a follow up. Ann Afr Med. 2003; 2:4–53. [Google Scholar]
- 29.Mandong B, Manasseh A, Ayuba D, Olugbenga S, Emmanuel I, Kwaghe B, Mandong J. Burden of Cancer in Plateau State, Central Nigeria: A 27-Year Report from a Tertiary Hospital-Based Cancer Registry. Journal of Advances in Medicine and Medical Research, 2019; 28:1-11. [Google Scholar]