Syphilis occurs in secondary and tertiary manifestations, usually first in the testis, sometimes in the epididymis, but always in the testicle before the cord. It produces nodules which may be mistaken for those of tuberculous trouble, but which often attain much larger size. They are usually painless. Nevertheless a syphilitic testicle is sometimes tender, and constantly so, to a degree causing no little annoyance. The occurrence of nodules in the epididymis, in connection with other evidences of syphilis, is regarded by some as pathognomonic. In this location the condition yields readily to properly directed treatment.
CYSTS OF THE TESTICLE.
Cysts are frequently found along the course of the epididymis. Some of them are expansions of the natural tubes of the paradidymis, while others are distinctly new. Dermoids are occasionally met, and either of these may attain considerable size. Cyst of the epididymis proper is to be distinguished from encysted hydrocele of the cord. All of these purely cystic conditions are essentially innocent, and need similar treatment. They may be evacuated and injected with an irritant like pure carbolic acid, which is sometimes an effective way, or they are better treated by open incision with extirpation of the cyst, which is, in the end, far the more satisfactory course to pursue.
EPIDIDYMITIS AND ORCHITIS.
Each of the separate portions of the testis may have its own nearly self-limited inflammations and infections, or both may participate in a common lesion. The most frequent cause of an acute epididymitis is gonorrhea, the infection travelling from the urethra along the vas, and causing acute and well-marked swelling of the epididymis, which becomes tender and painful in proportion to the amount of exudate. It may come on early or late, during the course of the urethritis. The condition is known to the laity as “swelled testicle.” It has been frequently called orchitis, which is an error, since however much the testis may later participate the primary trouble is in the epididymis. It may be easily distinguished by palpation, the enlarged and hardened epididymis, often very tender, being prominent behind the testis proper. The condition may, however, be masked by the acute effusion likely to occur in the tunica vaginalis, constituting a mild degree of acute hydrocele. This may be expected in nearly all severe cases, and serves to increase the size of the entire mass. A testicle thus affected may assume much more than normal dimensions, and, becoming thereby much heavier, drag upon the cord, which is its normal support. More or less fever and malaise accompany the condition, part of which may be due to the toxemia of gonorrheal infection. Usually but one side is involved. Both are rarely affected simultaneously, but one may follow the other.
The acute stage of gonorrheal epididymitis persists for a week or ten days, even under the best of treatment, and is followed by gradual subsidence, characterized by amelioration of symptoms and decrease in size.
Treatment.
—This improvement is to be induced, first, by rest in bed, with elevation of the scrotum, and the ordinary eliminative treatment suitable for any febrile condition. Local relief may come from the application either of heat or of ice-bags, the latter being preferable, but will be made more effective by the application over the scrotum of a mixture of two parts of olive oil with one part of methyl salicylate, or of guaiacol reduced with equal parts of oil or glycerin. The anointed surface should be covered with some impervious material, and the dressing be changed every few hours. Later, as the acute merges into the chronic condition, absorption may be stimulated by the ordinary mercurial ichthyol ointment.
In some exceedingly acute cases suppuration ensues, the consequences being a collection of pus in the epididymis, which will give the ordinary signs and call for the usual evacuation which every collection of pus demands. Epididymitis, more or less acute, has been known to follow the introduction of the catheter or sound, even in cases so far as known not previously infected. It is difficult to explain, but requires the same treatment as above.