Normal embryology and anatomy

 The normal adult testis is a paired organ that lies within the scrotum
suspended by the spermatic cord
 . The average weight of each testis is 15 to 19 g,
 the right usually being 10% heavier than the left.
 The organ is covered by a capsule composed of three layers the outer
serosa or tunica vaginalis (covered by a flattened layer of mesothelial
cells), the tunica albuginea, and the inner tunica vasculosa
The posterior portion of the capsule, called the mediastinum, contains
blood and lymph vessels, nerves, and the mediastinal portion of the rete
testis
 The parenchyma is divided into approximately 250 lobules,
 each lobule containing up to four seminiferous
Inside the Scrotum

 Each testes is enclosed by the

tunica vaginalis, a continuation of
the peritoneum that lines the
abdominopelvic cavity.
 A fibrous capsule covers each
testis called the tunica albuginea.
Testicle 3

 The tunica albuginea gives

rise to septa (partitions) that
divide the testis into lobules
(about 250)
 Each lobule contains 3 or 4
highly coiled seminiferous
tubules
 These converge to become
rete testis which transport
sperm to the epididymis
Seminiferous Tubules

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Seminiferous Tubules Histology

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 cryptorchidism
 Absence of one or both testes in the scrotum
 Most common congenital abnormality of the genitourinary tract
 Associated with infertility and subfertility, testicular germ cell
tumor, testicular torsion and inguinal hernia
 In one out of every ten males, the testis has not descended into the
scrotum at the time of birth but has remained in the inguinal region or
abdomen
 Most of these "retained" or "retractile" testes descend into the scrotum
during the first year of life
 In only 1 in 100 individuals will a permanent retention of the testis out
side the scrotum occur a condition known as cryptorchidism
 The exact pathogenesis is unknown, but most evidence
favors a role for testosterone under the influence of the
hypothalamic-pituitary axis.
 Cryptorchidism is unilateral in 80% of the case
 Long-term consequences of cryptorchidism may include
testicular malignancy and infertility/subfertility.
 Undescended testicle may be located in the abdomen or
inguinoscrotal region
•80% of undescended testicles palpated within inguinal canal or
high scrotal area
•20% of undescended testicles not palpated
• 50% lie in abdomen, 50% are atrophic .
•Associated with increased risk of testicular germ cell tumor
• Increasing risk of malignancy with delayed treatment
• Relative risk of malignancy is 2 - 8x; higher risks
associated with delayed repair, bilateral cryptorchidism
• Seminoma is most common malignancy
Grossly,
cryptorchid testes in adults are small and brown.

Microscopic (histologic) description

•Histopathologic differences become much more pronounced after 2 years of life and are
increased with delayed orchiopexy
•Peritubular fibrosis
•Seminiferous tubule atrophy
•Decreased / absent spermatogenesis
•Sertoli cell only seminiferous tubules: tubules with only bland, monotonous pale cells with
granular cytoplasm attached to the basement membrane; absent germ cells and no
spermatogenesis
Atrophy and infertility
• Atrophy
• Definition / general
•Testicular atrophy is a nonneoplastic process characterized by the
disappearance of tubular or germinal epithelium and replacement with variable
degrees of fibrosis
•Atrophy can present in the setting of testicular regression syndrome,
postvasectomy, vascular accidents, testicular torsion, cryptorchidism, infectious
process, external insults, iatrogenic and other settings
Etiology
•Vascular accident, testicular torsion, thrombosis .
•Trauma
•Cryptorchidism
•Genetic abnormalities, such as microdeletion of Y chromosome, persistence of Müllerian duct
structures .
•Filariasis and other infectious etiologies .
•AIDS .
•Chemotherapy and radiation
•Vasectomy, outflow obstruction
•Hormonal imbalances (e.g., persistent FSH stimulation, elevated serum estrogen)
•Sequela of COVID-19 infection .
Microscopic (histologic) description
•Small tubules, thick basement membrane and few or no germ cells in
Sclerotic tubules
•Interstitial fibrosis
•Increased Leydig cells
The causes of male infertility fall into one of three categories:
pretesticular,
testicular,
and post-testicular.
• The pretesticular causes are extragonadal endocrine disorders usually originating in the
pituitary or adrenal gland.
• The testicular causes are primary diseases of the testes, and little treatment is available at the
present time.
• The post-testicular causes consist mainly of obstructions
of the ducts leading away from the testes.
Infertility
•Definition / general
Causes: pretesticular, testicular, posttesticular
•Pretesticular: extragonadal endocrine disorders (hypothalamic, pituitary, adrenal); includes elevated
prolactin levels .
•Testicular: little treatment currently available
•Posttesticular: duct obstruction (congenital, inflammatory, postsurgical); surgical treatment often
successful since spermatogenesis is normal
• Impaired sperm motility due to epididymal or immunologic factors is considered posttesticular
•Evaluation: history and physical examination, semen analysis, white blood cell count in semen, detection of
antisperm antibodies, sperm function tests (cervical mucus interaction, ova penetration, hemizonal assay)
•Testicular biopsy is helpful for azoospermia without endocrine abnormalities
•RNA binding motif: nuclear immunostain identifies spermatogenesis in biopsies that appear to be Sertoli
cell only.
The evaluation of the infertile male includes
1. clinical history and examination
2. semen analysis
3. white blood cell count in semen
4. search for antisperm antibodies.
5. sperm function tests (cervical mucus interaction, ova penetration)
6. testicular biopsy particularly useful in the individual with azoospermia
and normal endocrine findings

The material should be handled with extreme care Zenker's and

Bouin's fixatives are used.
Biopsy specimens from infertile men with total lack of
spermatozoa (azoospermia) usually show one of the following
conditions:
1. Germ cell aplasia (Sertoli cell-only syndrome) (29%),
In which the tubules are populated by only Sertoli cells,
thickening of the tubular basement membrane;
germ cells are completely absent
2. Spermatocytic arrest (26%), characterized by a halt of
the maturation sequence, usually at the stage of the
primary spermatocyte no spermatids or spermatozoa are present despite the
presence ofabundant cells in division

3. Generalized fibrosis (18%).

4 .Normal spermatogenesis(27 %).
Sertoli cell only syndrom
Maturation arrest
• Definition / general
• Complete maturation arrest: germ cell maturity ceases at a specific point frequently at primary
spermatocyte level; sperm counts usually zero
• Incomplete maturation arrest: similar to complete but a few late spermatids are present in a
few seminiferous tubules, some prefer the term hypospermatogenesis instead of incomplete
maturation arrest; patients are usually oligospermic .
•Etiologies (diabetes mellitus, toxins, excess heat, varicocele, hypothyroidism, irradiation); also
postpubertal gonadotropin deficiency, alkylating agents
•Patients with early maturation arrest have a greater incidence of genetic anomalies and are more
likely to have worse reproductive outcomes than are patients with late maturation arrest.
Microscopic (histologic) description
• Numerous spermatogonia,
• few spermatocytes,
• no mature spermatozoa
• Sertoli cells prominent since reduced germ cells
• Tubules often contain degenerated cells.
 Torsion of the testis:- (rotation of the organ 360ْ around it
longitudinal axis resulting in interruption of its blood supply) Sudden
severe physical exercise or congenital anomalies that leads to
increasing the mobility of the testis and epididymis such high
attachment of tunica vaginalis on the spermatic cord, incomplete
descened of the testis or absent of the scrotal ligments. These
above causes may lead to complete torsion with sudden onset of
severe scrotal pain followed by swelling and hemorrhagic infarction
of the testicular germ cells within few hours. Recurrent incomplete
torsion of the spermatic cord results in small fibrotic testis.

Vascular Related

 Torsion
 Venous
compression
 Hemorrhagic
infarct
 Young men
 At night
 Very painful
 Can be reduced
Inflammatory Lesions
 Inflammatory lesions of the testis are more common in the epididymis than in
the testis proper. Some of the more important inflammatory diseases of the testis are
associated with venereal disease.
 Other causes of testicular inflammation include nonspecific epididymitis and orchitis,
mumps, and tuberculosis.
 Nonspecific epididymitis and orchitis usually begin as a primary urinary
tract infection with secondary ascending infection of the testis through the vas
deferens or lymphatics of the spermatic cord. The involved testis is typically swollen
and tender and contains a predominantly neutrophilic inflammatory infiltrate.
 Orchitis complicates mumps infection in roughly 20% of infected adult males but
rarely occurs in children. The affected testis is edematous and congested and
contains a predominantly lymphoplasmacytic inflammatory infiltrate. Severe cases
may be associated with considerable loss of seminiferous epithelium with resultant
tubular atrophy, fibrosis, and sterility.
Epididmitis
 Disorders of the testicular tunica:-
 Hydrocele: - is the most common cause of the scrotal swelling
and it refers to collection of serous fluid in the scrotal sac (tunica
vaginalis). It is either congenital or acquired due to inflammatory
disorders of the epididymis and the testis. Uncomplicated hydrocele
usually presented with unilateral scrotal swelling.
 Hematocele:- refers to hemorrhage into a hydrocele
 Hydrocele
 Fluid filled scrotal cyst.
 Benign
 Often with inguinal
hernia
 Transilluminates
 Fluid will recollect if
aspirated.
 Can be large
 Spermatocele:- a cystic enlargement of the efferent ducts or
ducts of rete testis. Clinically it is indistinguishable from the
hydrocele but the presence of sperm in the fluid of the
spermatocele differentiates this cystic enlargement from a
hydrocele.
 Varicocele: - dilation of the testicular vein which is usually a
symptomatic. Most varicoceles are detected during the physical
examination of infertile men, it usually accompanied by testicular
atrophy resulting in infertility. Surgical treatment with ligation of the
internal spermatic vein may need but the subsequent fertility is
inversely related with the duration and the severity of injury to the
testicular germ cells prior to the treatment.