SYPHILIS AND TUBERCULOSIS OF THE TESTIS
Syphilis of the testicle was once a common sequela of untreated primary syphilis but is now very unusual. Historically, syphilitic orchitis occurred as an interstitial infection or caused necrosis or gumma formation. The interstitial infection is insidious and indolent, unilateral or bilateral, and usually painless. An accompanying hydrocele is the rule. The testicle is usually hard and smooth like a “billiard ball” as a result of inﬁltration of plasma cells and ﬁbrous tissue, which eventually leads to testicular ﬁbrosis. Gummas or syphilitic granulomas are characterized by areas of necrotic nodules in the testicle. The ﬁbrous tissue surrounding the coalesced gummatous nodules also results in considerable hardness to palpation. The epididymis is rarely involved during the initial stage of testis infection, although syphilitic epididymitis may be a primary presentation of syphilis. As the tunica vaginalis and epididymis become involved, there is adherence and extension to the scrotal skin, which may slough and ulcerate. Although patients do not experience signiﬁcant pain, there may also be enlargement of the inguinal nodes. Despite the dramatic presentation of a hard testis, it was frequently unnoticed by both patient and physician.
Tuberculosis of the testicle is almost always preceded by epididymal infection; primary involvement of the testicle alone is rare. Once uncommon, there has been a resurgence of tuberculous epididymitis in inner-city areas and in HIV-positive men. Because 15% of tuberculosis occurs as an isolated genitourinary infection without systemic miliary signs or symptoms, this presentation of tuberculosis appears identical to other forms of bacterial epididymitis but is suspected when the infection becomes refractory to common bacterial antibiotics. The disease is frequently bilateral and will not heal without speciﬁc antituberculous therapy. Extension of tuberculous epididymitis to the testicle is a common but later development in untreated cases. More often, epididymoorchitis occurs from constitutional disease. Systemic tuberculous infection proceeds in a descending fashion down the genitourinary tract from renal tuberculosis to the bladder, prostate, vas deferens, and epididymis. The affected vas deferens often feels like a “string of pearls” with intermittent, skip areas of scarring and atrophy between areas of normal vas deferens.
Genital tuberculosis begins with classic tubercle formation, either localized or diffuse. Destruction of tissue by caseation follows, often accompanied by ﬁbrosis and calciﬁcation. Not uncommonly, there may be involvement of the scrotal skin through cutaneous sinuses or the development of a rigid, thick tunica vaginalis containing clear or purulent ﬂuid. When untreated, there is a great tendency for the infection to become chronic and stagnant. The process may remain dormant for long periods of time and then become acute or subacute.
Left untreated, tuberculosis is lethal to two of every three infected persons. The mainstay of treatment for the last 50 years has involved multidrug therapy with isoniazid, rifampicin, pyrazinamide, and ethambutol. Although this therapy is considered curative, multidrug-resistant strains are increasing. With healing, scar tissue is common and surgical procedures may be necessary to restore function in the genital tract.