Duplex cryptorchid testis presenting as a strangulated hernia: A Case Report

Mr. Marc Clancy, Consultant Surgeon

Western Infirmary, Glasgow

marcclancy@hotmail.com

Mr. Bryce Renwick, Surgical Trainee

brycie@doctors.net.uk

SMJ 2009 54(1): 58

Abstract

Testicular duplication is an extremely rare condition. It is usually asymptomatic or found incidentally at examination. In this case a relatively common clinical scenario proves to represent a duplex, cryptorchid testis. The aetiology of this condition, its management and implications for malignancy and fertility are reviewed.

 

Background

Duplex testis is a rare congenital abnormality. It may present with torsion, inguinal hernia, cancer or hydrocele. Two main theories of development have been proposed, involving transverse or longitudinal division of the embryological genital ridge.1 The testis may be functional or nonfunctional, depending on the attachment to other structures such as the vas and epididymis. In 50% of cases there are three scrotal testes, the remainder being made up of a range of developmental outcomes involving one to four testes.

 

Cryptorchidism is a relatively common finding, with an incidence of 1% in the healthy population. It is associated with inguinal hernia formation, increased incidence of torsion and of germ cell tumors. Fertility may be affected.

 

A tender, reducible groin lump is a common presenting symptom to the emergency general surgeon. The differential diagnosis is broad, including impending incarceration of an inguinal hernia, femoral artery aneurysm and infective or malignant processes.2 We report on a duplex, cryptorchid testis presenting as a tender, reducible groin lump.3

 

Case presentation

A previously fit and well 25 year old male, presented to his local Emergency Department with an intensifying left groin pain over the last five days. This was not associated with any altered bowel habit, although he had vomited several times. He did not complain of any urinary symptoms. He had no significant family history and was yet to begin his family. His job involved some heavy lifting. 

 

On examination he was in obvious discomfort, but was hemodynamically stable and apyrexial. Abdominal examination was essentially unremarkable, being non-tender with normal bowel sounds. Abdominal distension was absent. Rectal examination was normal. 

 

The right groin was unremarkable. The left groin was tender with a small round reducible mass. Examination of the external genitalia revealed a normal scrotum with two nontender testes. There was no abnormality at the penis or epididymis. 

 

On this basis a diagnosis of intermittently irreducible left inguinal hernia was made. The admitting unit had a policy of immediate operation on all such herniae and the patient was taken to theatre for groin exploration and hernia repair. 

 

The routine approach to an inguinal hernia revealed a small ovoid structure slightly distal to the deep ring. After further delivery and dissection this was discovered to be a duplex cryptorchid testis, complete with a separate testicular artery and venous plexus. It was attached to the epididymis of the larger scrotal testis.  

 

At this stage a urology specialist opinion was sought. The presence of two palpably normal testes was reassuring, together with his well-developed secondary sexual characteristics and the absence of a vas deferens on the duplex organ. Therefore, the decision to remove the duplex testis was made. Subsequently, the anterior wall of the inguinal canal was reconstructed in a standard fashion and the skin closed. 

 

After an uncomplicated postoperative course the patient was discharged. Subsequent ultrasound scanning of his abdomen revealed normal appearances, with no evidence of contralateral testicular duplication.

 

Conclusions

Testicular duplication is an extremely rare condition with less than 100 reported cases worldwide. It is associated with inguinal hernia,4,5,6, torsion5, hydrocele5, cryptorchidism5,6 and malignancy.7 Previous diagnoses have been made by chance at operation for coincident hernia or torsion. The case presented is unique in that the tender reducible groin lump is the cryptorchid duplicate testis and there is no associated inguinal hernia.

 

The exact mechanism by which duplexes arise is unknown but is thought to involve transverse or longitudinal division of the germinal ridge.1 This may give rise to either functional or non-functional testes. Since there is a significant risk of malignancy in cryptorchid testes,7 orchidectomy is indicated where a duplex testis is maldescended. In this case, gross appearance and histology indicated that there would be no effect on fertility so immediate orchidectomy was performed.

 

When doubt exists over potential fertility and the future plans of the patient are uncertain, urgent specialist advice is necessary. A more conservative course with biopsy of all ipsilateral testicular tissue is preferable. This allows counseling and informed consent in the light of histology prior to definitive surgical management.

 

References

  1. Nocks BN: Polyorchidism with normal spermatogenesis and equal sized testes, ibid 120: 638 (1978)

  2. Kajbafzadeh AM: Bilateral duplication of undescended testes associated with testicular torsion. British Journal of Urology 1996; 78 (2): 305-319

  3.  Sujka SK, Ralabate JA, Smith RA. Polyorchism. Urology 1987; XXIX No3:307-309

  4. Leung AK, Polyorchidism. Am Fam Physician 1988; 38: 153-156

  5. Kale N, Basaklar AC. Polyoprchidism. J Pediatr Surg 1991; 26: 1432-1434

  6. Besner GE, Qualman SJ, Gosche JR. Identification of a duplicated undescended testicle (polyorchia): An unidentified benefit of laparoscopic localization. J Laparoendosc Surg 1996: 6(Suppl 1):S107-S114

  7. Kulkarni JN, Bhansali MS, Tongaonkar HB, Kamat MR, Borges AM. Carcinoma in the third testis in a case of polyorchidism and persistent Mullerian structure syndrome. Eur Urol 1992; 22: 174-176

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