Detection and Management of Pediatric Conditions That may Affect Male Fertility

Geolani W. Dy, MD; Melissa Rust, MSPAC; Pamela Ellsworth, MD, FAAP, FACS

Disclosures

Urol Nurs. 2012;32(5):237-248. 

In This Article

Acquired Insults

Acquired insults impacting male fertility include testicular torsion, incarcerated hernia inguinal hernia (interrupting testicular blood flow), and trauma or rupture of the testis or any component of the male reproductive system. Ischemia or reperfusion injury, development of immunologic infertility, and obstruction from scar tissue are major contributing mechanisms. Infectious causes include mumps orchitis in the post-pubertal male. In a study of adolescent youth (age 14.9 +/- 1.0 year) in the United States, Durant, Rickert, Ashworth, Newman, and Slavens (1993) found that 6.5% reported using steroids without a physician's prescription. These children were likely to use other drugs, such as cocaine, smokeless to bacco, and marijuana. The reproductive effects of anabolic steroids may not be permanent and may reverse with discontinuation of the steroids (National Institute on Drug Abuse, 2006). Cocaine use has been associated with oligospermia and defects in sperm morphology and motility (Bracken et al., 1990; Hurd et al., 1992). Cigarette smoking may have adverse effects on male fertility by reducing sperm production, motility, and morphology. Smoking tobacco may also lead to the development of pyospermia, decreased sperm penetration, and hormonal alterations (Nudell, Monoski, & Lipshultz, 2002; Sigman, 2007; Thonneau et al., 1991; Vine, Margolin, Morrison, & Hulka, 1994).

Testicular Torsion

Torsion of the spermatic cord is a common urologic emergency among adolescent males and a risk factor for infertility. In terruption of testicular blood supply in complete torsion can cause irreversible ischemia requiring orchiectomy. If diagnosed and corrected surgically within six hours, the testis is usually salvageable. However, long-term damage may occur despite timely correction by various mechanisms. The blood-testis barrier is damaged, and the immune system becomes inoculated with testis antigens and anti-sperm antibodies that cause immunologic infertility during reproductive years.

Prepubertal torsion does not appear to impact fertility because the contralateral testes undergo normal development (Puri, Barton, & O'Donnell, 1985). Further, torsion in the prepubertal male does not cause autosensitization and diminished fertility in adult life.

Evaluation. Patients are often prepubertal or early postpubertal males who present to the emergency department with sudden onset severe lower abdominal or scrotal pain with scrotal swelling. Physical findings include an edematous, extremely tender testis, which may be elevated or retracted compared to the contralateral size due to shortening of the cord. The cremasteric reflex is usually absent on the torsed side.

Because the treatment for torsion is surgical, it is important to distinguish this from other etiologies of scrotal pain, such as orchitis, epidydimitis, torsion of the appendix testis, and testicular trauma. Technetium-99m pertechnetate scans, and color Doppler ultrasound have been used to differentiate infectious or inflammatory causes from torsion based on blood flow patterns; the former shows increased flow, the latter ischemia. Ultra sound is easier to obtain and more cost-efficient than nuclear imaging (see Figure 2) (Karadeniz et al., 1996). When history, physical examination, and imaging are not adequate, surgical exploration provides a definitive diagnosis and is the appropriate treatment.

Figure 2.

Scrotal Ultrasound Demonstrating Testicular Torsion
Note: The inhomogeneous appearance to testis and reactive hydrocele can be seen in this image. The Doppler component showed no flow to the testis.

Management. The clinician may first attempt manual reduction of the torsed cord, but immediate surgical exploration is still required. If detorsed within six hours, up to 90% of patients may have testicle salvage; at 24 hours, however, salvage rates drop to 10% (Tryfonas et al., 1994). Bilateral orchiopexy is indicated for acute torsion of the spermatic cord because bilateral involvement is common, especially in males with the "bell clapper" deformity who have failure of normal anchoring of the testis. In these and other patients, there is high risk of recurrent torsion, threatening fertility.

Impact on Fertility. Postpubertal unilateral testicular torsion appears to be responsible for inducing pathologic changes in both testes. While duration of torsion determines initial ischemia, surgical correction may contribute to ischemia/reperfusion injury and oxidative stress that further impairs spermatogenesis (Minutoli et al., 2009; Turner, Bang, & Lysiak, 2004). Various studies have highlighted more insidious mechanisms of testis damage: breakdown of the bloodtestis barrier causing immunologic infertility (Merimsky, Orni-Wasserlauf, & Yust, 1984), extensive apoptosis in the contralateral testis via cytokine release (Hadziselimovic, Geneto, & Emmons, 1998), and most recently, late impairment of both endocrine and exocrine functions of the testis (Romeo et al., 2010).

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