Testicular atrophy is a decrease in the mass and volume of the sex glands, accompanied by a violation of function or its complete cessation. Symptoms depend on the time of occurrence: during puberty, testicular atrophy is accompanied by a violation of puberty, adult men develop erectile dysfunction and infertility associated with androgen deficiency. Diagnostic measures correlate with the clinical situation: hormonal background, spermogram are evaluated, scrotum ultrasound is performed, STI testing is performed. Treatment is prescribed taking into account the pathogenesis, testosterone-based drugs are more often used.
General information
Testicular atrophy (testicular atrophy, primary hypogonadotropic hypogonadism) is an acquired pathology. Most often, the process develops as a result of the abuse of anabolic steroids and narcotic drugs, as well as after radiation therapy during the treatment of tumor processes of the testicle and pelvic organs. In patients over 60 years of age, symptoms are associated with a natural decrease in androgen production (a variant of the norm). The difference between atrophy and hypoplasia is the initially normal size of the testicles, the presence of fully developed cellular structures and the fact of their full functioning.
Reasons of testicular atrophy
There are many reasons contributing to the development of testicular atrophy; more often the pathology is associated with external factors. Hormonal imbalance is considered one of the most common initiators of the process. Sometimes hormonal disorders develop primarily, but usually the disorder is a consequence or side effect of taking medications or other treatment methods, for example, undergoing radiation therapy. Conditions that potentially cause atrophy include:
- Varicocele, testicular torsion. Dilation of the veins of the spermatic cord causes excessive blood flow to the testicle. The death of the spermatogenic epithelium and a decrease in the size of the organ is associated with exposure to elevated temperature. Twisting of the spermatic cord with untimely help for 6 hours can lead to testicular atrophy due to the cessation of blood flow.
- Injuries, operations. Trauma to the inguinal region, operations on the genitals or for an inguinal hernia with damage to innervating structures potentiate trophic disorders. Sometimes delayed relegation with orchipexia with bilateral cryptorchidism leads to the death of functioning cells, compaction of testicles. The danger of such a condition is the risk of developing a tumor process. The passage of radiation and chemotherapy is considered as a damaging factor.
- Inflammatory and infectious processes. Bacterial orchitis often develops with STIs (chlamydia, gonorrhea). Contributing circumstances include prolonged catheterization. Viral orchitis is more often diagnosed against the background of endemic mumps. Testicular atrophy is a common phenomenon in HIV infection and tuberculosis lesion of the testicles.
- Testosterone replacement therapy. It has been proven that testicular atrophy develops in people who receive hormonal drugs for a long time. This is due to the fact that exogenous administration of the hormone disrupts the work of the hypothalamic-pituitary-gonadal axis. The endocrine glands receive a command not to produce their own testosterone, since it already circulates in sufficient quantities in the blood.
- Taking anabolic steroids, estrogens. The use of anabolics to achieve success in sports, building muscle mass causes the same effect as hormone replacement therapy with testosterone. Estrogens are prescribed for prostate cancer to suppress the synthesis of androgens, since the tumor in most cases is hormone-dependent on testosterone.
Predisposing factors include obesity, chronic alcohol intoxication, contributing to hypoandrogenism and damage to testicular structures. The process is based on the degeneration of the germinal epithelium with the replacement of functional tissue with connective tissue. In men during andropause, testosterone synthesis decreases, which affects the size of the testicles. The process is considered physiological. Less common causes of pathology are hypoparathyroidism, hemochromatosis, severe liver and kidney diseases.
Pathogenesis
Testicles consist of two different types of cells. The spermatogenic epithelium of the convoluted seminal tubules produces spermatozoa, and Leydig cells produce the sex hormone testosterone. With atrophy, one or both types of cells gradually die off, which leads to a violation of spermatogenesis (later infertility), contributes to the appearance of symptoms of androgen deficiency and a disorder of spermatogenesis. Toxic substances initiate cellular hypoxia, since they have a competing ability to displace oxygen in the hemoglobin molecule with toxic damage to red blood cells.
An infectious-toxic factor has a pathological effect on the male sex glands. In chronic and acute intoxication, direct effects on the generative structures of the glands and indirect effects are recorded due to a violation of the barrier function of the liver, central nervous system damage. Taking estrogens leads to sclerosis, replacement of functional structures with connective tissue elements. Damage to the iliac-subcutaneous nerve during herniation or against the background of scarring in the postoperative period causes testicular atrophy due to innervation disorders.
Symptoms of testicular atrophy
With the development of pathology before puberty, symptoms include the absence of secondary sexual characteristics: there is no hair on the face, in the pubic area, armpits, there is an underdevelopment of the penis, a lag in development. If the process began after the age of 16, it is characterized by a decrease in libido, a decrease in muscle mass with a normal penis size, gynecomastia. The testicles are soft on palpation, the size does not correspond to age. The growth of body hair is poorly expressed. During ejaculation, the volume of ejaculate is reduced, the sperm is watery, orgasmic sensations are erased.
Hypoandrogenemia is manifested by asthenic symptoms: fatigue, a tendency to depression. Patients complain of cognitive impairment, typically memory impairment, ability to concentrate. With pronounced androgen blockade, hot flashes occur periodically, similar to those in women during menopause, accompanied by redness of the face, profuse sweating, palpitations. Atrophy of one testicle does not lead to such significant clinical manifestations, some symptoms of hypogonadism may be observed.
Complications
The consequences of a long-term androgen deficiency include impaired sexual function, infertility. Improper metabolism associated with glandular atrophy leads to fat deposition in the abdomen, buttocks and thighs (female obesity), diseases of the cardiovascular system. Patients with symptoms of hypogonadism are more susceptible to the development of persistent hypertension, heart attack, stroke. Hypoandrogenism increases the probability of diabetes mellitus by 2-4 times. With atrophy (more often against the background of cryptorchidism), testicular tumors are often formed.
A complication of the pathological process is a decrease in bone density (osteoporosis), in which the probability of fractures even after a minor traumatic impact increases due to calcium leaching. It has been proven that the lack of adequate therapy for hypotestosteronemia increases the risk of mortality in men over 45-50 years of age by 78%. Patients with undiagnosed pathology often suffer from depressive disorders.
Diagnostics
After analyzing the complaints, the andrologist proceeds to a physical examination. The specialist pays attention to the size of the testicles, their consistency, the condition of the appendages. Soft insensitive testicles indicate a violation of the functions of the organ. After the transferred inflammation, a thickened appendage can be palpated. Scrotal hernias, large cysts, bilateral hydrocele contribute to dystrophy. Palpation of the prostate confirms a decrease in its size, a testy consistency. Diagnostics include:
- Laboratory tests. A spermogram with complete testicular atrophy shows azoospermia. Pathological forms of spermatozoa are suspicious of genetic pathology. To exclude inflammatory genesis, PCR tests for STIs are performed, ejaculate seeding on flora. According to the indications, a study of the hormonal profile, blood biochemistry is prescribed. Testicular atrophy is confirmed by low testosterone levels with an increase in FSH hormones, LH. The HcG test is negative.
- Instrumental examination. Ultrasound of the scrotum visualizes the deviation of the size of the genital glands from the norm (length less than 4-5 cm, thickness less than 2.5-2 cm for an adult male). MRI and CT are more indicative in the diagnosis of bilateral tumor process. If the pathology occurred before puberty, radiography confirms that the bone age is lagging behind the passport age. Densitometry makes it possible to determine the mineral density of bone tissue.
Differentiation is carried out with congenital hypoplasia of the testicles, hypogonadism of central genesis (with tumors of the pituitary gland, hypothalamus). Physical examination does not allow distinguishing acquired glandular atrophy from congenital hypoplasia, so the examination plan is made depending on the clinical picture as a whole. If genetic syndromes are suspected, one of the symptoms of which is hypogonadism, the consultation of a geneticist is justified.
Treatment of testicular atrophy
Therapeutic measures depend on the patient’s age, concomitant pathology, and the severity of hypoandrogenism. Treatment is usually aimed at correcting the underlying cause. Total testicular atrophy is often irreversible, the symptoms are leveled by HRT with testosterone. Hormone therapy is contraindicated in patients with breast and prostate cancer (until the condition stabilizes for several years). The possibility of the subsequent use of testosterone in prostate carcinoma is still debatable.
Conservative treatment
Modern pharmacology has many forms for comfortable administration of natural testosterone preparations: transdermal patches, intramuscular, subcutaneous injections, including with prolonged action. In age-related patients with testicular atrophy, the level of PSA – an oncomarker of prostate cancer is assessed during therapy, with an increase in the indicator, hormones are canceled. For the possibility of rapid withdrawal of the drug, men over 45 years of age are usually prescribed short-acting drugs. It is important to avoid the superfysiological level of androgens in the blood.
Due to the development of polycythemia during therapy during the first year, blood counts are monitored every 3 months, then 1 time a year. The lack of effect implies the cancellation of treatment. For some patients with sexual dysfunction, HRT alone is not enough, therefore, phosphodiesterase-5 inhibitors are included in the scheme. As a rule, testosterone stabilizes the emotional state of the patient, with additional intake of antidepressants, some of them can negatively affect spermatogenesis.
When using sex hormones against the background of treatment, the symptoms of androgen deficiency are leveled, but the own production of germ cells worsens. Therefore, given the importance of the prospect of fatherhood, it is better to discuss optimal approaches to therapy with an andrologist. Regular exercise, sufficient calcium intake can reduce or prevent the symptoms of osteoporosis. Bone strength is also affected by vitamin D, the intake of which is especially necessary for men living in areas impoverished by year-round sunlight.
Surgical treatment
In some cases, a donor organ transplant is resorted to, which allows the patient not to depend on lifelong hormone intake. There are several options for the location of the transplanted male sex gland: under the skin of the thigh or anterior abdominal wall, into the rectus abdominis muscle. During the Kirpatovsky transplant, the testicle is placed in the scrotum, but the blood supply to the organ is carried out through larger vessels that previously anatomically did not feed the gland. This allows us to achieve better results, reduce the risk of transplant rejection against the background of ischemia.
Other types of operations for testicular atrophy are aimed at eliminating the contributing cause: with cryptorchidism, organ reduction, orchopexy (hemming) is performed, while it is important to observe the dynamics, since prolonged thermal exposure to the gland in the abdominal cavity is considered as a risk factor for a tumor. With varicocele, blood circulation in the veins of the spermatic cord is surgically normalized. Habitual or acute hydatid implies orchopexy to ensure immobility of the testicle.
Prognosis and prevention of testicular atrophy
The vital prognosis is favorable, but testicular atrophy and infertility in some cases are irreversible. For some men, the only way to become a father to a biologically native child remains assisted reproductive technologies – IVF by ICSI after sperm extraction with testicular biopsy. Regular intake of hormonal drugs allows you to maintain a normal quality of life.
Prevention means giving up alcohol and smoking. It is unacceptable to take corticosteroids independently to improve a sports career, especially during puberty. A man needs to limit contact with industrial poisons as much as possible: ethylamine, ammonia, organic peroxides and heavy metal salts. Regular examinations by a urologist and an andrologist are important to identify predisposing conditions. Timely referral to a specialist for acute scrotum syndrome helps prevent the process of necrotization and testicular atrophy.
Literature
- Andrology. Men’s health and dysfunction of the reproductive system/ ed. Nishlaga E., Bere G.M. — 2005. link
- Andrology/ Tiktinsky O.L., Mikhailichenko V.V. – 1999.
- International web survey shows high prevalence of symptomatic testosterone deficiency in men/ Trinick TR, Feneley MR, Welford H, Carruthers M.// TheAgingMale – 2015 – №1. link
