Dialysis

Dialysis is an artificial process for removing waste products and excess fluids from the body, a process that is needed when the kidneys are not functioning properly.

There are a number of reasons why people may need dialysis, but kidney failure is the most common. For kidney failure, many doctors recommend dialysis when urine output is low and certain conditions develop. For acute kidney failure, doctors continue dialysis until the person's blood test results indicate that adequate kidney function has been restored. For people with chronic kidney failure, dialysis may be used as long-term therapy or as a temporary measure until a kidney can be transplanted. Short-term or urgent dialysis can also be used to remove certain drugs or poisons from the body.

Making the decision to begin long-term dialysis is not easy because it entails a major change in lifestyle, including a dependency on machines to maintain life. However, for most people, a successful dialysis program results in an acceptable quality of life. Most people undergoing dialysis are able to eat a tolerable diet, have normal blood pressure, and avoid progression of nerve damage, severe anemia, and other severe complications.

Dialysis usually requires the effort of a team of people. A doctor completes a dialysis prescription, manages complications, and monitors the medical care. A nurse monitors the person's general well-being and mental health and educates the person about dialysis and what needs to be done to maintain the best possible health. A social worker arranges transportation and home assistance. A dietitian recommends an appropriate diet and monitors the person's response to dietary changes.

Reasons for Dialysis in Kidney Failure Doctors decide to place a person on dialysis when kidney failure is causing certain conditions: Abnormal brain function (uremic encephalopathy) Certain other severe symptoms, such as loss of appetite or vomiting with weight loss Inflammation of the sac around the heart (pericarditis) A high level of acid in the blood (acidosis) that does not respond to other treatments Heart failure Total body fluid overload Fluid overload in the lungs (pulmonary edema) that does not respond to other treatments A very high level of potassium in the blood (hyperkalemia) A high level of calcium in the blood (hypercalcemia) Greatly reduced kidney function

Types of Dialysis

There are two types of dialysis: hemodialysis and peritoneal dialysis.

Hemodialysis: In hemodialysis, blood is removed from the body and pumped by a machine outside the body into a dialyzer (artificial kidney). The dialyzer filters metabolic waste products from the blood and then returns the purified blood to the person. The total amount of fluid returned can be adjusted. Hemodialysis requires repeated access to the bloodstream. Doctors can achieve temporary access by inserting a large intravenous catheter in a big vein, usually one near the neck. An artificial connection between an artery and a vein (an arteriovenous fistula) is surgically created to make long-term access easier. In this procedure, typically the radial artery in the forearm is joined with the cephalic vein. As a result, the cephalic vein subsequently enlarges and blood flow through the vein increases, making the vein suitable for repeated puncture with a needle. When a fistula cannot be created, an artery and a vein may be surgically connected to each other using a synthetic connector (graft). In this situation, the synthetic graft is punctured by the needle for hemodialysis.

Hemodialysis

Heparin, a drug that prevents clotting, is administered during hemodialysis to prevent blood from clotting in the dialyzer. Inside the dialyzer, a porous artificial membrane separates the blood from a fluid (the dialysate). Fluid, waste products, and electrolytes in the blood filter through the membrane into the dialysate. Blood cells and large proteins are unable to filter through the small pores of the membrane and so remain in the blood. The dialyzed (purified) blood is then returned to the person's body.

Dialyzers have different sizes and degrees of efficiency. Dialysis treatment time is usually about 3 to 4 hours. Most people who have chronic kidney failure need hemodialysis 3 times a week.

Possible Complications of Hemodialysis Complication Usual Cause Fever Bacteria or fever-causing substances (pyrogens) in the bloodstream Overheated dialysate Life-threatening allergic reaction (anaphylaxis) Allergy to a substance in the dialyzer or blood tubing Low blood pressure Removal of too much fluid or excessive fluid gain between dialysis Abnormal heart rhythms Abnormal levels of potassium and other substances in the blood Low blood pressure Air embolus Air entering blood in the machine Bleeding in the intestine, brain, eyes, or abdomen Use of heparin to prevent clotting in the machine Infection Bacteria entering the bloodstream through a dialysis catheter or through a needle inserted into veins for hemodialysis access

Peritoneal Dialysis: In peritoneal dialysis, the peritoneum—a membrane that lines the abdomen and covers the abdominal organs—acts as a filter. This membrane has a large surface area and a rich network of blood vessels. Substances from the blood can easily pass through the peritoneum into the abdominal cavity. A fluid (dialysate) is infused through a catheter inserted through the abdominal wall into the peritoneal space within the abdomen. The dialysate must be left in the abdomen for a sufficient time to allow waste products from the bloodstream to pass slowly into it. Then the dialysate is drained out, discarded, and replaced with fresh dialysate.

A soft silicone rubber or porous polyurethane catheter allows the dialysate to flow smoothly and is unlikely to cause damage. A catheter can be put in place temporarily at the person's bedside, or it may be surgically put in place permanently. One type of permanent catheter eventually forms a seal with the skin and can be capped when not in use.

Various techniques are used for peritoneal dialysis.

Manual intermittent peritoneal dialysisis the simplest technique. In manual intermittent peritoneal dialysis, bags containing dialysate are warmed to body temperature and infused into the peritoneal (abdominal) cavity, which takes about 10 minutes. The dialysate is allowed to remain there (dwell time) for 60 to 90 minutes and then is drained out in about 10 to 20 minutes. This process is then repeated. The entire treatment can take 12 to 24 hours.

Automated cycler intermittent peritoneal dialysis is another technique. This technique uses a machine (cycler) to do automated exchanges of dialysate. Use of an automated cycler can reduce the need for nursing attention.

Peritoneal Dialysis

In continuous ambulatory peritoneal dialysis, the dialysate is kept in the abdomen for much longer intervals. Typically, the dialysate is drained and replenished 4 or 5 times a day. Generally three of these dialysate exchanges are performed during the day, with dwell times of 4 hours or longer. An exchange is performed at night with a long dwell time of 8 to 12 hours during sleep.

Continuous cycler-assisted peritoneal dialysis uses an automated cycler to perform short exchanges at night during sleep, whereas longer exchanges are performed manually—without the cycler—during the day. This technique minimizes the number of exchanges during the day but prevents mobility at night because of cumbersome equipment.

Choice of Method: Many factors, including lifestyle, must be considered in determining which type of dialysis is best for a person. People typically undergo hemodialysis at a dialysis center, usually outside of a hospital. Peritoneal dialysis can be performed at home, eliminating the need for travel to a hemodialysis center.

Doctors recommend hemodialysis for people with recent abdominal wounds or abdominal surgery or defects in the abdominal wall that make peritoneal dialysis difficult. Peritoneal dialysis is better tolerated in people whose blood pressure fluctuates frequently between periods of high or normal pressure and periods of low blood pressure.

Possible Complications of Peritoneal Dialysis Complication Cause Bleeding Unintentional perforation of an internal organ during placement of the catheter Removal of the catheter from the body Irritation and inflammation of the internal lining of the abdomen (peritoneum) or the area around the insertion site (when the catheter does not seal to the abdominal wall) Infection Unsterile techniques during dialysis Low level of albumin (a protein) in the blood Loss of protein in fluid removed during dialysis along with inadequate protein in diet Scarring of the peritoneum Inflammation and infection Electrolytes in the dialysis fluid Use of certain drugs A high sugar (glucose) level in the blood Use of a peritoneal dialysate that has a high concentration of glucose (used to remove water and sodium during dialysis) Hernias in the abdomen or groin Increased pressure within the abdomen caused by continued exposure to high fluid levels, which weaken the barriers that normally prevent excessive movement of organs and other structures Constipation Intake of inadequate fiber or use of calcium salts to treat high phosphate levels in the blood, causing the intestine to widen, which possibly interferes with dialysate flow in and out of the abdomen

Comparing Hemodialysis With Peritoneal Dialysis When the kidneys fail, waste products and excess water can be removed from the blood by hemodialysis or peritoneal dialysis. In hemodialysis, blood is removed from the body into a dialyzer (called an artificial kidney), which filters the blood. An artificial connection between an artery and a vein (arteriovenous fistula) is made to facilitate the removal of blood. In peritoneal dialysis, the peritoneum is used as a filter. The peritoneum is a membrane that lines the abdomen and covers the abdominal organs, creating a space within the abdomen called the peritoneal space or abdominal cavity.

Special Considerations

Diet: People undergoing dialysis need a special diet. In people undergoing peritoneal dialysis, appetite is generally poor, and protein is lost during dialysis. The diet should be relatively high in protein, roughly ½ gram of protein per pound of ideal body weight a day. (The American Association of Kidney Patients has a food guide.) Salt, both the usual salt containing sodium and the salt containing potassium, is restricted.

For those undergoing hemodialysis, daily consumption of sodium and potassium is even more restricted. Foods high in phosphorus also may have to be limited. Daily fluid intake is limited for people who have very little urine output or a persistently low or decreasing sodium concentration in the blood. Daily weighing is important to monitor weight gain. Excessive weight gain between hemodialysis treatments indicates that the person is consuming excessive fluid. Usually, excessive fluid intake is the result of excessive sodium intake, which makes a person thirsty.

Multivitamin supplements are needed to replace the nutrients lost through hemodialysis or peritoneal dialysis.

Medical Considerations: Erythropoietin 
or darbepoietin may be given to stimulate the production of red blood cells. Iron may also be needed to help the body produce new red blood cells. Phosphate binders, most often those such as calcium carbonate 
or calcium acetate, are used to remove excess dietary phosphate.

Normally, the body's bone tissue is continually replaced, helping bones remains strong and dense. The kidneys secrete hormones that help regulate the production of bone tissue. In people with kidney failure, the kidneys are not able to regulate hormone production, so parathyroid hormone levels may increase. The active form of vitamin D 
(calcitriol 
) or a similar substance is given to control high parathyroid hormone levels because high parathyroid hormone levels can weaken bones by decreasing their density, a bone condition called renal osteodystrophy.

Psychosocial Considerations: People undergoing dialysis may experience losses in every aspect of their lives. The potential loss of independence can be especially distressing. Coping with disruptions in lifestyle can be difficult. Many people undergoing dialysis become depressed and anxious. Psychologic and social counseling is often helpful to families as well as to those undergoing dialysis. Many dialysis centers provide psychologic and social support. Dealing with a loss of independence is helped when people are encouraged to pursue their previous interests. People undergoing hemodialysis need to arrange for transportation to and from dialysis centers on a regular basis. Dialysis sessions may interfere with work, school, or leisure activities.

More than half of the people on long-term dialysis are 60 years of age or older. Older people often are better able to adapt to long-term dialysis and the loss of independence than are younger people. However, older people undergoing dialysis may become more dependent on their grown children or may not be able to continue living alone. Older people are more likely to experience fatigue from treatments. Often, family roles and responsibilities must be modified to fit the dialysis routine, creating stress and feelings of guilt and inadequacy.

Considerations in Children: Children whose growth has been stunted may feel isolated and different from their peers (see Social Issues Affecting Children and Their Families: Illness in Children). Young adults and adolescents coping with identity, independence, and body image issues may find these issues further complicated by dialysis. Diet is an important issue for children undergoing dialysis because children must receive enough nutrients to support their growth.

Penile and Testicular Disorders ---- Epididymitis and Epididymo-orchitis· Growths on the Penis· Inflammation of the Penis· Inguinal Hernia· Injuries to the Penis and Scrotum· Peyronie's Disease· Phimosis and Paraphimosis· Priapism· Swelling in the Scrotum· Testicular Cancer· Testicular Torsion· Urethral Stricture

INTRODUCTION

The penis and testes (testicles) can be affected by inflammation, scar tissue, infection (including sexually transmitted diseases), or injury. Skin cancer can also develop on the penis. Birth defects can cause difficulty in urinating and in engaging in sexual intercourse. Disorders of the penis and testes can be psychologically disturbing as well as physically damaging. Disorders that affect only the skin of the penis do not affect sexual function or fertility. Disorders that affect the testes or that damage deeper parts of the penis may affect both.

Epididymitis and Epididymo-orchitis Epididymitis is inflammation of the epididymis (the coiled tube on top of the testis that provides the space and environment for sperm to mature), and epididymo-orchitis is inflammation of the epididymis and testes. Epididymitis and epididymo-orchitis are usually caused by a bacterial infection. Infection can result from surgery, the insertion of a catheter into the bladder, or the spread of infections from elsewhere in the urinary tract. Sometimes, particularly in young men, the cause is a sexually transmitted disease. Rare causes include infection by certain viruses or fungi. Sometimes there is no infection of any kind. In such cases, doctors believe the epididymis becomes inflamed by reverse flow of urine into the epididymis, perhaps because of straining (as when people lift something very heavy). Symptoms of epididymitis and epididymo-orchitis include swelling and tenderness of the affected area, pain that may become constant and severe, fluid around the testes (hydrocele), and sometimes a fever. Rarely, an abscess (collection of pus) that feels like a soft lump develops in the scrotum. Epididymitis and epididymo-orchitis are diagnosed by physical examination, urinalysis, and sometimes Doppler ultrasonography, which assesses blood flow to the testes. These disorders are usually treated with antibiotics taken by mouth, bed rest, pain relievers, and ice packs applied to the scrotum. Immobilizing the scrotum with a jockstrap decreases pain from repetitive, minor bumps. Abscesses usually require surgical drainage.

Growths on the Penis Growths on the penis are sometimes caused by infections. One example is syphilis (see Sexually Transmitted Diseases: Syphilis), which may cause flat pink or gray growths (condylomata lata). Also, certain viral infections can produce one or more small, firm, raised skin growths (genital warts, or condylomata acuminata) or small, firm, dimpled growths (molluscum contagiosum). Skin cancer can occur anywhere on the penis, but it most commonly occurs at the glans penis (the cone-shaped end of the penis), especially its base. Cancers affecting the skin of the penis, uncommon in the United States, are even rarer in men who have been circumcised. The cause of cancer of the penis may be long-standing irritation, usually under the foreskin. Squamous cell carcinoma (see Skin Cancers: Squamous Cell Carcinoma) occurs most commonly. Early forms of cancer that are less common include Bowen's disease (see Skin Cancers: Bowen's disease), Paget's disease (see Skin Cancers: Paget's Disease of the Nipple), and erythroplasia of Queyrat. Cancer usually first appears as a painless, reddened area with sores that do not heal for weeks. Erythroplasia of Queyrat usually occurs in uncircumcised men. It produces a discrete, reddish, velvety area on the penis, usually on or at the base of the glans penis. To diagnose cancer of the penis, doctors remove a tissue sample for examination under a microscope (biopsy). To treat early or small cancers, doctors prescribe a cream containing fluorouracil  or remove the cancer and some normal surrounding tissue with a laser or during surgery. For other cancers, doctors surgically remove the cancer, sparing as much of the penis as possible. When a lot of tissue is removed, the penis needs to be rebuilt surgically. In most men, cancers are small and have not spread. These men survive for many years after treatment. Most men with cancer that has spread die within 5 years. Inflammation of the Penis The foreskin of the penis and the glans penis (the cone-shaped end of the penis) can be inflamed. Balanitis is inflammation of the glans penis. Posthitis is inflammation of the foreskin. Balanoposthitis is inflammation of both the glans penis and the foreskin. Inflammation of the penis can be caused by infections, such as yeast infections, sexually transmitted diseases (STDs), and scabies. Noninfectious causes include skin disorders, including balanitis xerotica obliterans. The inflammation causes pain, itching, redness, and swelling and can ultimately lead to a narrowing (stricture) of the urethra. Balanoposthitis often begins with balanitis. It develops more often if the foreskin is tight or if a man has diabetes mellitus. Men who develop balanoposthitis have an increased chance of later developing balanitis xerotica obliterans, phimosis, paraphimosis, and penile cancer. Diagnosis is usually by physical examination. Blood sugar may be measured to test for diabetes, and tests for yeast infections and STDs may be done. The cause of inflammation is treated. Balanitis xerotica obliterans (also called lichen sclerosus et atrophicus) occurs when chronic inflammation causes the skin near the tip of the penis to harden and turn white. The opening of the urethra is often surrounded by this hard white tissue, which eventually blocks the flow of urine and semen. Antibacterial or anti-inflammatory creams may relieve the inflammation, but if the urethra must be reopened, it is done surgically. Inguinal Hernia An inguinal hernia is a protrusion of a piece of intestine through an opening in the abdominal wall in the groin. Inguinal Hernia An inguinal hernia extends into the groin, and can extend into the scrotum. Other types of hernias (such as umbilical hernias and femoral hernias) occur at other locations (seeGastrointestinal Emergencies: Abdominal Wall Hernias). With an inguinal hernia, the opening in the abdominal wall can be present from birth or develop later in life. What Is an Inguinal Hernia? In an inguinal hernia, a loop of intestine pushes through an opening in the abdominal wall into the inguinal canal. The inguinal canal contains the spermatic cord, which consists of the vas deferens, blood vessels, nerves, and other structures. Before birth, the testes, which are formed in the abdomen, pass through the inguinal canal as they descend into the scrotum. Inguinal hernias usually produce a painless bulge in the groin or scrotum. The bulge may enlarge when men stand and shrink when they lie down because the intestine slides back and forth with gravity. Sometimes a portion of the intestine is trapped in the scrotum (incarceration). If the intestine becomes trapped, the intestine's blood supply can be cut off (strangulation). Strangulated intestine may die (become gangrenous) within hours. Surgical repair usually aims to tighten the opening so the hernia cannot slide back into the groin. Surgery usually relieves the symptoms of a hernia, depending on its size and the amount of discomfort it causes. For strangulated hernias, emergency surgery is needed to pull the intestine out of the inguinal canal and tighten the opening. Injuries to the Penis and Scrotum Several types of injuries can affect the penis. Cuts to the Penis: Catching the penis in a pants zipper is common, but the resulting minor cut usually heals quickly. Cuts usually heal quickly if they are simply kept clean, but people may need to take antibiotics by mouth if the cuts become infected. The penis can be partially or fully severed. Reattachment of a severed penis is sometimes possible, but full sensation and function are rarely recovered. Urethral Injury: Injuries to the tube that carries urine through the penis (the urethra) are serious because they may result in scarring that obstructs the flow of urine. These injuries may result from blunt injury, such as a fall straddling a fence rail or bicycle handlebar, from deep cuts, or as a complication of surgical procedures. They typically require treatment by a urologist. Fracture of the Penis: Excessive bending can fracture an erect penis. Such bending may occur during vigorous sexual intercourse if the penis is stubbed against the partner's pelvic bone. The “fracture” is actually a tear in one of the two tube-like structures in the penis (corpus cavernosum) that hold the extra blood flow that maintains erection. The man has immediate pain and swelling, and the penis appears deformed. The injury often damages the structures that control erection and after the injury heals, the man may have difficulty with intercourse, urination, or both. Emergency surgery is usually necessary to repair such fractures to prevent abnormal curvature of the penis or permanent erectile dysfunction. Did You Know... The penis can fracture during vigorous sexual intercourse. Injury of the Scrotum and Testes: The location of the scrotum makes it susceptible to injury. Blunt forces (for example, a kick or crushing blow) cause most injuries. However, occasionally gunshot or stab wounds penetrate the scrotum or testes. Rarely, the scrotum is torn off the testes. Testicular injury causes sudden, severe pain, usually with nausea and vomiting. Ultrasound examination may show whether the testes have ruptured. Ice packs, a jockstrap, and drugs for pain and nausea usually effectively treat bleeding in or around the testes. Ruptured testes require surgical repair. When the scrotum is torn off, the testes can die or lose their capacity for hormone or sperm production. Surgery to cover the testes by reconstructing the scrotum or simply by burying them under the skin of the thighs protects the testes. Peyronie's Disease Peyronie's disease is a fibrous thickening that contracts and deforms the penis, distorting the shape of an erection. Many men have a small degree of curvature of their erect penis. Peyronie's disease produces a more severe curvature. Inflammation in the penis results in the formation of fibrous scar tissue that causes curvature in the erect penis, making penetration difficult or impossible. However, what causes the inflammation is not known with certainty. The condition can make an erection painful. The scar tissue can extend into the erectile tissue (corpora cavernosa), preventing erection from occurring. Minor curvature that does not impair sexual function does not require treatment. Peyronie's disease may resolve over several months without treatment. No treatment has proven clearly successful. Vitamin E, which can aid wound healing and decrease scarring, may be taken by mouth. Para-aminobenzoate  can also be taken by mouth but sometimes causes stomach pain or digestive problems and requires taking many pills each day. Corticosteroids or verapamil  can be injected into the scar tissue to decrease inflammation and reduce scarring. Ultrasound treatments can stimulate blood flow, which may prevent further scarring. Radiation therapy may decrease pain, but radiation therapy often worsens tissue damage. Surgery is not recommended unless the disease has progressed and the curvature has become too severe for successful intercourse. Surgery to remove the scar tissue shortens the penis and may worsen the disease or result in erectile dysfunction. Phimosis and Paraphimosis Phimosis: In phimosis, the foreskin is tight and cannot be retracted over the glans penis (the cone-shaped end of the penis). This condition is normal in newborns and young boys and usually resolves without treatment by about age 5. In older men, phimosis may result from prolonged irritation or recurring balanoposthitis. The tightened foreskin can interfere with urination and sexual activity and may increase the risk of urinary tract infections. The usual treatment is circumcision. However, in children, sometimes the application of a corticosteroid cream 2 or 3 times daily and periodic gentle stretching of the foreskin are effective and spare the child a circumcision. The cream may be used for up to 3 months. Paraphimosis: In paraphimosis, the retracted foreskin cannot be pulled forward to cover the glans penis. The condition most commonly develops when the foreskin is left retracted after a medical procedure (such as catheterization) or after cleaning the penis of a child. The glans penis swells, increasing pressure on the retracted foreskin, which then becomes trapped. The increasing pressure eventually prevents blood from reaching the penis, which could result in the destruction of penile tissue if the foreskin is not pulled back forward. Immediate treatment involves squeezing the glans penis to shrink it so that the foreskin can be pulled forward. If this technique does not work, the penis is anesthetized and the foreskin is slit to relieve the constriction. Later, circumcision is done. Priapism Priapism is a painful, persistent erection unaccompanied by sexual desire or excitement. Priapism probably results from abnormalities of the blood vessels and nerves that cause blood to become trapped in the erectile tissue (corpora cavernosa) of the penis. In most cases, priapism is caused by drugs taken to cause erection. Drugs may be those taken by mouth (for example,sildenafil  , tadalafil  , or vardenafil  ) or injected into the penis (for example, alprostadil  ). Other causes of priapism include blood clots, leukemia, sickle cell disease (particularly in children), a tumor in the pelvis, an injury to the penis or surrounding areas, dysfunction of the spinal cord, and use of other drugs, such as certain antidepressants, drugs used to treat other psychologic disorders, cocaine, and marijuana. Sometimes, however, no cause can be found. Several symptoms help differentiate priapism from normal erections. Priapism lasts longer, usually several hours. Sexual excitement does not accompany priapism, and the erection is usually painful. Also, in priapism, the glans penis (the cone-shaped end of the penis) may be soft. Did You Know... A man with a prolonged, painful erection should see a doctor immediately. Applying ice, climbing stairs, or both may help. These measures can be taken immediately and done easily. Any drug that appears to cause the priapism is stopped immediately. Injection into the penis of a drug that decreases erection (for example,phenylephrine  ) can relieve priapism, particularly priapism caused by injection of a drug into the penis. Spinal anesthesia may relieve priapism caused by a spinal cord injury. When a blood clot is the probable cause, surgery to remove the clot or restore normal circulation in the penis is necessary. Usually, when other treatments are ineffective or priapism has lasted more than 4 hours, priapism can be treated by draining excess blood from the penis with a needle and syringe and using fluid to wash out any blood clots or other blockages from the blood vessels. One or more of many possible drugs may also be used, depending on the cause. Prolonged priapism usually impairs erectile function permanently. Swelling in the Scrotum The scrotum can swell for many reasons. Possible causes include cancer (see Penile and Testicular Disorders: Testicular Cancer), testicular torsion (see Penile and Testicular Disorders: Testicular Torsion), inguinal hernia (see Penile and Testicular Disorders: Inguinal Hernia), epididymitis (see Penile and Testicular Disorders: Epididymitis and Epididymo-orchitis), hydrocele, edema, orchitis, spermatocele, and varicocele. Hydrocele: A hydrocele is a collection of fluid in the membrane that covers the testis or testes. A hydrocele may be present at birth or develop later in life. It is most common after age 40. Usually the cause is unknown. However, the condition occasionally results from a testicular disorder (for example, injury, epididymitis, or cancer). Usually, a hydrocele does not cause symptoms. It is found as a painless swelling surrounding the testis. Doctors may shine a bright light on the swelling (transillumination) to confirm the diagnosis. Ultrasound examination of the testis is done in unusual instances—for example, in a young man with no apparent cause for the hydrocele. The ultrasound scan may reveal an infection or tumor. Most hydroceles need no treatment. However, unusually large hydroceles are sometimes removed surgically. Edema: Edema is fluid retention involving the entire scrotum. Edema may result from salt and water retention or blockage of the flow of lymphatic fluid (see Lymphatic Disorders: Lymphedema). In both cases, people have no pain. Salt and water retention most commonly occurs because of heart failure, kidney failure, or chronic liver disease. Lymphedema results from blockage of lymph fluid most often because of compression of the abdominal or pelvic lymph vessels (for example, by a tumor or infection by certain kinds of parasites). Doctors usually diagnose the cause of edema based on people's symptoms and findings from a physical examination. Sometimes blood tests are done to evaluate liver and kidney function. Doctors treat edema by treating the cause. Orchitis: Infection of the testes (orchitis) is usually caused by a virus, most often mumps. Mumps usually affects children. If an adult contracts mumps, the testes can become painful and swollen and may sometimes later shrink and stop working (atrophy). Usually the diagnosis can be determined based on symptoms. Analgesics and cold or warm packs can help relieve pain. Infection usually resolves on its own without causing permanent problems. Sometimes mumps can permanently damage the ability of the testes to produce sperm but does not usually cause complete infertility unless it affects both testes. Spermatocele: A spermatocele is a collection of sperm in a sac that develops next to the epididymis. Most are painless. While most spermatoceles need no treatment, one that becomes large or bothersome can be removed surgically. Varicocele: Varicocele is the development of varicose veins in the blood vessels that drain the testis. Veins contain valves that prevent blood from flowing backward. Faulty valves can result in a varicocele. Varicoceles usually develop on the left side of the scrotum and may produce no symptoms. Alternatively, varicoceles may cause a sense of fullness and aching and throbbing pain that become bothersome when a man stands. The varicocele feels like a bag of worms if the scrotum is touched when the man is standing. However, the swelling usually disappears and symptoms resolve when he reclines because blood flow to the enlarged veins decreases. Rarely, a varicocele impairs fertility. If symptoms are severe, doctors may surgically tie off the affected veins. Testicular Cancer Testicular cancer is common among young men. Usually a painless lump is present. Ultrasound scans and blood tests are done. The testis is removed, and sometimes radiation therapy or chemotherapy is given. Most testicular cancers develop in men younger than age 40. It is one of the most common cancers in young men. Among the types of cancer that develop in the testes are seminoma, teratoma, embryonal carcinoma, and choriocarcinoma. The cause of testicular cancer is not known, but men whose testes did not descend into the scrotum (cryptorchidism—see Problems in Infants and Very Young Children: Undescended and Retractile Testes) by age 3 have a greater chance of developing testicular cancer than do men whose testes descended by that age. Cryptorchidism is best corrected surgically in childhood. Correcting cryptorchidism decreases the risk of testicular cancer. However, even if cryptorchidism is corrected, the risk of cancer is still higher than for men who never had cryptorchidism. Sometimes in adults, doctors recommend removal of a single undescended testis to reduce the risk of cancer. Symptoms Testicular cancer may cause an enlarged testis or a lump. A testis normally feels like a smooth oval, with the epididymis attached behind and on top. Testicular cancer produces a firm, growing lump in or attached to the testis. With cancer, the testis loses its normal shape, becoming large, irregular, or bumpy. Although testicular cancer is usually painless, the testis or lump may hurt when lightly touched and may even hurt without being touched. A firm lump on the testis requires prompt medical attention. Occasionally, blood vessels rupture within the tumor, yielding a suddenly enlarged, severely painful swelling. Diagnosis Physical examination and ultrasound scanning may indicate whether a lump is part of the testis and whether it is solid (and thus more likely to be cancer) or filled with fluid (cystic). Determining the blood levels of two proteins, alpha-fetoprotein and human chorionic gonadotropin, may help in making the diagnosis. The levels of these proteins often increase in men with testicular cancer. If cancer is suspected, surgery to remove the testis is done promptly. Most doctors recommend testicular self-examination. Did You Know... Loss of one testis does not impair sex drive or the ability to have children or erections. Treatment The initial treatment for testicular cancer is surgical removal of the entire affected testis (radical orchiectomy). An artificial testis (prosthesis) can be placed if the man desires. The other testis is not removed, so men retain adequate levels of male hormones and remain fertile. Infertility sometimes occurs in men with testicular cancer, but fertility may return after treatment. With certain types of cancers, lymph nodes in the abdomen are also removed (retroperitoneal lymph node dissection) because the cancer often spreads there first. Radiation therapy may also help, especially for a seminoma. A combination of surgery and chemotherapy often cures testicular cancer that has spread. Blood levels of alpha-fetoprotein and human chorionic gonadotropin that were elevated at diagnosis decline after successful treatment. If levels rise after treatment, the cancer may have recurred. The prognosis for men with testicular cancer depends on the type and extent of the cancer but is usually excellent if the cancer has not spread. Even if the cancer has spread, cure is sometimes possible. Testicular Torsion Testicular torsion is the twisting of a testis on its spermatic cord so that the testis's blood supply is blocked. What Is Testicular Torsion? Testicular torsion usually occurs in men between puberty and about age 25, but it can occur at any age. Abnormal development of the spermatic cord or the membrane covering the testis makes testicular torsion possible. With torsion, the testis usually dies within 6 to 12 hours after the blood supply is cut off unless it is treated. Severe pain and swelling develop suddenly in the testis. The pain may seem to come from the abdomen, and nausea and vomiting may develop. Doctors may diagnose the condition based on a description of the symptoms and the physical examination findings. Alternatively, doctors may use a scan, usually an ultrasound scan, for diagnosis. Testicular torsion is an emergency because the testis will die unless it is untwisted rapidly. Doctors may try to untwist the testis without surgery by rotating it within the scrotum. Occasionally, this procedure is successful and surgery is done later. However, usually the procedure is unsuccessful, and surgery to untwist the spermatic cord is required immediately. During surgery, whether done immediately or later, urologists usually secure both testes to prevent future episodes of torsion. http://www.merck.com Urethral Stricture A urethral stricture is scarring that narrows the urethra. A urethral stricture most commonly results from a previous injury. Often no cause can be found. Prior infection is an infrequent cause. A less forceful urinary stream or a double stream usually occurs with mild strictures. Severe strictures may completely block the stream of urine. Pressure builds up behind the stricture and may cause passages from the urethra into the surrounding tissues (diverticula). By decreasing the frequency or completeness of urination, strictures often lead to urinary tract infections. Urologists (doctors who specialize in the diagnosis and treatment of genitourinary disorders) diagnose strictures by obtaining an x-ray after putting radiopaque dye into the urethra (retrograde urethrogram) or by looking directly into the urethra through a flexible viewing tube (cystoscope) after administering a lubricant containing a local anesthetic. To treat a stricture, urologists widen (dilate) the urethra by anesthetizing it and then inserting an instrument that forces the narrowing farther open. Or urologists can cut the stricture open (urethrotomy). Sometimes, scar tissue forms after strictures are treated, causing urethral strictures to recur. If strictures recur, the scar tissue may have to be removed surgically and the urethra may need to be rebuilt. Last full review/revision October 2008 by Paul D. Lui, MD