Undescended testicle, also known as testicular descent disorder or cryptorchidism,is a congenital malformation in which one or both testicles are not located in the scrotum. Normally, the testicles descend from the abdominal cavity through the inguinal canal into the scrotum during the last third of fetal development. In Estonia, this malformation occurs in about 2% of newborns. It is significantly more common in premature infants. In 20% of cases, the malformation is bilateral; in the remaining cases, only one testicle fails to descend into the scrotum. In about half of the cases — and in most premature infants — spontaneous descent of the testicle occurs within the first three months after birth.

In recent years, a separate form of the disease known as secondary cryptorchidism has also been recognized. In this condition, the testicle initially descends into the scrotum but, for some as yet unknown reason, later moves back out of it. In cases of secondary cryptorchidism, the testicle may first behave like a typically undescended testicle — located in the inguinal canal at birth, descending properly into the scrotum during the first months of life, but then rising back up later. However, some testicles that were located in the scrotum at birth may also become cryptorchid in this way.

The causes of both primary and secondary descent disorders are not fully understood, but the hormonal environment affecting testicular development in the womb is considered important. A special form of the disease is cryptorchidism associated with an inguinal hernia, which, after successful treatment, should not cause further problems later on.

If left untreated — or if treated too late — cryptorchidism can lead to reduced male fertility or infertility. The condition is also a significant risk factor for testicular cancer. In more severe cases, cryptorchidism may cause deficiency of male sex hormones, which requires hormone replacement therapy.

The treatment for cryptorchidism is surgical, with the goal of bringing the testicle into its natural position in the scrotum or as close to it as possible. Treatment should be carried out within the first year of life, since the later it begins, the greater the risk of testicular damage. Parents of baby boys should always check whether both testicles are palpable in the scrotum. Adult men with cryptorchidism should also undergo regular andrological check-ups to monitor their sex hormone levels and to examine the structure of the testicles for the early detection and prevention of tumors.

Testicular torsion, or twisting of the testicle, is a condition in which the spermatic cord twists around its own axis, causing a sudden interruption of blood flow to the testicle and the surrounding tissues. The risk of testicular torsion is highest during early puberty (ages12–15) and is related to the rapid developmental changes in the scrotum. The underlying cause is the relative weakness or absence of the ligaments that normally fix the testicle within the scrotum. In rare cases, when these ligaments are absent, torsion can even occur before birth (in the womb) or shortly after birth. Torsion occurring during this period does not cause pain and is manifested only by redness and tension of the scrotum. However, torsion developing during puberty is characterized by a sudden, very severe pain, usually on one side of the scrotum, accompanied by rapid swelling and redness.

The diagnosis is based on the typical clinical presentation and the absence of blood flow in the testicular vessels as seen on ultrasound examination. Treatment is usually surgical and must be performed as soon as possible after the testicular torsion occurs. In order to preserve the function of the testicle, the condition should be corrected within the first six hours after the onset of symptoms.

Testicular torsion that occurs during the newborn period does not require active treatment, as by the time the changes are noticed, the testicle has usually already been irreversibly damaged.

Varicocele, or varicose veins of the scrotum, is a cluster of enlarged veins that originate from the testicle and pass from the scrotum through the inguinal canal into the abdominal cavity. Essentially, it is a vascular condition similar to varicose veins in the legs.

Varicocele usually develops during puberty, in parallel with the growth and development of the testicles, and typically does not change significantly afterward. In some boys, scrotal varicose veins may develop even before puberty, during childhood.

In most cases, varicocele occurs above or behind the left testicle. Bilateral varicoceles are less common, and isolated right-sided varicocele is very rare.

Varicocele is divided into three categories.

In the third (largest) degree, the varicose veins form a visible cluster (often described as resembling a bunch of grapes) that can be seen through the skin of the scrotum.

In the second (moderate) degree, the enlarged veins are not visible but can be felt by touch, as the cord originating from the left testicle feels thicker than on the right side.

In the first (mildest) degree, the varicose veins can be felt only when the intra-abdominal pressure is increased, for example, when straining. Varicocele is found in 15–20% of Estonian males during adolescence. Larger varicoceles may occasionally cause a mild feeling of discomfort or tension in the testicular area. Typically, this discomfort subsides when lying down.

In some cases, varicocele may lead to impaired testicular function, which can in turn affect male fertility later in life. Only those varicose veins that clearly damage testicular function require treatment. The most evident sign of such damage is a reduction in the volume of the left testicle compared to the right one — specifically, when the volume difference exceeds 20%.

Treatment is surgical, and the need for surgery is determined based on hormone testing and semen analysis. About 10% of all boys and men diagnosed with varicocele require treatment.

In the case of hydrocele, or fluid-filled testicle,an excessive amount of fluid accumulates around the testicle, causing it to enlarge. What distinguishes hydrocele from more serious conditions is that it causes painless and usually soft swelling of the scrotum.

Hydrocele occurs relatively often during the first year of life. This type of hydrocele is harmless and usually resolves on its own within the first year. The size of the scrotum may vary from day to day, as the condition is caused by the free movement of fluid between the scrotum and the abdominal cavity.

If a hydrocele does not disappear (or significantly decrease) by the child’s first birthday, a consultation with a pediatric surgeon is recommended.

In adulthood, hydrocele is caused by an imbalance between the amount of fluid produced between the membranes surrounding the testicle and the rate at which this fluid is absorbed and drained from the tissues.

Possible causes include operations affecting the lymphatic pathways in the pelvic area, as well as varicocele or hernia surgeries. Severe testicular injuries can also increase fluid production. In older individuals, the cause of hydrocele formation often remains unclear. The condition is not dangerous to health, as it usually does not affect testicular function. Treatment for hydrocele is mainly necessary when it interferes with a person’s social or psychological well-being. The treatment for hydrocele is surgical.

A spermatocele, or epididymal cyst, is a clearly defined fluid-filled sac located in the epididymis, typically in the head region of the epididymis. There are two types of such cysts. One type is connected to the male reproductive tract and contains sperm cells. The other, rarer type, is not connected to the reproductive ducts and contains only clear fluid. The formation or enlargement of an epididymal cyst is usually associated with an increase in pressure within the male reproductive tract, causing an outpouching in a structurallyweaker area. A spermatocele may cause mild discomfort mainly during its development, when the surrounding tissues react slightly to the pressure exerted by the cyst. In most cases, however, it is an incidental finding that causes no physical symptoms or health risks.

Orchitis, or inflammation of the testicle, and epididymitis, or inflammation of the epididymis. In real life, these diseases are often difficult to distinguish from one another, as they typically affect both organs. However, in most cases, one condition tends to be more dominant.

In younger and sexually active men, the most common causes are sexually transmitted infections, most frequently chlamydia of the urogenital tract. In such cases, a subacute urethritis (inflammation of the urethra) often accompanies or precedes the changes in the testicle.

In older men, who often already have significant urination difficulties, the typical causative agents are uropathogenic bacteria belonging to the group of common microbes, most frequently Escherichia coli (E. coli).

In the early stage of the disease, before inflammation of the testicle or epididymis develops, there is usually an inflammation of the prostate (prostatitis).

The disease is typically characterized by pain in the testicle, enlargement of the testicle and epididymis, and tenderness on palpation. In cases with a subacute course, the symptoms and signs may be mild to moderate.

Treatment usually lasts about ten days, but the swelling of the testicle and epididymis may persist for several months after the active phase of the disease has resolved.

If treatment is inadequate, or if prostatitis or a sexually transmitted infection persists, the inflammation can become chronic, with recurrences occurring later. Follow-up examinations are essential to rule out persistent infections of the reproductive tract.

Epididymitis and orchitis are potentially dangerous for male health, as they can lead to infertility, and in the case of bilateral inflammation, they can also significantly reduce the level of male sex hormones in the body.

Mumps orchitis can occur only at a certain stage of testicular development — after the onset of puberty. It develops in approximately 25% of males who contract mumps after puberty. The disease is bilateral in 30–35% of cases, and in these instances, fertility is significantly more affected. Testicular inflammation is usually preceded by the clinical signs of parotitis (inflammation of the salivary glands). Rapid initiation of treatment is extremely important, because delayed treatment can cause severe testicular damage.

Phimosis, or narrowing of the foreskin, is a condition in which the foreskin is so tight that it cannot be freely retracted or pulled back over the head of the penis.

Phimosis can be classified as physiological or pathological. Physiological phimosis occurs in boys up to 5–9 years of age and does not require treatment.

Pathological phimosis refers to cases in which the foreskin narrowing develops due to anatomical abnormalities or external factors, such as skin changes typically caused by trauma or inflammation.

Most boys are born with the glans completely covered by the foreskin, a situation referred to as physiological (natural) phimosis. The separation of the foreskin from adhesions to the glans and the development of retractability over the glans usually occur gradually between ages 2 and 7, though in some cases it may happen a few years later.

Forcibly retracting the foreskin over the glans can cause skin tears, bleeding, and scarring, and may also lead to serious psychological trauma for the child (and parents).

Sometimes, in addition to foreskin narrowing—or even without it—adhesions between the foreskin and glans may be present. These adhesions can also be corrected gradually through stretching or, if needed, hormonal treatment.

Early childhood phimosis requires active treatment only if the foreskin opening is so narrow that urination is persistently difficult (requiring straining) or if recurrent inflammation under the foreskin occurs, characterized by redness and discomfort.

For the treatment of phimosis, children should see a pediatric surgeon, and adults should consult an andrologist or urologist. The treatment method depends on the severity of the phimosis.

In most cases, regular, moderate stretching of the foreskin until mild discomfort occurs is sufficient. The doctor usually instructs how to stretch the foreskin and to what extent, after which the procedure is continued at home by the parents or the boy himself. In adulthood, the man stretches the foreskin himself, or in a healthy sexual relationship, this may be incorporated into sexual activity.

Topical steroid creams are often applied to the narrowed area in addition to stretching. These creams increase skin elasticity and accelerate the desired treatment outcome. Steroid therapy usually lasts a few weeks, though achieving the desired result can sometimes take much longer.

Once the foreskin can be retracted over the glans, the use of the hormone cream can be discontinued, but daily stretching should continue to prevent recurrence of phimosis. If stretching and hormone therapy fail, or if there is scarring of the foreskin or a rare anatomical form with an extremely narrow foreskin tip, surgical treatment is indicated. Surgical treatment is essentially of two types:

Foreskin-preserving surgery: in this type, the foreskin is retained, and the portion of skin that restricts movement is either removed or incised through a plastic surgical procedure.

Circumcision: a more extensive procedure in which the foreskin is completely removed, leaving the glans exposed.

Paraphimosis is a condition in which the foreskin has been pulled or moved behind the glans of the penis and cannot return to its normal position.

Paraphimosis can occur when a tight foreskin is forcibly pulled over the glans, which typically may happen during the first sexual activities. During such forceful stretching, the foreskin tissue can become severely traumatized, leading to swelling and intense pain within a few hours.

Paraphimosis requires urgent medical attention. In most cases, a specialist can reduce the condition without surgery. However, if the condition has persisted for a long time and severe swelling has developed, surgery may be necessary, during which the foreskin is either widened or removed.

Prostatitis, or inflammation of the prostate gland,can be divided into the following major forms:

• Acute prostatitis
• Chronic bacterial prostatitis (caused by microbes)
• Chronic abacterial prostatitis with inflammation
• Chronic abacterial prostatitis without inflammation, also known as chronic pelvic pain syndrome
• Asymptomatic inflammatory prostatitis (with or without microbial presence)

Typical symptoms of prostatitis include urination difficulties and discomfort or pain in the lower pelvic area.

Regarding urination problems, prostatitis is typically associated with irritative symptoms: frequent urination, urgent need to urinate, and nighttime urination. Discomfort or pain is usually felt between the testicles and rectum, in the testicles, penis, above the pubic bone, and less commonly in the lower back.

The prevalence of prostatitis depends greatly on climatic conditions. At our latitude, 10–20% of men experience symptoms characteristic of prostatitis. Over a lifetime, more than half of men are diagnosed with the disease at least once.

The frequency of asymptomatic prostatitis is not yet fully known. However, studies of prostate tissue suggest that this form is very common, with inflammation found in up to 90% of prostates in older men. Prostatitis likely develops in its early stages over several years without significant symptoms and is often detected incidentally during examinations for other reasons, such as semen analyses performed for infertility investigations.

Prostatitis is most commonly found during peak sexual activity, i.e., between ages 25 and 35. In this age group, the disease is mainly associated with infections of the urinary and reproductive tract — including (hidden) sexually transmitted infections, vaginal infections of a partner, and similar causes.

The incidence of prostatitis rises again in men aged 45–55, when early prostate enlargement and inflammation together contribute to symptoms. In addition to reproductive tract infections, repeated exposure to cold is also considered a contributing factor. Consequently, prostatitis problems are more common in athletes exposed to cold, such as cyclists, skiers, swimmers, and orienteers. Genetic predisposition is also considered an important factor.

Acute prostatitis, which causes severe urination problems and high fever, is fortunately a relatively rare condition. The most challenging form from a treatment perspective is chronic pelvic pain syndrome, which usually results from damage to the prostate and surrounding tissues caused by a previously experienced inflammatory prostatitis. Advanced forms of the disease can significantly impair a man’s quality of life, with effects comparable to serious heart disease, diabetes, and several other severe illnesses.

Prostatitis, including its hidden forms, is an important cause of infertility and sexual dysfunction in young and middle-aged men. It also increases the risk of developing prostate cancer later in life and promotes earlier-than-normal benign prostate enlargement.

Overall, prostatitis is the main cause of sexual dysfunction in men.

Benign prostatic enlargement, or prostatic adenoma, is the most common benign tumor in men, and its prevalence is directly related to age. Prostatic adenoma is found in 20% of men aged 41–50, 50% of men aged 51–60, and in over 90% of men older than 80.

There is no direct correlation between prostate size and urinary problems. However, the frequency of urination difficulties increases with age. Approximately 25% of 55-year-old men report significant weakening of the urine stream, whereas among 75-year-old men, this proportion rises to 50%.

The causes of prostatic adenoma are still unclear. One factor that definitely influences the development of the disease is the level of male sex hormones, as prostate enlargement rarely occurs in castrated men, and castration in older men reduces prostate size and alleviates urinary problems caused by adenoma. Prostatic adenoma always develops in the central part of the prostate and involves an increase in both stromal and epithelial cell numbers. However, the ratio of stroma to epithelium is not the same in all men with adenoma, and this significantly affects the effectiveness of different treatment methods.

Benign prostatic enlargement is a natural age-related process in men and usually does not cause symptoms that affect quality of life. However, prostate enlargement can narrow the urinary tract, primarily leading to obstruction of urine flow. Typical complaints include weakening of the urine stream, the need to strain at the beginning of urination, and incomplete emptying of the bladder.

Malignant tumor of the prostate, or prostate cancer, is the most common malignant tumor among Estonian men, and its incidence is increasing rapidly. The risk of prostate cancer rises significantly with age.

• In men under 40, the likelihood of developing the disease is 1 case per 10,000 men.
• In men aged 40–59, it is 1 case per 103 men.
• In men aged 60–79, it rises to 1 case per 8 men.

According to American data, 1 in 6 men is diagnosed with prostate cancer, but fortunately, only 1 in 33 men dies from it. This means that some prostate cancers are latent and do not directly threaten a man’s life, whereas some cases, particularly in younger men, can be very aggressive.

The fact that the course of the disease can vary widely has led to sometimes conflicting approaches to the management of prostate cancer.

Most cases of prostate cancer originate from the glandular tissue of the prostate. In the early stages, the cancer grows slowly over several years and may not cause any noticeable symptoms. In more aggressive forms, prostate cancer can invade surrounding tissues through the prostate capsule over time. The disease can also spread via lymph nodes and, more distantly, often to the bones.

In the early stages, prostate cancer is successfully treatable. When the cancer is confined to the prostate, the average survival of affected men at 5 and 10 years after diagnosis is comparable to men without a cancer diagnosis. However, if the tumor is detected in a later, advanced stage, the prognosis is significantly worse — only 34% of men with advanced prostate cancer are alive 5 years after diagnosis.

Hypogonadism is a condition in men in which the testes do not produce enough of the male sex hormone testosterone.

There are two main types:
Biochemical hypogonadism, characterized by a testosterone level below the optimal range without overt symptoms.

Clinical hypogonadism, which is accompanied by typical signs of hormone deficiency, such as reduced sexual interest, decreased frequency and strength of morning erections, and reduced erectile quality.

The causes of hypogonadism can be:

• Testicular (primary) hypogonadism, related mainly to developmental abnormalities of the testes or damage to the testes acquired during life.
• Central (secondary) hypogonadism, associated primarily with hormone production by the pituitary gland, or more rarely, higher regulatory centers controlling testicular function.

Very often, combined hypogonadism occurs, in which the causes are present both at the testicular level and centrally in the brain. This type of hypogonadism is frequently associated with severe chronic diseases and overweight.

In older men, hypogonadism can also develop despite normal or even compensatorily elevated testosterone levels, due to an increase in SHBG (sex hormone-binding globulin), which reduces the amount of testosterone available to tissues.

The main factor affecting a man’s health is the reduction of tissue-available testosterone. Therefore, simply detecting a low total testosterone level has limited value, and decisions regarding treatment and associated health risks are primarily based on the free testosterone fraction.

Gynecomastia is the enlargement of the glandular tissue of the male breast. The condition is most often caused by an imbalance between male and female sex hormones in the body. Gynecomastia can occur at any stage of a man’s life.

It is common in newborns, caused by maternal hormones, and usually resolves within a few weeks. During puberty, when the body undergoes rapid hormonal adjustments, up to 70% of boys may develop enlargement of the nipples and moderate growth of breast glandular tissue. These pubertal breast changes usually regress within a few months, and less commonly, over a few years.

After puberty, gynecomastia is usually associated with hypogonadism (low testosterone levels), use of anabolic steroids, or increased body fat due to overweight and obesity, all of which result in a hormonal imbalance in the body.

In men, gynecomastia can sometimes be the first sign of a serious systemic disease (for example, a testicular tumor). Therefore, all cases of gynecomastia occurring after puberty require thorough medical evaluation.

The condition is diagnosed through physical examination and hormone testing. Treatment is based on restoring hormonal balance.

It is important to distinguish true enlargement of glandular breast tissue from fat deposition in the breast area. Additionally, investigations should rule out the rare possibility of male breast cancer.

The most common ejaculation disorder is premature or overly rapid ejaculation. Premature ejaculation is defined as a condition in which ejaculation occurs in most cases within less than one minute after the start of intercourse, or when ejaculation occurs in most cases within less than three minutes after the beginning of intercourse and is accompanied by negative emotional reactions such as stress, avoidance of sexual activity, frustration, or relationship problems.

Retrograde ejaculation is a condition in which ejaculation occurs, but the semen flows into the bladder during climax. This may happen as a result of certain diseases or medications, and the issue becomes particularly significant when pregnancy is desired.

Delayed ejaculation refers to a situation in which it takes an undesirably long time to reach ejaculation, causing distress or difficulties within the relationship.

Anejaculation is the absence of ejaculation. It most commonly occurs in connection with neurological disorders, such as injuries at various levels of the spinal cord or after diseases affecting the lower body. It can also occur as a complication of diabetes. However, anejaculation may also occur idiopathically, meaning that the man has no underlying disease, or it may result from factors such as exhaustion or erectile dysfunction.

Anorgasmia, or the absence of orgasm, may accompany anejaculation or retrograde ejaculation. It is also possible for a man to experience orgasm — that is, a feeling of satisfaction — without actual ejaculation.

Dysorgasmia refers to a condition in which orgasm or sexual satisfaction occurs, but is accompanied by certain problems — for example, discomfort, pain, or other disturbances.

All of these conditions may have a wide variety of causes and solutions.

Erectile dysfunction

Erectile dysfunction refers to a man’s inability to achieve and maintain an erection sufficient for sexual intercourse. Erectile dysfunction can be classified as temporary or persistent. Temporary dysfunctions may occur in almost all men at some point. The causes are oftenphysical or mental fatigue, excessive alcohol consumption, relationship problems, and similar factors. Once the underlying cause is resolved, erectile function usually returns.

As a man ages, longer breaks in sexual activity begin to have a greater effect on erectile ability. However, this form of erectile dysfunction is usually easy to treat and treatment often leads to lasting improvement.

Persistent erectile dysfunction usually develops gradually. It was once believed that the causes of erectile dysfunction were mainly psychological, but today it has been proven that most persistent cases are linked to a man’s overall health, particularly to changes in the blood vessels. Erectile dysfunction may even be the first sign of serious cardiovascular diseases.

A man’s erectile ability is also influenced by his testosterone level. However, hormonal balance primarily affects a man’s sexual desire (libido) and somewhat less his ability to achieve an erection.

In younger middle-aged men, erectile dysfunction may sometimes be the only symptom of prostatitis (inflammation of the prostate). More rarely, the cause of erectile problems lies in serious neurological diseases. Erectile dysfunction is not directly related to aging, as many men over the age of 90 still lead an active sexual life. However, studies have shown that while only about 2% of men under the age of 40 report erectile problems, more than half of men over 40 experience milder or more severe forms of erectile dysfunction that affect their normal sexual activity.

Sexually transmitted infections detectable from the urethra

Chlamydia – the most common cause of acute urethritis. Symptoms may range from acute to minimal or may be entirely absent.
Prevalence: common.

Mycoplasma genitalium – an important cause of urethritis. Symptoms may likewise be acute, minimal, or absent.
Prevalence: common.

Gonorrhea (tripper) – a classical sexually transmitted disease. Usually presents with clear signs of urethritis, though milder symptoms may occasionally occur.
Prevalence: relatively uncommon.

Trichomoniasis – a classical sexually transmitted disease. Typically causes obvious urethral inflammation, though in some cases symptoms may be mild.
Prevalence: relatively uncommon.

Note:
Testing for all the above microorganisms should preferably be performed using the first-catch morning urine sample. It is essential that the first drops of urine are included in the sample. Testing is recommended no earlier than the third day after a potential risk contact.

Sexually transmitted infections detectable from blood tests

HIV – a serious and life-threatening sexually transmitted viral infection. The risk of sexual transmission for men is relatively low.
Prevalence: relatively uncommon.

There are several testing options for HIV:

• Standard HIV test: can detect infection from the second month after exposure. A confirmatory test is necessary six months after contact.
• HIV RNA test: can be used from the third week after potential exposure, with a confirmatory test recommended at six months.

Syphilis – a classical sexually transmitted disease.
Prevalence: relatively uncommon.
Testing is recommended no earlier than four weeks after potential exposure.

Sexually transmitted diseases and inflammatory agents detectable from the foreskin Herpes viruses (HSV-1, HSV-2) – classical sexually transmitted infection. Typically present on the foreskin and glans penis with the characteristic course of itching → blister → ulcer →crust → healing. Occasionally, herpes may also cause urethritis.
Prevalence: common.

Candidiasis (Candida albicans) – a sexually transmitted infection and a typical cause of inflammation of the foreskin and glans penis (balanoposthitis).
Prevalence: very common.

Aerobic bacteria – non–sexually transmitted microbes (typically E. coli, Enterococcus faecalis, etc.) that can cause inflammation of the foreskin and sometimes the urethra. To identify these bacteria, an aerobic culture test is performed.
Prevalence: common.

Note: When samples are taken from the foreskin, it is recommended not to wash the penis for 24 hours before visiting the doctor or nurse.

Inflammations of the urinary and genital tract and diagnostic tests

Prostatitis (inflammation of the prostate gland) – a typical male condition that usually presents with mild lower abdominal or pelvic discomfort or may even be asymptomatic.
Prevalence: very common.
Acute form: rare. Vesiculitis (inflammation of the seminal vesicles) – usually a chronic condition accompanied by vague lower abdominal symptoms.
Prevalence: relatively uncommon.

Epididymitis (inflammation of the epididymis) – typically an acute, serious condition that poses a risk to fertility.
Prevalence: relatively uncommon.

Orchitis (inflammation of the testis) – usually an acute and severe illness carrying a risk of infertility and hypogonadism.
Prevalence: relatively uncommon.

Recommended diagnostic tests:
- Semen analysis for inflammation – the primary test for younger men.
- Prostate secretion analysis – the primary test for middle-aged and older men (aged 50 and above) and for men suspected of having prostatitis.