1. Scrotal disorders
Dr.Saad Dakhil

2. Anatomy;
Scrotum;can be considered as an outpouching of the lower part of the anterior abdominal wall.it contains the Testis,Epididymides,lower end of spermatic cord

4. Spermatic cord Structure of spermatic cord ; 1-vas deferens
2-testicular artery
3- testicular veins (pampiniform plexus)
4-testicular lymph vessels
5-autonomic nerves
6-processus vaginalis
7-cremasteric artery
8-artery of the vas deferens
9-genital branch of the genitofemoral nerve

5. Scrotal Swellings Cystic Solid Neither varicocele Hernia Epididymal
Tumor
(benign/
Malignant)
varicocele
Hernia
Hydrocele
Epididymal
cyst/
spermatocele
Hematocele

6. Hydrocele;
Collection of abnormal quantity of serous fluid in the tunica vaginalis.
If it contains pus or blood it is called pyocele or haematocele respectively.
Hydrocele is more common than the two other varieties.

8. Hernia / Hydrocele
Hydrocele: incomplete obliteration of the processus vaginalis
Hernia: large opening of the processus vaginalis which may allow abdominal contents to enter scrotal sac.

9. Scrotal Ultrasound
Large left hydrocele

10. Cont;
Causes;
1-primary;cause unknown associate with patency of proccessus vaginalis.
It classified as follows;
1-communicating;it connect with the peritoneal cavity.
2-noncommunicating;it dose not connect with peritoneal cavity.

11. Cont;
2- Secondary; where the fluid accumulate secondary to pathology inside the testis like epididymo-orchitis,testicular tumor and trauma.

12. Clinical presentation;
Symptoms;
1-painless swelling
2-embarrassment
3-frequent and painful micturation may occur if hydrocele is secondary to epididymo-orchitis
Hydrocele not affect fertility

13. Cont;
Examination;
Position; the swelling usually unilateral but can be bilateral .if communicating can not feel the cord above the lump.
Colour and temperature; normal
Tenderness; primary are not tender but secondary may be tender
Composition; fluctuant and have fluid thrill if large enough
Reducibility; can not reduced
Testis impalpable and transillumenate

15. Mangement; Primary; in children:
most neonatal hydrocel resolve in first 2 year of life if persists repair as herniotomy.(communicating).
The scrotal approach (Lord or Jaboulay technique) is used in the treatment of a secondary non-communicating hydrocele.

16. Cont; In adult; surgical excision. Secondary :
treatment the underlying condition.

17. ACUTE SCROTUM IN CHILDREN
A child or adolescent with acute scrotal pain, tenderness, or swelling should be looked on as an emergency situation requiring prompt evaluation, differential diagnosis, and potentially immediate surgical exploration.

18. Painful scrotal swellings

19. Causes
Testicular Torsion
Epididmyo-orchitis

20. Is it torsion or not Adolescent Children Gradual Sudden present absent
By History
Epidimyo-orchitis
Testicular torsion
Adolescent
Children
Gradual
Sudden
present
absent
Age
Onset
Fever

21. Epidimyo-orchitis Testicular torsion
moderate
Sever
present
absent
Severity
Irritative symptoms

22. Testicular Torsion The most urgent problem.
High risk of loss due to infarction (90%)
May have torsion of cord or appendages
Neonatal and adolescence
more common in undescended testes due to absence of fixation
Extravaginal: exclusive to perinatal
Intravaginal: 90% of adolescent age group

23. Extravaginal Torsion

24. Intravaginal Torsion

25. Testicular Torsion History Physical Sudden onset of pain
Past history of similar pain in 50%
Physical
Cremasteric reflex may be absent
Prehn’s sign: elevation of testes does not relieve pain
lateral testicular lie.

26. Testicular Torsion Diagnosis if certain : emergent surgery
if uncertain:
Nuclear scan: not done often depending on facility
Ultrasonography: documents blood flow
PROVIDES ANATOMY

27. Testicular Torsion Refer Emergently! Attempt manual detorsion- outward
< 6 hours, 90% salvage
> 24 hours, 100% loss and atrophy
Attempt manual detorsion- outward
“ open the book “
Some may be twisted 360, 720 degrees

30. Testicular Appendages
Appendix testis
Appendix epididymis

31. Testicular Appendages
Torsion of appendages rarely seen after puberty
Presents with pain
Physical
may develop scrotal swelling & erythema
“blue dot sign” seen early
Ultrasound required to rule out testis torsion
Treat symptomatically
Be sure of early exam before swelling makes any further exam suspect!

32. Torsion of Appendix Testis
Blue dot of gangrenous
appendix testis

34. Epididymitis Most common acute scrotum post-pubertal
Gradual onset of pain
Fever in 40% of patients
Dysuria in 50% of patients
Urinalysis may show pyuria in 50%

35. Doppler Epididymitis
Left Epididymitis
Increased blood flow

36. Epididymitis Confirm that torsion of testis does not exist Treatment
scrotal elevation
Antibiotics considered: keflex, septra
Refer for persistence of pain/swelling.

37. CRYPTORCHIDISM Background
Almost 1% of all full-term male infants are affected at the age of one year.
Categorisation into palpable and non-palpable testis seems to be most the appropriate method.

38. Iliac fossa 3rd-5th month Deep inguinal ring 7th month
Empty Scrotum
Iliac fossa rd-5th month
Deep inguinal ring 7th month
Superficial ring th month
Scrotum th month

39. Higher incidence of: Complications (THIN)
Empty Scrotum
Complications (THIN)
Higher incidence of:
Cancer times increased risk.
not affected by orchiopexy.
Infertility.
50% abnormal semen in unilat. UDT
70% in bilateral.
Testicular torsion.
Trauma.
Hernia

40. Assessment
A physical examination is the only method of differentiating between palpable or non-palpable testes.
Radiological imaging: 44%
There is no reliable examination to confirm or rule out an intra-abdominal, inguinal and absent/vanishing testis (nonpalpable testis), except for diagnostic laparoscopy.

41. Assessment
In cases of bilateral non-palpable testes and any suggestion of sexual differentiation problems, urgent endocrinological and genetic evaluation is mandatory.

42. Treatment
To prevent histological deterioration, treatment should be undertaken and completed before the age of months.
Medical therapy
Medical therapy using human chorionic gonadotrophin (hCG) or gonadotrophin-releasing hormone (GnRH) is based on the hormonal dependence of testicular descent, with success rates of a maximum of 20%.

43. Surgery Palpable testis:
Surgery for the palpable testis includes orchidofuniculolysis and orchidopexy, with success rates of up to 92%.
Non-palpable testis:
Inguinal surgical exploration with the possibility of performing laparoscopy should be attempted. Laparoscopy is the most appropriate way of examining the abdomen for a testis.
Microvascular autotransplantation is also an option.

44. Laparoscopy

45. perineal prepenile. femoral. inguinal pouch. Ectopic Testes
Empty Scrotum
Ectopic Testes
perineal
prepenile.
femoral.
inguinal pouch.
Vs undescended?

46. normal size & consistency scrotum well developed.
Empty Scrotum
Retractile Testes
functions normally.
normal size & consistency
scrotum well developed.
? Hyperactive cremasteric reflex.
most are normal by 12 yrs.

47. Atrophied Testes ? - Trauma. - Torsion. - Infection.
Empty Scrotum
Atrophied Testes ?
- Trauma.
- Torsion.
- Infection.
- Previous inguinal surgery.

48. VARICOCELE Background
Ectatic and tortuous veins of the pampiniform plexus of the spermatic cord are found in approximately 15% of male adolescents, with a marked left-sided predominance .
This is unusual in boys under 10 years of age, but becomes more frequent at the beginning of puberty.
Fertility problems will arise in about 20% of adolescents with varicocele.
The adverse influence of varicocele increases with time.

50. Assessment

51. Treatment
Surgery
Surgical intervention is based on ligation or occlusion of the internal spermatic veins. Microsurgical lymphatic-sparing repair (microscopic or laparoscopic) are associated with the lowest recurrence and complication rate.
Follow-up
During adolescence, testicular size should be checked annually. After adolescence, repeated sperm analysis is to be recommended.

52. The potential complications of varicocelectomy
hydrocele formation, varicocele recurrence and testicular infarction (atrophy).
Hydrocele formation is related to failure to preserve the lymphatic vessels associated with the spermatic cord.

53. Testicular tumors Commonest malignancy in men < 35 years.
Rare in african men and before puberty.
Peaks in the early twenties.
One in 10 testicular tumors occurs in association with maldescent of the testis.
Prognosis is good particularly if there was no lymph node involvement.

54. Classification
According to the cells of origin, they’re classified into:
Primary cell tumors (90-95%), which include:
Germ cell tumors: Seminoma, teratoma,Embryonal CA, Yolk Sac Tumor. Non-germ cells tumors: like sertoli cells tumors, Lyedig cell tumor.
2. Secondary tumors: lymphoma, leukemic infiltration of the testes.

55. Germ cell tumors 1. Seminomas - 40% (a) Classic Typical Seminoma
(b) Anaplastic Seminoma
(c) Spermatocytic Seminoma
2. Embryonal Carcinoma %
3. Teratoma %
(a) Mature
(b) Immature
4. Choriocarcinoma - 1%
5. Yolk Sac Tumour

56. Clinical features Painless Swelling of One testis
Dull Ache or Heaviness in Lower Abdomen
10% - Acute Scrotal Pain
10% - Present with Metatstasis
- Neck Mass / Cough / Anorexia / Vomiting / Back Ache/ Lower limb swelling
5% - Gynecomastia
Rarely - Infertility

57. Physical Examination Examine contralateral normal testis.
Firm to hard fixed area within tunica albugenia is suspicious.
Seminoma expand within the testis as a painless, rubbery enlargement.
Embryonal carcinoma or teratocarcinoma may produce an irregular, rather than discrete mass.

58. Differential Diagnosis
Testicular torsion
Epididymitis, or epididymo-orchitis
Hydrocele,
Hernia,
Hematoma,
Spermatocele,
Syphilitic gumma .

59. DICTUM FOR ANY SOLID SCROTAL SWELLINGS
All patients with a solid, Firm Intratesticular Mass that cannot be Transilluminated should be regarded as Malignant unless otherwise proved.

60. Tumor markers TWO MAIN CLASSES Onco-fetal Substances : AFP & HCG
Cellular Enzymes : LDH & PLAP
AFP - Trophoblastic Cells
HCG - Syncytiotrophoblastic Cells
( PLAP- placental alkaline phosphatase, & LDH lactic acid dehydrogenase)

61. ROLE OF TUMOUR MARKERS
Degree of Marker Elevation Appears to be Directly Proportional to Tumor Burden
Markers indicate Histology of Tumor:
If AFP elevated in Seminoma - Means Tumor has Non-Seminomatous elements
Negative Tumor Markers becoming positive on follow up usually indicates - Recurrence of Tumor
Markers become Positive earlier than X-Ray studies

62. Investigation:
US testis
CXR  metastasis
CT scan abdomen and chest to identify lymph nodes and pulmonary mets
Tumor markers :AFP (yolk-sac cell), βHCG (trophoblastic cells).

63. Tumor staging
Primary Tumor (T)pTX - Primary tumor cannot be assessed .
pT0 - No evidence of primary tumor.
pTis - Intratubular germ cell neoplasia.
pT1 - Tumor limited to the testis and epididymis.
pT2 - Tumor limited to the testis and epididymis with vascular/lymphatic invasion
or tumor extending through the tunica albuginea with involvement of tunica vaginalis
pT3 - Tumor invades the spermatic
pT4 - Tumor invades the scrotum

64. Regional Lymph Nodes
Clinical NX - Regional lymph nodes cannot be assessed
N0 - No regional lymph node metastasis
N1 - Lymph node mass 2 cm or less in greatest dimension.
N2 - Lymph node mass, more than 2 cm but not more than 5 cm in greatest dimension.
N3 - Lymph node mass more than 5 cm in greatest dimension

65. Distant metastasis M0 - No evidence of distant metastases
M1 - Nonregional nodal or pulmonary metastases
M2 - Nonpulmonary visceral masses

66. Serum tumor markers LDH HCG Miu/ml AFP Ng/ml S0 < N <N S1
<1.5 x N
< 5000
< 1000 S2
1.5-10x N
5000 to
1000 to 10000 S3
>10x N
> 50000
>10000

67. Treatment: Explore testis through an inguinal incision.
Radical Orchidectomy.
Further treatments depends on the type and stage ( see Table) .
Chemotherapy regimen : BEP :Bleomycine , Etopside ,Cisplatine
DXT=deep x-ray therapy, RPLND=retroperitoneal lymph node dissection

68. Staging Treatment of seminoma Stage I.
Staging
Treatment of seminoma
Treatment of non-seminomatous germ cell tumor
Stage I
confined to the testis
DXT to the abdominal nodes or single agent carboplatine chemo therapy
Observation or
RPLND
Or primary chemotherapy
Stage II Retroperitolneal LN involvement
II a : nodes <2cm
II b : nodes 2-5cm
II c : nodes >5cm
DXT to abdominal nodes. or
Chemotherapy
Chemo & RPLND of residual tumor
Stage III
nodal dx above the diaphragm
DXT to abdominal wall & thoracic nodes or chemo therapy
Stage IV
visceral metastasis

69. Fournier’s Gangrene Necrotizing fasciitis of the perineum
May ascend of fascial planes
Colles > Dartos > Scarpas
20% to 50% Mortality Rate
Polymicrobial infection
Treat with Gent, Pen G and Flagyl
Debridement surgically

71. Thank you