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Scrotal disorders 6th practise

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1 Scrotal disorders 6th practise
Differential diagnosis and treatment of varicocele, hydrocele, testicular retention, testicular atrophy, epididymitis, orchitis, testicular trauma, testicular torsion, testicular tumour, inguinal hernia, scrotal oedema 6th practise

2 Summary of scrotal disorders
Acute scrotum testicular torsion torsion of the appendix testis acute epididymitis Scrotal masses varicocele hydrocele inguinal hernia scrotal oedema testicular cancer Scrotal trauma scrotal haematoma haematokele testicular dislocation testicular rupture Miscellaneous scrotal disorders Fournier gangrene

3 Acute scrotum acute scrotal/testicolar pain
emergency situation (risk of testicular torsion)

4 Acute scrotum differential diagnosis: testicular torsion
torsion of the appendix testis epididymitis scrotal oedema mumps orchitis varicocele scrotal haematoma incarcerated hernia appendicitis

5 Testicular torsion synonyms: torsion of the testis, spermatic cord torsion, testicular torque definition: spermatic cord twists forms: intravaginal (usually) extravaginal (perinatal period)

6 Testicular torsion symptoms and sygns: acute testicular pain
(sudden, severe) nausea, vomiting phisical finding abnormal position of the testis (elevation, anterior epididymal position) testicular tenderness abscence of the cremasteric reflex

7 Testicular torsion urinalysis: normal
cololor doppler ultrasuond: decreased, absent blood flow

8 Testicular torsion treatment: urgent surgical exploration:
detorquation and bilateral orchidopexy semicastration (removal of the testicle) manual detorsion, then immediate bilateral orchidopexy (fixation of the testis)

9 Torsion of the appendix testis
definition: appendix testis twists symptoms: sudden testicular pain phisical finding tenderness of the superior pole of the tesis nodule superior to the testis blue dot sign intact cremastric reflex

10 Torsion of the appendix testis
scrotal ultrasound: enlarged appendix testis color doppler ultrasuond: normal testicular blood flow

11 Torsion of the appendix testis
treatment: conservative: NSAID, rest surgical exploration: excision of the appendage

12 Acute epididymitis definition: acute inflamation of the epididymis
etiology: <35 years of age: STD (clamidia trachomatis, neisseria gonorrhoae) >35: common uropathogens: e. coli, proteus, klebsiella

13 Acute epididymitis symptoms: pshisical finding
epididymal/testicular pain (gradual onset) swollen scrotal erithema fever pshisical finding epididymal/testicular tenderness, swollen intact cremasteric reflex

14 Acute epididymitis urinalysis, urine culture, urethral smear: may be positive scrotal ultrasound: thickened epididymis color doppler ultrasound: hypervascularised epididymis, hypervasularisated testis (in case of epididymoorchitis)

15 Acute epididymitis complication: epididymoorchitis abscess
testicular infarction atrophy infertility chronic epididymal induration

16 Acute epididymitis treatment: conservative:
antibiotics (fluorokinolons) NSAID bed rest, uo-positioning of the testis, local cooling surgical: in case of complications, abscess

17 Acute scrotum DD Testucular torsion Appendix testis torsion
Acute epididymitis Pain onset sudden gradual Fever - + Blue dot sign Tenderness testicular upper pole of the testis epididymal Cremastric reflex Urinalysis Testicular color doppler US decreased or absent blood flow norm. hypervascularisation

18 Scrotal trauma blunt penetrating scrotal haematoma haematokele
testicular dislocation testicular rupture penetrating

19 Scrotal haematoma definition: haematoma of the scrotal skin
symptoms: scrotal pain US: intact tunica albuginea treatment: conservative

20 Haematokele definition: collection of blood between the two layers of tunica vaginalis testis symphtoms, phisical signs: scrotal enlargement scrotal haematoma scrotal pain US: intact tunica albuginea fluid collection arround the tesicle treatment smal hematocele: conservative large hematocele: surgical exploration, blood clot evacuation

21 Testicular rupture definition: rupture of the tunica albuginea
symptoms: testicular pain nusea, vomiting fainting phisical finding: testicular tenderness, swollen scrotal haematoma US: Tunica albuginea rupture Hematocele Intratesticular hematoma treatment: surgical exploration - haemtoma avacuation, necrotic testicular tissue excision, closure of the tunica albuginea

22 Scrotal masses varicocele hydrocele inguinal hernia scrotal oedema
testicular tumour

23 Varicocele definition: abnormal dilation (3 mm<) of the internal spermatic veins main effects (indications for surgical treatment): scrotal pain, discomfort infertility testicular atrophy

24 Varicocele epidemiology symptoms all men: 12%
men with abnormal semen analysis: 25% symptoms testicular pain, discomfort palpable scrotal mass indolent

25 Varicocele classification:
subclinical: only can be shown by color doppler US grade 1: palpable during Valsalva manouvre grade 2: palpable grade 3: visible

26 Varicocele diagnosis phisical examination color doppler US
inspection palpation color doppler US check retroperitoneal mass semen analysis

27 Varicocele treatment varicocelectomy (ligation of the internal spermatic vein) suprainguinal open (Palomo) laparoscopic inguinal (open) subinguinal open microsurgical (gold standard) sclerotherapy retrograde antegrade

28 Hydrocele definition: fluid collection between the two layers of tunica vaginalis symptoms: scrotal enlargement indolent

29 Hydrocele diagnosis anamnesis, phisical examination transillumination
ultrasuond

30 Hydrocele treatment punction hydrocelctomy op sec. Winkelmann
op sec. Bergmann

31 Inguinal hernia definition: protrusion of a portion of abdominal organs through the abdominal wall

32 Inguinal hernia classification direct indirect

33 Inguinal hernia – hydrocele differential diagnosis
inguinal / inguinoscrotal hernia

34 Inguinal hernia treatment open hernioplasty (Bassini, Lichtenstein)
laparoscopic hernioplasty (transperitoneal, extraperitoneal)

35 Testicular cancer epidemiology: 1-1,5% of male tumours peak incidence:
non-seminoma: 3rd decade of life pure seminoma: 4th decade of life etiology – risk factors: cryptorchidism Kinefelter's syndrome infertility contralateral tumour first grade relatives

36 Testicular cancer pathological classification
germ cell tumors (90-95%) seminoma embryonal carcinoma yolk sac tumor choriocarcinoma teratoma mixed tumors sex cord/gonadal stromal tumors miscellaneous non specific stromal tumors

37 Testicular cancer pathological classification – practical clinical consideration seminoma (only seminoma) non-seminoma (other germ cell npl. or mixed germ cell npl. even with seminoma)

38 Testicular cancer symptoms painless (scrotal pain 27%)
palpable testicular mass – self examination! gynecomastia back, flank pain (retoperitoneal lymph node metastasis) varicocele (lymp node met.) fever, weight loss, cahexia (advanced stage)

39 Testicular cancer diagnosis phisical examination
palpation of the scrotum(painless hard intratesticular mass) palpation of the supraclavicular limph nodes (Virchow's node)

40 Testicular cancer diagnosis imaging of the primer tumour
US of the testicle MR of the testicle staging (looking for metastasis) abdominopelvic CT chest CT serum tumour markers AFP hCG LDH

41 Testicular cancer treatment

42 radical inguinal semicastration
pathological examination abdominopelvic CT chest CT serum tumor markers staging surveillance chemotherapy retroperitoneal lymphadenectomy radiotherpy only early, localised stage cisplatin based only seminomas Progression, relapse Second line treatments: Chemotherapy Retroperitoneal lymphadenectomy

43 polimicrobal bacterial infection
Fournier gangrene definition: polymicrobal necrotising fasciitis of the external genitalia, perineum, perianal region etiology: polimicrobal bacterial infection (aerobs, anaerobs) risk factors (immuno-compromised patient – diabetes, malnutrition; elderly patient; recent perineal surgery, catheterisation)

44 Fournier gangrene features: agressive fulminant (hours)
life threatening rare symptoms, phisiclal findings painful scrotal swelling scrotal erythema, oedema crepitus necrotic skin areas

45 Fournier gangrene treatment
immediate intravenous broad spectrum antibiotics immediate surgical debridement supportive treatment

46 Test images

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