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6 th practise Scrotal disorders Differential diagnosis and treatment of varicocele, hydrocele, testicular retention, testicular atrophy, epididymitis,

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Presentation on theme: "6 th practise Scrotal disorders Differential diagnosis and treatment of varicocele, hydrocele, testicular retention, testicular atrophy, epididymitis,"— Presentation transcript:

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

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 Miscellaneous scrotal disorders Fournier gangrene Scrotal trauma scrotal haematoma haematokele testicular dislocation testicular rupture

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:  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 torsionAppendix testis torsion Acute epididymitis Pain onsetsudden gradual Fever--+ Blue dot sign-+- Tendernesstesticularupper pole of the testis epididymal Cremastric reflex-++ Urinalysis--+ Testicular color doppler US decreased or absent blood flow norm.hypervascularisation

18 Scrotal trauma blunt  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 epidemiology – all men: 12% – men with abnormal semen analysis: 25% symptoms – testicular pain, discomfort – palpable scrotal mass – indolent Varicocele

25 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 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 diagnosis anamnesis, phisical examination transillumination ultrasuond Hydrocele

30 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 hydroceleinguinal / 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: 3 rd decade of life pure seminoma: 4 th 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 staging surveillance chemotherapy retroperitoneal lymphadenectomy radiotherpy Progression, relapse Second line treatments: Chemotherapy Retroperitoneal lymphadenectomy abdominopelvic CT chest CT serum tumor markers only early, localised stage only seminomas cisplatin based

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

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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