Scrotal Problems Yewande Ogunyemi

Introduction The scrotum is a protuberance of skin and muscle containing the testicle. Function is to regulate the temp of the testicles through the cremaster muscle and the dartos fascia in the scrotum. Ideal temp is about 34.4, > 36.7 may damage sperm count.

Incidence of common causes of acute scrotal problems in infants and children. Davenport, M. BMJ 1996;312:435-437 Copyright ©1996 BMJ Publishing Group Ltd.

Rarer causes in children Henoch – Schonlein purpura Leukaemia Scrotal hyperpigmentation – congenital adrenal hyperplasia Epididymo-orchitis

Acute scrotal pain Causes; Acutely painful scrotum is torsion of testis until proven otherwise. Strangulated inguino-scrotal hernia is tender, painful, irreducible groin lump. Torsion of the hydatid of Morgagni Acute epididymitis Haematocoele - trauma or scrotal surgery Fournier’s gangrene-necrotising fasciitis Appendicitis - referred pain (same visceral afferent nerve supply as testis - T10)

Chronic scrotal pain Causes; Inflammation Chronic bacterial epididymitis Recurrent incomplete testicular torsion Chronic scrotal discomfort-in absence of infection. Often hx of scrotal surgery or trauma. TB

Testicular torsion in newborn infant Twist of the whole spermatic cord due to unfixed nature of newly descended testis. Almost all of such torsions present late with overt testicular necrosis Pain and tenderness are not prominent. scrotum usually red and swollen and contains hard testicular mass surgery to excise damaged organ and to fix other testis.

Testicular torsion in older boys and adults Many cases yearly of ‘epididymitis‘ treated with antibiotics. Slight left sided bias, incidence higher in winter months Major predisposing factor is undescended testis Symptoms include severe testicular pain which may radiate to the groin +/- nausea and vomiting. Examination - gentle. high riding or horizontal testis. No specific path gnomonic clinical signs to differentiate from epididymitis. Treatment - successful testicular salvage highly dependent on time b/w start of symptom and surgery. Detorsion and fixation of viable testis. contra lateral testis fixed at same time.

Rates of testicular salvage by time from start of symptoms. Davenport, M. BMJ 1996;312:435-437 Copyright ©1996 BMJ Publishing Group Ltd.

Scrotal swellings May or may not be confined to scrotum The cardinal sign of true scrotal swelling is that it is possible to get above it. Cystic masses transilluminate, solid masses do not.

Cystic scrotal swellings Separate from testis - Epididymal cysts - Spermatocoele Testis lies within swelling - Hydrocoele -Haematocoele - does not transilluminate

Solid scrotal masses Separate from testis -Acute/chronic epididymitis -Torsion of hydatid of Morgagni Within the testis -Testicular tumour -Torsion of testis -Orchitis- bac/viral (mumps,influenza,TB,STD) -Testicular gumma

Scrotal mass not confined to scrotum Examiner is unable to get above - Inquino- scrotal hernia - Varicoecoele of the pampiniform plexus - Encysted hydrocoele of the spermatic cord

Hydrocoele Result of excessive fluid in tunica vaginalis Congenital/acquired Primary - occur in absence of disease in testis. Tends to be large and tense. Common in young boys. Secondary - represent a rxn to testicular pathology - tumour, infection, and torsion Presentation is usually as a soft non tender and cystic swelling in scrotum which transilluminates. One can get above lesion. Testis lies within fluid collection and is not palpable Conservative mgt. Scrotal support. Refer if symptomatic or children > 1 yr. needle aspiration, surgery. Secondary- Rx underlying cause

Varicocoele Varicose veins in the pampiniform plexus of the spermatic cord and scrotum.affects 15 - 20% of males. rare after 40yrs. Most are asymptomatic found during investigation for infertility in 40 % males. Pelvic mass compressing venous drainage of testicle Dull ache at the end of the day or following exercise Dragging or feeling of heaviness Visible on standing and feels like a ‘bag of worms’. Pos cough impulse. Disappears when recumbent. Surgical intervention only if painful, infertile or testicular atrophy

Testicular tumours Most common cancer in men ages 20 – 40 Most growths in scrotum are benign. However take seriously painless lump in scrotum or in testicle or unexplained pain in one testis. Presence of hydrocoele. Mass is hard and does not transilluminate Predisposing factor is hx of undescended testis Urgent referral under 2 wk rule.- tumour markers LDH, AFP and HCG NICE GUIDELINES-refer pts with a swelling or mass in body of testis. Consider urgent USS in men with scrotal mass that does not transilluminate and when body of testis cant be distinguished

Epididymitis Inflammation of epididymis +/- orchitis Predisposing factors ;UTI,Urethral instrumentation, STI; E.coli and Chlamydia with hx of discharge CF- pain and swelling, inflammation, fever +/- rigors. Prehn’s sign - scrotal elevation relieves pain Secondary hydrocoele Clinically indistinguishable from torsion Inv –fbc,blood culture,msu,plain abdo xray, IVU/USS Rx –rest, scrotal elevation, broad spectrum abx,nsaid and non exertion for 1-3 wks

Other causes Idiopathic scrotal oedema CCF Kidney/liver disease Contact dermatitis Yeast infection

Epididymitis: swollen, tender, non-transilluminable scrotum in 18 month old child (top) and the underlying acute epididymitis (bottom). Davenport, M. BMJ 1996;312:435-437 Copyright ©1996 BMJ Publishing Group Ltd.

Scrotal bruising due to idiopathic haemorrhage in a 3 day old infant. Davenport, M. BMJ 1996;312:435-437 Copyright ©1996 BMJ Publishing Group Ltd.