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Abnormalities of the testes and scrotum and their surgical management

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Presentation on theme: "Abnormalities of the testes and scrotum and their surgical management"— Presentation transcript:


2 Abnormalities of the testes and scrotum and their surgical management
Dr. S. Vahidi

3 Undescended testis Definition:
Testes located anywhere between the abdominal cavity and just outside the anatomic scrotum Abnormally position testis Cryptorchidism = hidden testis UDT Ectopic Un descended testis Multiple etiologies  diversity of this congenital disorders

4 Incidence One of the most common congenital anomalies at birth
3% of full-term male newborns % unilateral 30.3% in prematures Preterm- low birth weight -twin - small for gestational age 70-77% spontaneously descend, by 3 month. 1% at 1 year of age

5 Epidemiology Gestational age Birth weight Prematurity
Genetic- hormonal- environmental

6 Classification Variation in testicular size & consistency
Epididymial & vassal anomalies Patent processos vaginalis Cryptorctidism: paplable- non palaplable: Intra abdominal Absent (vanishing) Atrophic Missed on Ph.E.

7 Cryptorchidism Intra abdominal Intra canalicular Extra canalicular
Supra Pubic Infra Pubic Ectopic Denis-browne pouch Transverse scrotal Femoral Perineal Prepenile

8 Retractile testis Over active cremasteric reflex Groin
3-7 years of age Infertility? Delayed spontaneous T. Ascent

9 Theories of Descent & maldescent
3 phase of descending Trans abdominal 23 week Trans inguinal Extra canalicular 23 week Endocrine factors Gubernaculum Epididymis Intra abdominal pressure Histopathology

10 Normal hypothalamic- pituitary-gonadal axis  testicular descent
Endocrine factors Normal hypothalamic- pituitary-gonadal axis  testicular descent Androgenes: testosterone & DHT  inguinal-scrotal phase of descent Mullerian inhibiting substance (MIS)? Estrogen? Descendin: gubernacular specific growth factor

11 Gubernaculum Major factor responsible for testicular descent Physiologic mechanism? Testicular descent: Hormonal factors Mechanical factors Genito femoral nerve and calcitonin Gene- related peptide?

12 Epididymis Epididymal abnormalities  cryptorchidism Fertility in UDT
Germ cell development EP. Anomalies

13 Intra abdominal pressure
Defects or agenesis of abdominal wall musculars UDT Significant Role in trans inguinal descent

14 Histopathology Similar pathology in the contralateral descended testis
Leidig cells Degeneration of sertoli cells Delayed disappearance of gonocytes Delayed appearavice of (Ad) spermatogonia Failure of primary spermatocytes to develop  Germ cells Similar pathology in the contralateral descended testis < 2 years of age

15 Consequences of UDT Infertility Neoplasia Hernia Torsion

16 Consequences of UDT Infertility Neoplasia Bilateral or unilateral UDT
Early or delayed orchiopexy Neoplasia 10% of T. tumors arise from UDTs T. tumors in UDT: 1/2550 T. tumors in population: 1/100,000

17 Neoplasia (continued)
Presentation time: puperty Orchiopexy affect the T. tumor? The age of orchiopexy and T. tumor? The location of T. & T. tumor Seminoma is most common T. tumor The cause of increased Risk: temprature or intrinsic pathologic process? Routine T. biopsy during child hood orchiopexy?

18 Hernia T. Torsion Patent processus vaginalis in >90% of UDT
Patent processus vaginalis affect the hormonal treatment of UDT T. Torsion

19 Work-up of UDT 80% palpable 20% non palpable 20% absent 30% atrophic
50% intra abdominal

20 Work-up of UDT History Ph.E Paraclinic Workup in Bilateral UDT
Preterm H. Perinatal H. Past medical & surgical H. Family H. Ph.E Other birth defect Genital examination Contralateral testis Paraclinic Accuracy of radiologic testing in UDT is 44% Workup in Bilateral UDT Hormonal workup (HCG stimulation test)- FSH- inhibin B- MIS

21 Definitive treatment should occur before 1 year of age
Management of UDT Tenets of treatment Proper identification of the Anatomy- position- viability identification of coexisting syndrome Placement of the testis within the scrotum Permanent fixation and easy palpation No further T. damage Definitive treatment should occur before 1 year of age

22 Indication for orchiectomy in UDT
Post pubescent males Contralateral normal T. Anatomically & morphologically abnormal Too far from scrotum

23 Hormonal therapy The lower position the better the success rate
HCG GnRH or LHRH The lower position the better the success rate Reascent in 25% of patient Not indicated in: Ectopic T. Inguinal Hernia

24 HCG treatment GnRH 14-59% success rate
10,000 IU (1500 Iu/m2 im/2 week – 4 week) Complications: GnRH % success rate 1.2 mg/day for 4 weeks. (nasal spray) Overall efficacy of hormonal treatment < 20% Surgery remains the Gold standard in the management of UDT

25 Surgical management of UDT
Standard orchiopexy Ancillary techniques for the high UDT Reoperative orchiopexy







32 Management of intra- abdominal testis
Laparoscopy Fowler- stephenes orchiopexy Microvascular auto transplantation Complications of orchiopexy

33 Hydrocele Simple Hydrocele Communicating Hydrocele
Hydrocele of the cord Abdomino scrotal hydrocele


35 Acute scrotum Acute scrotal pain – tenderness or swelling
Diff diagnosis

36 Differential diagnosis of the acute subacute scrotum
Torsion of the spermatic cord Torsion of the appendix testis Torsion of the appendix epididymis Epididymitis Epididymo-orchitis Inguinal hernia Communicating hydrocele Hydrocele Hydrocele of the cord Trauma/insect bite Dermatologic lesions Inflammatory vasculitis (henoch- schönlein purpura) Idiopathic scrotal edema Tumor Spermatocele Varicocele Nonurogenital pathology (e.g., adductor tendinitis)

37 Torsion of the spermatic cord (intravaginal)
Golden time (4 hours) Degree of torsion Acute or gradual onset Severe or minimized pain Nausea & vomiting- the absence of cremasteric reflex Manual detorsion Doppler examination: false positive & false negative Color doppler: 89% sensitivity 99% specifity? Radinuclide imaging: sens 90% speci= 89%

38 Torsion (continued) Explore Both side
Dartos pouch placement (no sutures) Sympathetic orchiopathy?

39 Intermittent torsion Torsion of the testicular and epididymal appendages Perinatal torsion of the spermatic cord (extra vaginal) No surgical exploration Exploration of contralateral T.? In postnatal torsion: exploration is needed (Bilateral)

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