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Scrotal disorders
1.
2. Learning Outcomes
Discuss the embryology & surgical anatomy of testis.
List the scrotal lesions.
Describe the causes, clinical features, complications &
treatment of various scrotal & testicular conditions.
Outline the types of testicular tumours & explain the etiology,
clinical features, staging & treatment of testicular tumours.
3. Embryo & Descent
Testes develop RP below
kidneys - 5th
week of IUL.
The gubernaculum forms
within fold of the peritoneum.
Envagination of peritoneum
(PV) develops adjacent to
gubernaculum.
4.
5. Scrotum - Layers
Skin
SF - Dartos muscle
Ext.spermatic fascia
Cremasteric Fascia
Int.spermatic fascia
Tunica vaginalis
6. Surgical Anatomy - Testis
Lt lies lower than Rt.
It is 1 ½ inches long / 1 inch
broad and ¾ inch thick.
An adult testis weighs about 10-
15gm.
Epididymis lies along the lateral
parts of the posterior border.
Epididymis continues as vas
deferens.
7. Structure - Testis
Seminiferous tubules – are about 400-
600 in each testis, with an average of 2-3
tubules per lobules. It is made up of 2
cell types namely :-
> The spermatogenic cells – vast majority
> The sustentacular cells or cells of Sertoli.
Interstitial cells [ Cells of Leydig ] – are
found in small clusters in between the
seminiferous tubules. They secrete
testosterone and small amount of
oestrogen.
8. Surgical Anatomy - Testis
Testicular artery - branch of abdominal
aorta given off at the level of L2 vertebra.
The venous plexus emerging from the testis
is called the pampiniform plexus. Finally
they fuse to form a single vein, which drain
into IVC – Rt side & Lt renal vein – Lt side.
The lymphatics drain into pre-aortic & para-
aortic of lymph nodes at the level of L2
vertebra.
Testis is supplied by sympathetic nerves
arising from T10 segment of spinal cord.
11. Epididymitis
Infection reaches the epididymis
via the vas.
Mode of infection.
Dysuria & fever is more common.
Scrotal swelling / tender & thickened
epididymis.
Sec.hydrocele may be present.
Urine : pyuria, bacteriuria, or a
positive urine culture (Gram-
negative bacteria)
12. Epididymitis
Bed rest for 1 to 3 days then
relative restriction.
Scrotal elevation, the use of an
athletic supporter.
Parenteral antibiotic therapy
should be instituted when UTI is
documented or suspected.
Reassurance – required.
13. Orchitis
Inflammation of testis.
Mode - Blood / Lymph / Epididymis
Causes - V / B / F / L / S
Testicular pain radiates - groin
Fever / Scrotal swelling / tender
Sec.hydrocele is common
Trt : Antibiotics / Analgesics / DEC
14. Idiopathic Gangrene - Fournier's
Vascular gangrene of infective origin.
Common - Old age / Immunosuppressed pts.
Causes - Minor injuries / Follow procedures.
Sudden pain in the scrotum / pallor and pyrexia.
Cellulitis spreads until the entire scrotal coverings
slough, leaving the testes exposed but healthy.
Treatment :
Broad spectrum Antibiotics
Wide excision of all necrotic scrotal skin.
Skin grafting later.
15. Hydrocoele
Formation of fluid between the
two layers of the TV.
Mostly idiopathic.
Defective adsorption – by TV.
Excessive production of fluid.
Interference - drainage of fluid
Comm. with the peritoneal
17. Features - Hydrocoele
One can get > swelling
Mild discomfort / pain
Transillumination +
Fluctuation positive
Dull on percussion
Testis cannot be
palpated separately.
Testicular sensation – N
18. Secondary Hydrocoele
Due to disease of the
testis / epididymis.
Causes – I / I / T
It is usually small / lax
Testis is usually palpable
separately from the
swelling.
Subsides – primary
lesion resolves.
19. Complication & D / D
H aematocele
H ernia of hyd.sac [rare]
I nfection – Pyocele
C alcification of the sac
– long standing cases
A trophy of testis
R upture – T / S
Inguinal hernia
Epididymal cyst
Testicular tumour
Scrotal edema [ Filariasis ]
Spermatocele
20. Treatment
Sub-total excision - Large
hydrocele / thick sac
Evacuation & Eversion -
when sac is small
Lord’s Plication - thin sac &
containing clear fluid
Jaboulay’s operation -
Partial excision & eversion
21. Spermatocoele
It is a unilocular / retention
cyst formed in epididymis -
blockage of sperm conducting
mechanism of the epididymis.
This is an acquired condition.
It is situated in the head of
epididymis.
The testis can be felt separated
from the swelling.
It is soft / cystic / transilluminant.
Aspiration / Excision.
22. Varicocoele
It means dilated / tortuousity of the veins of
the spermatic cord.
Usually asymptomatic. Frequent between 15
and 25 years of age
Dragging discomfort
Scrotum on the affected side hangs lower
than normal
On palpation, felt like ‘a bag of worms’
Positive cough impulse – Thrill like
On lying down, it is reducible (disappear)
Smaller and softer.
23. Left Side Common – Why?
LTV – LRV - Rt. Angle
Absence / incomp. valves > LTV
Loaded sigmoid colon - press
LTA – arches over LTV - 15% of
cases
L.SRV – also drains – LRV and
circulatory adrenalin may cause
constriction of the testicular vein
LRV pass between the aorta
behind & SMA in front and may
be compressed by these 2
vessels
24. Varicocoele - Treatment
Palamo’s Operation – Supra-ingiunal
extragenital ligation of the testicular vein.
Inguinal approach – Classical approach =
Inavissevich Approach - Easier and safer.
Sub-inguinal approach – It is sub-inguinal
approach at SIR outside the EOA. Cord is
easily identified.
Scrotal approach – In case of Grade – IV,
veins have to be excised through this
approach.
Laporascopic approach - presently accepted,
good approach.
25. Torsion Testis
Inversion of the testis - most
common predisposing cause. The
testis is rotated so that it lies
transversely or upside down.
High investment of the tunica
vaginalis causes the testis to hang
within the tunica like a “clapper in a
bell”.
Gap between epididymis & the body
of the testis permits the testis to
twists over epididymis.
Heavy straining – vig.contraction of
cremaster – attached spirally.
26. Torsion Testis
It is most common between 10 and
25 yrs.
Symptoms vary with the degree of
torsion.
Signs related to Torsion –
Deming’s / Angell’s / Prehn’s sign
Right testis rotates in clockwise
direction where as Left testis rotates
in anticlockwise.
Doppler U/S - confirm the absence
of the blood supply - affected testis.
If there is any doubt about the
diagnosis, the scrotum should be
27. Torsion Testis
Prompt exploration, untwisting and
fixation is the only way to save the
torted testis.
The patient should be counselled
and consented for orchidectomy
before exploration.
The anatomical abnormality is
bilateral & the contralateral testis
should also be fixed.
Other structure in scrotum which can
undergo torsion is ‘Appendage of
testis’.
28. Idiopathic Scrotal Oedema
It is an oddity that occurs between
the age of 4 and 12 years and
must be differentiated from torsion.
The scrotum is very swollen but
there is little pain or tenderness.
The swelling may extend into the
perineum, groin and penis.
The underlying tetis is normal.
It is thought to be an allergic
phenomenon; occasionally there is
eosinophilia.
The swelling subsides after a day
or so but may recur.
29. Testicular Tumour
99% - are malignant.
Life time prevalence of getting
testicular tumour is 0.2%.
Very common in Scandinavia. More
common in higher socio-economic
group.
Pre-disposing factors –
Undescended testis / Testicular
atrophy
Cryptorchidism
Klinefelter’s syndrome – [44-XXY] –
prone to Seminoma testis
30.
31.
32. Seminoma
Starts in the mediastinum of testis and
lower pole.
Grossly – it is lobulated / fleshy /
homogenous / creamy or pinkish in color.
It spreads - into the para-aortic lymph
nodes and then to left supraclavicular
lymph node. Through blood, it spreads to
lungs / bone / brain / liver.
Types of Seminoma
Typical / Classic form – It is most
common type. Occurs in middle age.
Spermatocytic – It occurs in older people.
Good prognosis.
Anaplastic type – High potentiality to
spread.
33. Teratoma
It arises from totipotent cells - ecto/ meso/
endo
Grossly tumor surface is irregular, cut
section shows solid and cystic spaces with
areas of hemorrhage.
It spreads mainly in blood, less common in
lymphatics.
Histologically there are 4 types –
Teratoma differentiated [1%]
Malignant Teratoma intermediate [30%] –
common {Teratocarcinoma}
Malignant Teratoma anaplastic [15%] –
secretes AFP. {Embryonal carcinoma}
Malignant Trophoblastic [1%] – shows high
level of β HCG. {Choriocarcinoma}
34. Interstitial Cell Tumours
Leydig Cell tumour [2%] = Masculinises
Prepubertal tumour
Sexual precocity – infant Hercules
Benign – spreads to lymph nodes &
lung
Radioresistant & Chemoresistant
Treated by surgery
Sertoli Cell tumour [1%] = Feminises
Post-pubertal tumour
Feminizing effect – gynaecomastia /
loss of libido / aspermia
Treatment is surgery
35. Clinical Features
Testis is enlarged / firm / heavy with loss
of testicular sensation [ early stage only ]
Pain - [ 30%] / In 10% of cases it present
identified incidentally / 3% - bilateral.
Secondary hydrocele is common
Cremaster is hypertrophied & thickened
Vas / prostate & Seminal vesicles - N
Para-aortic lymph nodes are enlarged.
Inguinal nodes are involved if tumour
breeches the tunica albuginea to spread
to scrotum.
36. Investigations
No FNAC / No scrotal approach /
No incision biopsy.
Chest X-ray – to look for lung secondaries
U/S abdomen – to see nodal status like
para-aortic nodes & liver secondaries. CT –
abd is better.
U/S scrotum – to see echogenicity of testis &
tumour within.
Tumour markers.
AFP β-hcg LDH
↑ T ↑ S ↑ 80% - S
↑ 60% - NSGCT
↓ ↓
Both are elevated in NSGCT – Teratoma –
65%
38. Treatment
Through inguinal approach. Clamp is
applied to the cord at / above the level of
the deep inguinal ring. High
orchidectomy is done – “Chevassou
manoeuver”.
Seminomas are radiosensitive. So after
high orchidectomy, RT is given to
increase the cure rate & to ↓ relapse.
In teratoma, Retroperitoneal Radical
lymph node dissection [ RPLND ] is
beneficial after high orchidectomy.
Chemotherapeutic drugs - are
Bleomycin / Etoposide / Cisplatin. [BEP]