Seminar presentation by 5th year Medical Student under the supervision of a pediatric surgery specialist from HRPZ II. Reference as mentioned in the slide.

1. INGUINOSCROTAL
ABDOMINAL WALL
DISORDERS IN
PEDIATRIC SURGICAL
PRACTICE
N I K ‘ A I N A M A R D H I YA H | G E J A L A C H U M Y | A U D I R A H M A N | J AYA N T H I

2. OUTLINES
ANATOMY
INGUINAL HERNIA
UNDESCENDED TESTIS
HYDROCELE
VARICOCELE
TESTICULAR TORSION
EPIDIDYMO-ORCHITIS
EPIDIDYMAL CYST

3. ANATOMY OF
INGUINOSCROTAL
REGION
N I K ‘ A I N A M A R D H I YA H

4. EMBRYOLOGY

5. Inguinal canal :
1. Openings
2. Boundaries
3. Contents
Hesselbach triangle :
Borders
Spermatic cord :
1. Layers
2. Contents

6. INGUINAL CANAL
4-6cm long oblique
passage above the
inguinal ligament,
from the deep to
superficial ring

7. OPENINGS
The inguinal canal has
2 openings:
1. Deep (internal) inguinal
ring
2. Superficial (external)
inguinal ring.

8. BOUNDARIES
Superior (Roof) - internal oblique muscle, transversus abdominis muscles 2M
Anterior wall - aponeurosis of internal oblique muscle, aponeurosis of external oblique
muscle 2A
Inferior (Floor) - Inguinal ligament, lacunar ligament (medially) 2L
Posterior wall - Transversalis fascia laterally; conjoint tendon medially 2T

9. CONTENTS
Males:
Spermatic cord (with the genital
branch of the genitofemoral nerve)
Ilioinguinal nerve (passes through the
superficial ring but does not
completely run through the entire
inguinal canal)
Females :
Round ligament
Genital branch of the genitofemoral
nerve
Ilioinguinal nerve.

10. HESSELBACH TRIANGLE
Borders of Hesselbach's
triangle
 Medially: rectus
abdominis muscle
 Laterally: inferior
epigastric vessels
 Inferiorly: inguinal
ligament

11. SPERMATIC CORD
3 Concentric Layers
3 Arteries
3 Nerves
3 Others

12. LAYERS
3 layers :

13. CONTENTS
3 Arteries :
 Testicular artery
 Artery to vas deferens
 Cremasteric artery
3 Nerves :
 Nerve to cremaster
 Autonomic nerves (T10)
 Genital branch of
genitofemoral nerve
3 Others :
 Vas deferens
 Pampiniform plexus
 Lymphatics

14. INGUINAL HERNIA
N I K ‘ A I N A M A R D H I YA H

15. INGUINAL HERNIA
DEFINITION
An inguinal hernia is an abnormal protrusion of intra-
abdominal contents either through the deep inguinal
ring (indirect inguinal hernia; lateral to the inferior epigastric
artery) or through the weakened posterior wall of the inguinal
canal (direct inguinal hernia; medial to the epigastric artery)

16. INGUINAL HERNIA
EPIDEMIOLOGY
 International incidence in paediatrics is 1 – 5%
 Inguinal hernia common in males than in females, ratio of 4 –
8 : 1
 Premature infants are at an increased risk of inguinal hernia,
with incidence of 7 – 30 %

17. INGUINAL HERNIA
ETIOLOGY
 Prematurity and low birth weight
(Incidence approaches 50%.)
 Urologic conditions
 Cryptorchidism
 Hypospadias
 Epispadias
 Exstrophy of the bladder
 Ambiguous genitalia
 Patent processus vaginalis, which may be
present because of increased abdominal
pressure due to ventriculoperitoneal
shunts, peritoneal dialysis, or ascites
 Abdominal wall defects
 Gastroschisis
 Omphalocele
 Family history
 Meconium peritonitis
 Cystic fibrosis
 Connective tissue disease
 Mucopolysaccharidosis
 Congenital dislocation of the
hip
 Ehlers-Danlos syndrome
 Marfan syndrome
 Cloacal exstrophy
 Fetal hydrops
 Liver disease with ascites
 Ventriculoperitoneal shunting
for hydrocephalus

18. INGUINAL HERNIA
CLASSIFICATION
DI REC T I NGUI NAL HERNI A
 Medial to the inferior epigastric blood vessels
(within Hesselbach's triangle)
 Hernial sac protrudes directly through the posterior wall
of the inguinal canal (without involvement of
the spermatic cord or round ligament of the uterus)
 Only herniates through the superficial (external) ring
 Only surrounded by the external spermatic fascia
I NDI REC T I NGUI NAL HERNI A
 Lateral to the inferior epigastric blood vessels
(outside Hesselbach's triangle)
 Runs from the deep (internal) inguinal ring through
the inguinal canal to the superficial (external) inguinal
ring (in men, along with the spermatic cord)
 Surrounded by the external spermatic fascia, cremasteric
muscle fibers, and internal spermatic fascia

19. INGUINAL HERNIA
HISTORY TAKING
 Visible, palpable groin protrusion or bulge
The bulge commonly occurs after crying or straining and
often resolves during the night while the baby is sleeping.
Indirect hernias are more common on the right side
because of delayed descent of the right testicle. Hernias are
present on the right side in 60% of patients, on the left in
30%, and bilaterally in 10% of patients.
 Inguinal pain (complication)

20. INGUINAL HERNIA
PHYSICAL EXAMINATION
I NSPEC T I ON
Position
Extent
Overlying skin
Cough impulse
PAL PAT I ON
Size, shape, surface, margin, consistency,
tenderness, temperature
Transillumination test
To get above swelling
Testis
Reducibility
Ring occlusion test
PERCUSSI ON
 Resonant : gut
 Dull : fatty tissue
AUSCULTAT I ON
 Bowel sound

21. INGUINAL HERNIA
COMPLICATIONS
 Incarcerated hernia: inability to reduce
the hernia back into abdominal cavity; fixation of
contents in the hernial sac
 Surgical emergency in case of concurrent bowel
obstruction
 Strangulated hernia: tight constriction of hernial
contents leading to constriction of blood vessels
and bowel ischemia
 Patients must undergo surgery within 4–6 hours to avoid
possible bowel loss.
 Symptoms of bowel obstruction
 Symptoms of intestinal necrosis: pain and erythema in
the lower abdomen and scrotum
 Possible intestinal perforation and/or peritonitis
 Possible systemic inflammatory response
syndrome (SIRS)
 The child may be fussy, unwilling to feed, and
inconsolably crying. The skin overlying the bulge
may be edematous, erythematous, and discolored.

22. INGUINAL HERNIA
DIAGNOSIS
 Inguinal hernia diagnosis is typically established based on
medical history and physical exam findings!
 Ultrasound
Imaging test of choice
Visualization of the hernial orifice and hernial contents may
be possible.
 CT/MRT: to distinguish from differential diagnoses in
ambiguous cases

23. INGUINAL HERNIA
DIFFERENTIAL DIAGNOSIS
 Undescended testis
 Testicular torsion
 Hydrocele
 Femoral hernia
 Inguinal or femoral lymphadenitis
 Tumors.

24. INGUINAL HERNIA
TREATMENT
 Inguinal hernias do not spontaneously heal and must be
surgically repaired because of the ever-present risk of
incarceration.
 Generally, a surgical consultation should be made at the time
of diagnosis, and repair (on an elective basis) should be
performed very soon after the diagnosis is confirmed.

25. INGUINAL HERNIA
SURGICAL MANAGEMENT
 Herniotomy is all that is required with ligation and excision of
the patent processus vaginalis.
 Paediatric surgeons will repair soon after diagnosis,
 regardless of age or weight, in healthy full-term infant boys with
asymptomatic reducible inguinal hernias.
 There is no significant difference in operative time for unilateral
hernias but laparoscopy is faster than open surgery for bilateral
hernias.
 There is no difference in recurrence rate but wound infection is higher
with open surgery than with laparoscopy.

26. INGUINAL HERNIA
SURGICAL MANAGEMENT
• Inguinal hernias in premature infants are usually repaired prior to discharge
from the neonatal intensive care unit (NICU).
• Since infants are now being discharged home at much lower weights there
has been a trend towards postponing surgery for 1-2 months to allow
further growth.
• However one study advocated early surgery in order to avoid perioperative
morbidity and to reduce the risk of incarceration, subsequent testicular
ischemia and hernia recurrence.

27. INGUINAL HERNIA
RISK OF SURGERY
 Vas deferens injury
 Spermatic vessels injury, dissection, or constriction, which may lead
to testicular necrosis
 Injury to femoral nerve, artery, or vein
 Chronic inguinal pain
 Bladder injury
 Recurrence: 1.0% - most happening within five years of operation.
Recurrence rate increases:
 In children aged younger than 1 year.
 After incarcerations.
 In those with ongoing increased intra-abdominal pressure.
 Where there is growth failure.
 With prematurity.
 Wound infection.

28. UNDESCENDED
TESTIS
J AYA N T H I

29. UNDESCENDED TESTIS
DEFINITION
Incomplete descent of the testis occurs when the testis is
arrested in some part of the normal path to the scrotum
INCIDENCE
 About 4% of boys are born with one or both testes incompletely
descended.
 About 2/3 of these reach the scrotum during the 1st three months of life,
but full descent after that is uncommon.
 The incidence of testicular maldescent at the age of one year is around 1%.
 The condition is sometimes missed in the neonatal period and only
discovered later in life.
 In a few cases, the presence of a hernia, testicular pain or acute torsion
directs attention to the abnormality.
 In 10% of cases, there is a family history.

30. UNDESCENDED TESTIS
PATHOLOGY
 More common on the right and is bilateral in 20% of cases.
 In adults, secondary sexual characterictics are typically normal.
 The testis may be:
 Intra- abdominal; usually lying extraperitoneally just inside the internal
inguinal ring
Intra- canalicular; it may or may not be palpable
Extra- canalicular usually at the scrotal neck;
Ectopic; the most common site is within the superficial inguinal pouch
which lies just inferior and medial to the superficial inguinal ring. Other
rarer ectopic sites include the femoral triangle, the root of the penis and
perineum.

32. UNDESCENDED TESTIS
CONSEQUENCES
CLINICAL FEATURES
 Infertility
 Malignancy
 Hernia
 Testicular torsion
 In some boys, any stimulation of the skin of the scrotum or thigh causes
the testis to ascend and to temporarily disappear into inguinal canal. This
is called a retractile testis.
 In comparison to a true undescended testis, the scrotum of a boy with a
retractile testis is normal as opposed to underdeveloped.
 When the cremaster relaxes, the testis reappears only to vanish when the
scrotal skin is touched again.
 A retractile testis can be gently milked from its position in the inguinal
region to the bottom of the scrotum.
 Retractile testes require no treatment

33. UNDESCENDED TESTIS
SURGICAL TREATMENT
ORCHI DOPEXY
 Performed before the boy reaches 12 months of age in an attempt to
prevent the consequences described earlier.
 Testis and spermatic cord are mobilized and the testis is repositioned in
the scrotum.
 The operation is performed through a short incision over the deep inguinal
ring.
 The inguinal canal is exposed by division of the external oblique
aponeurosis in the direction of its fibers.
FAI LURE TO B RI NG T HE T EST I S DOWN
 Sometimes for a high undescended testis a two- stage surgical procedure is
necessary.
 Orchidectomy should be considered if the incompletely descended testis is
atrophic, particularly in the post- pubertal boy if the other testis is normal.

34. HYDROCELE
G E J A L A C H U M Y

35. HYDROCELE
 Presence of abnormal collection of serous fluid within
the tunica Vaginalis
 Incidence : 3.5 to 5.0% in full term infants and 44 to
55% in premature and low birth weight babies
 Babies who are born prematurely have a higher risk of
having a hydrocele

36. HYDROCELE
CONGENITAL HYDROCELES
(COMMUNICATING TYPE)
 With the descent of the
testis, the parietal
peritoneum forms the
processus vaginalis and the
cavity of the tunica vaginalis
of the testis.
 The processus vaginalis
normally obliterates till the
fourth month of life.
 Congenital hydroceles occur
mostly through lack of
closure of the processus
vaginalis
ACQUIRED HYDROCELES
(NON COMMUNICATING TOO)
 Usually, there is a balance
between fluid production and
outflow in the cavity of the
tunica vaginalis.
 The following diseases
disturb this balance:
inflammation, tumors,
testicular trauma, torsion of
the testis or testicular
appendages, defective
lymphatic drainage (after
surgery for varicoceles or
inguinal hernias)

37. HYDROCELE
INCREASED PRODUCTION OF FLUID
 Inflammation of the testis (orchitis) or epididymis (epididymitis)
 Testicular torsion (rotation of the testis) may cause a reactive
hydrocele in 20% of cases.
 Tumors of the testis, especially germ cell tumors or tumors of the
testicular adnexa may cause hydrocele.
DECREASED RESORPTION OF FLUID
 Surgery in the inguinal region or a renal transplantation can affect the
lymphatics or venous system causing decreased absorption.
 Radiation therapy is associated with cases of hydrocele.
 Peritoneal dialysis and ventriculoperitoneal shunts.

38. HYDROCELE
CONGENITAL
NON
COMMUNICATING
COMMUNICATING
ACQUIRED
PRIMARY SECONDARY
INFECTION INJURY
POST
HERNIORRHAPHY
HYDROCELE
POST
VARICOCELECTOMY
HYDROCELE
TUMOUR TRAUMA

39. HYDROCELE

40. HYDROCELE
ETIOLOGY
 Primary hydrocele: when there is no definitive cause / idiopathic.
 Secondary hydrocele: when there is a prior diseases of testis:
1. TB of epididymis
2. Syphilitic orchitis
3. Testicular tumours: teratoma—1st and 2nd decades of life
4. Orchitis arising by virus
5. Trauma
6. Epididymo-orchitis
7. Testicular cancer
8. Hernia
9. Torsion

41. HYDROCELE

42. HYDROCELE
CLINICAL FEATURES
INSPECTION
1. Usually Unilateral
2. Cough impulse - Negative
3. Site – Scrotal area below Inguinal ligament
4. Size – may be very large
5. Shape – Globular
6. Skin – normal with prominent vein on scrotal skin

43. HYDROCELE
CLINICAL FEATURES
PALPATION
1. Able to get above the swelling
2. Relation to testis – inseparable from testis (impossible to
palpate separately)
3. Surface – smooth
4. Consistency – soft unless calcified, mixed with blood
5. Trans illumination test – Positive unless secondary infection,
mixed with blood/pus or calcified

44. HYDROCELE

45. INVESTIGATION
Generally not essential
Leukocytosis with a higher
percentage of neutrophils
suggests an infectious and/or
inflammatory process (eg,
epididymo-orchitis)
Uncomplicated hydroceles do
not require radiographic
studies
USG can help evaluate for an
underlying process, such as a
tumour or torsion
FNAC contraindicated

46. HYDROCELE
INVESTIGATIONS

47. HYDROCELE
NON SURGICAL
 In Children, a non-communicating hydrocele aka simple hydrocele usually
resolves spontaneously by the time the child reaches the age of 1 year.
 Thus, watch and wait – If the hydrocele is small.
 Aspiration under ultrasound guidance – To relieve symptoms but tend to re-
accumulate again. Not recommended for suspected testicular tumor to
prevent needle tract implantation

48. HYDROCELE
INDICATIONS FOR SURGERY
 Continued Scrotal discomfort or pain
 Cosmetic - disfigurement due to the sheer size of the hydrocele.
 Failure to resolve by age 2 years
 Enlargement or waxing and waning in volume
 Secondary infection (very rare)

49. HYDROCELE
SURGICAL
LIGATION & DIVISION OF PATENT PROCESSUS VAGINALIS THROUGH
SMALL INGUINAL INCISION
Done if hydrocele persists beyond one year of age
LORD’S PLICATION (when the sac is reasonably thin-walled)
Small incision through the scrotum to lift up the testis. Sac is
plicate with a series of interrupted suture to the junction of
testis and epididymis. It is used for small to medium
hydroceles with thin sac. Benefits - reduced risk of
hematoma. Some articles suggest a slight incidence of
recurrence of the hydrocele following this procedure.
JABOULAY’S OPERATION (larger)
Longitudinal incision and the sac is everted. Excess sac is
excised and remainder replace behind the cord or sutured
behind the testis. It is associated with a reduced risk of
recurrence but may have an increased risk of hematoma

50. HYDROCELE
SURGICAL
 SUBTOTAL EXCISION or HYDROCELECTOMY
In cases of large sac, where there is risk of a large redundant swelling post
operatively, excision of the sac with 1 cm margin around the testis &
epididymis.
 HERNIOTOMY
Congenital hydrocele (communicating type) treated by herniotomy if they
do not resolve spontaneously, hydrocele that persists longer than 12 to 18
month.
 SHARMA & JHAWERS TECHNIQUE
 ASPIRATION WITH/WITHOUT INJECTION OF SCLEROSING AGENT

51. HYDROCELE
COMPLICATIONS
 Haematocele due to spontaneous bleeding into the sac or as
result of trauma
 Herniation of the hydrocele sac through the dartos muscle
 Atrophy of the testis in long standing cases
 Infection: Pyocele
 Calcification Of Sac (D/D For Testicular Tumour)
 Infertility
 Herniation of hydrocele sac (Rare)
 Rupture (Rare)

52. VARICOCELE
G E J A L A C H U M Y

53. VARICOCELE
 Due to dilated pampiniform plexus of spermatic cord
(veins draining testis) and the internal spermatic vein
 Occurs in approximately 15- 20% of all males
 Onset usually after puberty , if it occurs in adults,
sought for other pathologies, renal carcinoma.
 Feel of a ‘bag of worms’ during palpation of the cord

54. VARICOCELE
GRADING
 Grade I: Small varicocele which is palpable only when patient
performs Valsalva maneuver (expiration against a closed glottis)
 Grade II: Moderate sized. Easily palpable varicocele without
Valsalva’s maneuver
 Grade III: Large varicocele visible through the scrotal skin
 Grade IV : Very much dilated and tortuous veins

56. VARICOCELE
ETIOLOGY
Idiopathic/Primary
Due to incompetency of valves. 98% occur on the left side
Secondary
 Pelvic or abdominal mass.
 Lt renal cell carcinoma with tumor thrombus in left renal vein.
 Nutcracker syndrome- SMA compressing left renal vein.
 Other conditions- Retroperitoneal fibrosis or adhesions

57. VARICOCELE
98% OF VARICOCELE ARE LEFT SIDED
WHY?
 Left spermatic vein is more vertical
where it connects to left renal vein.
 Left renal vein can be compressed by
colon
 Left testicular vein is longer than the
right
 Lacks of terminal valve
 Nephroblastoma in childhood
 Left testicular artery is arching over left
testicular vein
 Left renal vein is compressed b/w the
Aorta and SMA

58. VARICOCELE
CLINICAL FEATURES
It is usually more prominent when standing up.
I NSPEC T I ON
 Single/multiple : usually unilateral
 Cough impulse : may be positive
 Site : scrotal area below inguinal ligament, usually left sided & testis
hang lower than other side
 Skin : dilated tortuous vein
PAL PAT I ON
 Not Able to get above the mass(In severe)
 Able(mild)
 Relation to testis : testis can be palpated separately
 Surface : ‘Bag of worms’
 Consistency : soft
 Transilluminable : Negative

59. VARICOCELE
INVESTIGATIONS
 Venous color doppler of the scrotum and groin- standing/
valsalva’s manoeuvre
 USG abdomen to look for kidney tumours.
 Seminal analysis : Oligospermia or azospermia

60. VARICOCELE
INVESTIGATIONS

61. VARICOCELE
INVESTIGATIONS

62. VARICOCELE
CT SCAN

63. VARICOCELE
MANAGEMENT
 Aim to seal the affected veins
 Asymptomatic varicocele—No treatment is required, only
scrotal support and reassurance
 Non surgical - Radiologically-guided embolization of testicular
veins using sclerosants or spring coil.
 Surgical ligation – Palamo operation (high retroperitoneal
approach and ligation of internal spermatic vein above internal
inguinal ring

64. VARICOCELE
MANAGEMENT
Non-surgical Procedure.
 Steel coil or silicone balloon catheter is introduced into a vein
below the groin through a nick in the skin.
 Passed under X-ray guidance.
 Tiny metal coils or other embolizing agents introduced through
the catheter.
 No stitches needed.
 Patient can go back in 24hrs.
 Lower rates of complications. Less effective, higher
recurrence(5-11%), danger that the coil could migrate to the
heart and cause death Coil Embolization

65. VARICOCELE
MANAGEMENT
Surgical Procedure
 Symptomatic varicocele—Excision of the pampiniform plexus in
the inguinal canal after ligating them. Testis still has venous
drainage via the cremasteric veins
 VARICOCELECTOMY- The most common approaches are inguinal
(groin) -easier and safer.
 Retroperitoneal (abdominal)
 Suprainguinal extraperitonial( Palomo’s operation) Open &
Laparoscopic
 Scrotal approach- For Gr 4

66. VARICOCELE
MANAGEMENT

67. VARICOCELE
COMPLICATIONS
 Haemorrhage and scrotal haematoma
 Infection: Pyocele
 Injury to testicular artery
 Injury to ilioinguinal nerve and pain
 Recurrence—5-10%
 Shrinkage of the affected testicle ( atrophy )
 Infertility

68. TESTICULAR TORSION
A U D I R A H M A N

69. TESTICULAR TORSION
PATHOPHYSIOLOGY
 A condition whereby the testicle twists in such a way that its blood supply
becomes compromised
 If left untreated – ceases of blood flow to testicle and the testicle dies
THE EARLIER
THE SURGERY
TO UNTWIST
THE TESTIS
CAN BE
UNDERTAKEN
THE BETTER
THE RESULT

70. TESTICULAR TORSION
PATHOPHYSIOLOGY
 It is uncommon because the normal testis is anchored and cannot rotate
 For torsion to occur, one of the several abnormalities must be present:
i. Inversion of testis
ii. High investment of tunica vaginalis causes the testis to hang within
the tunica like a clapper in a bell
iii. Separation of epididymis from the body of testis permits torsion of
testis on the pedicle that connects the testis with the epididymis

71. TESTICULAR TORSION
TYPES OF TESTICULAR TORSION
 In 17% of males and 40%
bilaterally
 In a mature attachment, tunica
vaginalis is attached securely to
the posterior lateral aspect of
testicle
 But if the attachment of tunica
vaginalis is inappropriately high,
spermatic cord can rotate within it
 Common at adolescents
 Associated with bell clapper
deformity
INTRAVAGINAL TORSION

72. TESTICULAR TORSION
TYPES OF TESTICULAR TORSION
 Most often occurs in newborns without the ‘bell clapper’ deformity
 It is thought to result from a poor or absent attachment of the testis to
scrotal wall, allowing a rotation of testis, epididymis, and tunica vaginalis
as a unit of the cord at the level of external ring
EXTRAVAGINAL TORSION

73. TESTICULAR TORSION
CLINICAL FEATURES
 Most common age – between 10 and 25 years old, although a
few cases occur in infancy
 Typically, there is a sudden agonizing pain in the groin and the
lower abdomen
 Nausea and may vomit
 Torsion of a fully descended testis is usually easily recognized
 The testis seems high and the tender twisted cord can be
palpated above it
 Lost cremasteric reflex is lost
 High riding testes
 Bell clapper deformity
 Pain relief with detorsion
 Negative Phren’s sign

74. TESTICULAR TORSION
DIFFERENTIAL DIAGNOSIS
 Epididymo-orchitis
 Torsion of a testicular appendage
 Mumps orchitis
 Idiopathic scrotal edema
 Strangulated inguinal hernia

75. TESTICULAR TORSION
MANAGEMENT
 Management of the case should be determined primarily on
clinical grounds
 If there is doubt as to the diagnosis, then urgent scrotal
exploration is indicated
 While Doppler ultrasound scanning can confirm the absence
of blood supply to affected testis, false positive result can be
seen, so it is not routinely recommended
 Exploration of testis should be performed through a scrotal
incision

76. TESTICULAR TORSION
DOPPLER ULTRASOUND
N O R M A L U LT R A S O U N D A N D D O P P L E R F I N D I N G S

77. EPIDIDYMO-ORCHITIS
A U D I R A H M A N

78. EPIDIDYMO-ORCHITIS
PATHOPHYSIOLOGY
 Infection reaches the epididymis via the vas from a primary
infection of the urethra, prostate or seminal vesicles
 A general rule is that epididymitis arises in sexually active
young men from a genital infection, while in older men it
more usually arises from a urinary infection or may be
secondary to an indwelling urethral catheter
 Epididymitis must be differentiated from a testicular torsion

79. EPIDIDYMO-ORCHITIS
SIGNS AND SYMPTOMS
 Gradual onset of scrotal pain and swelling, usually unilateral
 Dysuria, frequency or urgency
 Fever and chills (up to 71% in children case)
 Usually no nausea and vomiting (contract with testicular
torsion)
 Urethral discharge preceding the onset of acute epididymitis
ASSOCIATED WITH CHRONIC EPIDIDYMITIS
 Long standing (>6 weeks) history of pain
 Scrotum that is not usually swollen but may be indurated in
long standing cases

80. EPIDIDYMO-ORCHITIS
PHYSICAL EXAMINATION
 Tenderness and induration occurring first in the epididymal tail
and then spreading
 Normal cremasteric reflex
 Erythema and mild scrotal cellulitis
 Reactive hydrocele (advanced epididymo-orchitis)
 Bacterial prostatitis or seminal vesiculitis
 In children, an underlying congenital anomaly of the
urogenital tract

81. EPIDIDYMO-ORCHITIS
INVESTIGATIONS
 Urinalysis
 Complete Blood Count
 Gram stain of urethral discharge – if present
MANAGEMENT
 Pharmacological treatment:
 Antibiotics
 Non pharmacological treatment:
 Reduction in physical activity
 Scrotal support and elevation
 Ice packs
 Avoidance of urethral instrumentation

82. EPIDIDYMO-ORCHITIS
MANAGEMENT
 Surgical options:
 Epididymotomy
Infrequently performed in patients with acute
suppurative epididymitis
 Epididymectomy
Typically reserved for refractory cases
 Orchiectomy
Indicated only for patients with unrelenting
epididymal pain
 Skeletonization of the spermatic cord via subinguinal
varicocelectomy
Performed in rare cases of refractory pain due to
chronic epididymitis and orchialgia

83. TESTICULAR TORSION VS EPIDIDYMO-
ORCHITIS
TORSION EPIDIDYMO-ORCHITIS
AGE 8 – 12 years old 18 – 25 years old
PAIN Sudden acute, more severe Acute, less severe
FEVER Usually negative Positive
UT SYMPTOM Usually negative Dysuria, frequency and urgency
URT INFECTION Usually negative Mumps
ABNORMAL SEXUAL
CONTACT
Negative May be positive
TESTIS  High locate
 Abnormal lie
 Normal
 Normal lie
PREHN’S TEST No relieve Relieve
CREMASTERIC REFLUX Absent Present
U/S DOPPER Vascularity decrease High vascularity
TREATMENT Emergency, surgery within 6 hours Antibiotic

84. EPIDIDYMAL
CYSTJ AYA N T H I

85. EPIDIDYMAL CYSTS
 Filled with crystal- clear fluid.
 Very common, usually multiple and vary in size at presentation.
 Represent as cystic degeneration of the epididymis.
 Usually found in middle- age and often bilateral.
 The clusters of tense cysts feel like tiny bunches of grapes that
lie posteriorly to and quite separate from the testis.
 Should transilluminate briliantly.
 Diagnosis confirmed by ultrasound.

87. EPIDIDYMAL CYSTS
 Aspiration is useless because the cysts are usually multi-
locular.
 Excised when it is a single large cysts and causes discomfort
 Partial or total epididymectomy when it is recurrent or
presence of multilocular cysts.
 Excision should be expected to interfere with the
transportation of sperm from the testis on that side and
young men should be counselled regarding this.

88. REFERENCE
Bailey and Love’s Short Practice of Surgery 26th Edition
 Dr Laurence Knott, Feb 2016. Inguinal Hernia.The
Information Standard [https://patient.info/doctor/inguinal-
hernias#nav-4]
 Ramsook C, Endom EE. Overview of inguinal hernia in
children. In: Post TW, ed. UpToDate. Waltham, MA:
UpToDate. [https://www.uptodate.com/contents/overview-
of-inguinal-hernia-in-children]. Last updated October 6,
2016. Accessed December 12, 2016.