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Inguinalscrotal Disease

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

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Inguinalscrotal Disease

  1. 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. 2. OUTLINES ANATOMY INGUINAL HERNIA UNDESCENDED TESTIS HYDROCELE VARICOCELE TESTICULAR TORSION EPIDIDYMO-ORCHITIS EPIDIDYMAL CYST
  3. 3. ANATOMY OF INGUINOSCROTAL REGION N I K ‘ A I N A M A R D H I YA H
  4. 4. EMBRYOLOGY
  5. 5. Inguinal canal : 1. Openings 2. Boundaries 3. Contents Hesselbach triangle : Borders Spermatic cord : 1. Layers 2. Contents
  6. 6. INGUINAL CANAL 4-6cm long oblique passage above the inguinal ligament, from the deep to superficial ring
  7. 7. OPENINGS The inguinal canal has 2 openings: 1. Deep (internal) inguinal ring 2. Superficial (external) inguinal ring.
  8. 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. 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. 10. HESSELBACH TRIANGLE Borders of Hesselbach's triangle  Medially: rectus abdominis muscle  Laterally: inferior epigastric vessels  Inferiorly: inguinal ligament
  11. 11. SPERMATIC CORD 3 Concentric Layers 3 Arteries 3 Nerves 3 Others
  12. 12. LAYERS 3 layers :
  13. 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. 14. INGUINAL HERNIA N I K ‘ A I N A M A R D H I YA H
  15. 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. 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. 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. 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. 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. 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. 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. 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. 23. INGUINAL HERNIA DIFFERENTIAL DIAGNOSIS  Undescended testis  Testicular torsion  Hydrocele  Femoral hernia  Inguinal or femoral lymphadenitis  Tumors.
  24. 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. 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. 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. 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. 28. UNDESCENDED TESTIS J AYA N T H I
  29. 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. 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.
  31. 31. 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
  32. 32. 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.
  33. 33. HYDROCELE G E J A L A C H U M Y
  34. 34. 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
  35. 35. 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)
  36. 36. 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.
  37. 37. HYDROCELE CONGENITAL NON COMMUNICATING COMMUNICATING ACQUIRED PRIMARY SECONDARY INFECTION INJURY POST HERNIORRHAPHY HYDROCELE POST VARICOCELECTOMY HYDROCELE TUMOUR TRAUMA
  38. 38. HYDROCELE
  39. 39. 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
  40. 40. HYDROCELE
  41. 41. 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
  42. 42. 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
  43. 43. HYDROCELE
  44. 44. 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
  45. 45. HYDROCELE INVESTIGATIONS
  46. 46. 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
  47. 47. 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)
  48. 48. 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
  49. 49. 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
  50. 50. 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)
  51. 51. VARICOCELE G E J A L A C H U M Y
  52. 52. 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
  53. 53. 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
  54. 54. 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
  55. 55. 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
  56. 56. 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
  57. 57. 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
  58. 58. VARICOCELE INVESTIGATIONS
  59. 59. VARICOCELE INVESTIGATIONS
  60. 60. VARICOCELE CT SCAN
  61. 61. 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
  62. 62. 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
  63. 63. 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
  64. 64. VARICOCELE MANAGEMENT
  65. 65. 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
  66. 66. TESTICULAR TORSION A U D I R A H M A N
  67. 67. 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
  68. 68. 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
  69. 69. 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
  70. 70. 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
  71. 71. 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
  72. 72. TESTICULAR TORSION DIFFERENTIAL DIAGNOSIS  Epididymo-orchitis  Torsion of a testicular appendage  Mumps orchitis  Idiopathic scrotal edema  Strangulated inguinal hernia
  73. 73. 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
  74. 74. 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
  75. 75. EPIDIDYMO-ORCHITIS A U D I R A H M A N
  76. 76. 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
  77. 77. 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
  78. 78. 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
  79. 79. 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
  80. 80. 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
  81. 81. 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
  82. 82. EPIDIDYMAL CYSTJ AYA N T H I
  83. 83. 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.
  84. 84. 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.
  85. 85. 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.
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Seminar presentation by 5th year Medical Student under the supervision of a pediatric surgery specialist from HRPZ II. Reference as mentioned in the slide.

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