Other scrotal swelling by Dr. Teo

Dr. Teo Zue Hiong

Content Hydrocele Hematocele Spermatocele & eppidydymal cyst Varicocele Testicular tumor Testic torsion Epidydymo-orchitis

Undescended testis

hydrocele

Excessive collection of fluid within tunica vaginalis

Divided into congenital & acquired (further divided into primary and secondary )

Congenital -patent connection with peritoneal cavity via patent

processus vaginalis

AcquiredPrimary:-Idiopathic-Can reach very large size with no pain

Secondary:-Trauma/infection/tumor-Small size. Tender if underlying testis tender

PE

Usually bilateral Translucent Testis impalpable

complication

Rupture Hematocele Infection Hernia of hydrocele sac Sac wall calcification Testic atrophic

hamatocele

Collection of blood within tunica vaginalis

Due to trauma or underlying malifnant

Not translucent (distinguished from hydrocele)

varicocele Dilated, tortuous & elongated veins of

pampiniform plexus of spermatid vein (varicose vein in spermatid cord)

90% on the left because Lt testicular vein drain into high pressure renal vein where the Rt testicular vein drains directly into IVC

Usually asymptomatic but pt usually infertile as it increases scrotal temperature which affect normal sperm function

Spermatocele & epididymal cyst Testis are palpable

Cant distinguished clinical. Only by aspiration.

-Spermatocele: slightly grey, opaque fluid containing spermatozoa

-Epidydymal cyst: clear fluid

Testicular tumor

20-40 years old >90% are derived from germ cells

Most common

-Seminomas: derived from spermatocyte

-Teratoma: dereved from 3 germ cell layer ectoderm/mesoderm/endoderm

Presentation

-solid testicular lump

- painless

- may cause secondary hydrocele

spread

Spread to para-aortic LN > thoracic duct > supraclavicular LN

Inguinal LN are not involved unless spread to scrotal skin

Investigation USG for scrotal content

Chest X-ray for lung secondaries

Tumour markero B-HCGo AFPo LDH

CT for staging

staging

I: confined to testis II: retroperitoneal LN III: metastasis above diaphragm

confined to LN IV: extralymphatic metastasis

treatment

orchidectomy Radiotherapy Chemotherapy LN dissection

Acute epidydymo- orchitis Primarily an infection of the epididymis

but then spread into testis

Organism : chlamydia/gonococcus/ E.coli

May be assoc with UTI

Presentation

Acute severe testicular pain Pain is decrease by raising the testis Scrotal skin red, hot & edematous

Aetiology and pathological features Rare,except a/w mumps Blood-borne infection Surgical procedure on the lower urinary

tract,e.g. TUR Organism: Neisseria gonorrhoeae,

Escherichia coli and Chlamydia. In young man, the commonest is Chlamydia

Tuberculosis

Clinical features

Preceding Hx of an operation or of dysuria, frequency and heamaturia

Acute pain in scrotum,swelling Epididymis:acutely tender and

enlarged(although it maybe difficult to differentiate from the equally tender testis)

Overlying redness and oedema maybe present

Investigation

FBC: leucocytosis Blood culture: helpful to direct antibiotic

treatment Urinalysis: pyuria, organism maybe

revealed by culture Aspiration of the epididymis USG: increased blood flow

Management

Bed rest,scrotal elevation Tetracycline or erthromycin Other antiobiotic refer to culture Partner should also be investigated and

treated

Epidemiology

Both testes are undescend in 30% of premature infants

Term:3% One year:1% Spontaneous descent after one year is

rare

Aetiology

Failure of migration along the normal line of descent

Ectopic testis:testicle deviates away from the line and lie in front of the penis in the superficial inguinal pouch,in the perineum or in the thigh.(reason unknown)

Risk factor Prematurity Low birth weight Twin gestation Down syndrome(fetus) or other chromosomal

abnormality Gestational diabetes mellitus Prenatal alcohol exposure Hormonal abnormalities (fetus) Toxic exposures in the mother Mother younger than 20 A family history of undescended testes

Clinical features

An empty scrotal sac or hemiscrotum at 1 year indicates:

Proximal to the external inguinal ring(undescended)

Truly absent Retractile-the cremaster muscle reflexly pulls the

organ up towards the inguinal canal Ectopic

Complication

Infertility:inevitable in bilateral and common in unilateral undescent,frequent in those who are undescent treated.

Torsion Trauma Inguinal hernia Malignant disease

Investigation USG,CT and laparoscopy

Management Target is to bring the testicle with its blood supply

into the scrotum as early as possible

Orchidopexy:should be done beyong puberty Testicular prosthesis can be placed in the

scrotum

1 Epididymis

2 Head of epididymis

3 Lobules of epididymis

4 Body of epididymis

5 Tail of epididymis

6 Duct of epididymis

7 Deferent duct (ductus deferens or vas deferens)

Testicular torsion occurs when the spermatic cord(from which the testicle is suspended) twists, cutting off the testicle's blood supply(ischemia)

Cause: recognised complication of testicular maldescent wherein the testis is inadequately affixed to the scrotum allowing it to move freely on its axis and susceptible to induced twisting of the cord and its vessels.

Occurs most probably between birth and early adolescence

Testicular torsion

Twist VS Untwist

Twist deprives the organ of its blood supply

If untwist does not take place within 6 hours,ischaemia is irreversible,gangrene develops and the testis either suppurates or atrophies

Presentation & Finding Acute severe testicular pain(affected side) Testis is tender,swollen and hang higher

up(compared to other side) Poorly localized central abdo pain Vomitting(sometimes) Scrotal skin become red,hot and edematous in

later stage Palpation may feel the twisted cord

Pain is increase or no improvement by raising the testis

Investigation

Urinalysis:sterile,acellular urine USG:absence of blood supply to the

affected testicle

Management

Surgical emergency Non-operative

Maybe possible to de-rotate the testis

Surgical Failure of non-operative reduction require

emergency operationThe testis is de-rotated and fixedThe gangrenous testis is removed

Dignosis of lumps in the scrotum1. Can u get above it? : if not, mostlikely is an

inguinoscrotal hernia.(or a hydrocele extending proximally)

2. Is it separate from the testis?3. Is it cystic or solid? Separate and cystic - epididymal cyst or

spermatocele Separate and solid - epididymitis (may also

orchitis) Testicular and cystic – hydrocele Testicular and solid – tumour, orchitis