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6th practise
Scrotal disordersDifferential diagnosis and treatment of varicocele, hydrocele, testicular retention,
testicular atrophy, epididymitis, orchitis, testicular trauma, testicular torsion, testicular tumour, inguinal hernia, scrotal oedema
Summary of scrotal disorders
Acute scrotumtesticular torsion
torsion of the appendix testis
acute epididymitis
Scrotal massesvaricocele
hydrocele
inguinal hernia
scrotal oedema
testicular cancer
Miscellaneous
scrotal disorders
Fournier gangrene
Scrotal traumascrotal haematoma
haematokele
testicular dislocation
testicular rupture
Acute scrotum
acute scrotal/testicolar pain emergency situation (risk of testicular torsion)
Acute scrotum
differential diagnosis: testicular torsion torsion of the appendix testis epididymitis scrotal oedema
mumps orchitis
varicocele
scrotal haematoma
incarcerated hernia
appendicitis
Testicular torsion
synonyms: torsion of the testis, spermatic cord torsion, testicular torque
definition: spermatic cord twists forms:
intravaginal (usually) extravaginal (perinatal period)
Testicular torsion
symptoms and sygns: acute testicular pain
(sudden, severe) nausea, vomiting
phisical finding abnormal position of the testis (elevation, anterior
epididymal position) testicular tenderness abscence of the cremasteric reflex
Testicular torsion
urinalysis: normal cololor doppler ultrasuond: decreased, absent
blood flow
Testicular torsion
treatment: urgent surgical
exploration: detorquation and bilateral
orchidopexy semicastration
(removal of the testicle) manual detorsion, then
immediate bilateral orchidopexy (fixation of the testis)
Torsion of the appendix testis
definition: appendix testis twists
symptoms: sudden testicular pain
phisical finding tenderness of the superior
pole of the tesis nodule superior to the
testis blue dot sign intact cremastric reflex
Torsion of the appendix testis
scrotal ultrasound: enlarged appendix testis color doppler ultrasuond: normal testicular
blood flow
Torsion of the appendix testis
treatment: conservative: NSAID, rest surgical exploration: excision of the appendage
Acute epididymitis
definition: acute inflamation of the epididymis etiology:
<35 years of age: STD (clamidia trachomatis, neisseria gonorrhoae)
>35: common uropathogens: e. coli, proteus, klebsiella
Acute epididymitis
symptoms: epididymal/testicular pain (gradual
onset) swollen scrotal erithema fever
pshisical finding epididymal/testicular tenderness,
swollen intact cremasteric reflex
Acute epididymitis
urinalysis, urine culture, urethral smear: may be positive
scrotal ultrasound: thickened epididymis
color doppler ultrasound: hypervascularised epididymis, hypervasularisated
testis (in case of epididymoorchitis)
Acute epididymitis
complication: epididymoorchitis abscess testicular infarction atrophy infertility chronic epididymal induration
Acute epididymitis
treatment: conservative:
antibiotics (fluorokinolons) NSAID bed rest, uo-positioning of the testis, local cooling
surgical: in case of complications, abscess
Acute scrotum DD
Testucular torsion Appendix testis torsion
Acute epididymitis
Pain onset sudden sudden gradual
Fever - - +
Blue dot sign - + -
Tenderness testicular upper pole of the testis
epididymal
Cremastric reflex - + +
Urinalysis - - +
Testicular color doppler US
decreased or absent blood flow
norm. hypervascularisation
Scrotal trauma
blunt scrotal haematoma haematokele testicular dislocation testicular rupture
penetrating
Scrotal haematoma
definition: haematoma of the scrotal skin symptoms: scrotal pain US: intact tunica albuginea treatment: conservative
Haematokele
definition: collection of blood between the two layers of tunica vaginalis testis
symphtoms, phisical signs:
scrotal enlargement
scrotal haematoma
scrotal pain
US:
intact tunica albuginea
fluid collection arround the tesicle
treatment
smal hematocele: conservative
large hematocele: surgical exploration, blood clot evacuation
Testicular rupture
definition: rupture of the tunica albuginea
symptoms:
testicular pain
nusea, vomiting
fainting
phisical finding:
testicular tenderness, swollen
scrotal haematoma
US:
Tunica albuginea rupture
Hematocele
Intratesticular hematoma
treatment: surgical exploration - haemtoma avacuation, necrotic testicular tissue excision, closure of the tunica albuginea
Scrotal masses
• varicocele
• hydrocele
• inguinal hernia
• scrotal oedema
• testicular tumour
Varicocele
• definition: abnormal dilation (3 mm<) of the internal spermatic veins
• main effects (indications for surgical treatment):
– scrotal pain, discomfort
– infertility
– testicular atrophy
• epidemiology
– all men: 12%
– men with abnormal semen analysis: 25%
• symptoms
– testicular pain, discomfort
– palpable scrotal mass
– indolent
Varicocele
Varicocele
• classification:
– subclinical: only can be shown by color doppler US
– grade 1: palpable during Valsalva manouvre
– grade 2: palpable
– grade 3: visible
Varicocele
• diagnosis
– phisical examination
• inspection
• palpation
– color doppler US
– check retroperitoneal mass
– semen analysis
Varicocele• treatment
– varicocelectomy (ligation of the internal spermatic vein)
• suprainguinal
– open (Palomo)
– laparoscopic
• inguinal (open)
• subinguinal
– open
– microsurgical (gold standard)
– sclerotherapy
• retrograde
• antegrade
Hydrocele
• definition: fluid collection between the two layers of tunica vaginalis
• symptoms:
– scrotal enlargement
– indolent
diagnosis
anamnesis, phisical examination
transillumination
ultrasuond
Hydrocele
Hydrocele
• treatment
– punction
– hydrocelctomy
• op sec. Winkelmann
• op sec. Bergmann
Inguinal hernia
• definition: protrusion of a portion of abdominal organs through the abdominal wall
Inguinal hernia
• classification
direct
indirect
Inguinal hernia – hydrocele differential diagnosis
hydrocele inguinal / inguinoscrotal
hernia
Inguinal hernia
• treatment
open hernioplasty (Bassini, Lichtenstein)
laparoscopic hernioplasty (transperitoneal, extraperitoneal)
Testicular cancer
epidemiology:
– 1-1,5% of male tumours
– peak incidence:
• non-seminoma: 3rd decade of life
• pure seminoma: 4th decade of life etiology – risk factors:
– cryptorchidism
– Kinefelter's syndrome
– infertility
– contralateral tumour
– first grade relatives
Testicular cancer
pathological classification
– germ cell tumors (90-95%)
• seminoma
• embryonal carcinoma
• yolk sac tumor
• choriocarcinoma
• teratoma
• mixed tumors
– sex cord/gonadal stromal tumors
– miscellaneous non specific stromal tumors
Testicular cancer
pathological classification – practical clinical consideration
– seminoma (only seminoma)
– non-seminoma (other germ cell npl. or mixed germ cell npl. even with seminoma)
Testicular cancer
symptoms
– painless (scrotal pain 27%)
– palpable testicular mass – self examination!
– gynecomastia
– back, flank pain (retoperitoneal lymph node metastasis)
– varicocele (lymp node met.)
– fever, weight loss, cahexia (advanced stage)
Testicular cancer
diagnosis
– phisical examination
• palpation of the scrotum(painless hard intratesticular mass)
• palpation of the supraclavicular limph nodes (Virchow's node)
Testicular cancer
diagnosis
– imaging of the primer tumour
• US of the testicle
• MR of the testicle
– staging (looking for metastasis)
• abdominopelvic CT
• chest CT
– serum tumour markers
• AFP
• hCG
• LDH
Testicular cancertreatment
radical inguinal semicastration
pathologicalexamination
staging
surveillance chemotherapy retroperitoneallymphadenectomy radiotherpy
Progression, relapse
Second line treatments:Chemotherapy
Retroperitoneal lymphadenectomy
abdominopelvic CTchest CTserum tumor markers
only early, localised stage only seminomascisplatin based
Fournier gangrene• definition: polymicrobal necrotising fasciitis of the
external genitalia, perineum, perianal region
• etiology:
risk factors(immuno-compromised patient –
diabetes, malnutrition; elderly patient; recent perineal surgery, catheterisation)
polimicrobal bacterial infection
(aerobs, anaerobs)
Fournier gangrene• features:
agressive
fulminant (hours)
life threatening
rare
• symptoms, phisiclal findings
painful scrotal swelling
scrotal erythema, oedema
crepitus
necrotic skin areas
Fournier gangrene• treatment
immediate intravenous broad spectrum antibiotics
immediate surgical debridement
supportive treatment
Test images