Empty Scrotum

7/29/2019 Empty Scrotum

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Empty scrotumSupervised by

Dr.Saber M. Waheeb


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Definition

Cryptochidism is the absence of one

or both testes from the scrotum


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Normal fetal testicular development

and descent

The testes begin as an immigration of

primordial germ cells into testicular cordsalong the genital ridge in the abdomen of

the early embryo .


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The testes remain high in the abdomen untilthe 7th month of gestation, when they movefrom the abdomen through the inguinal canals

into the two sides of the scrotum. It has been proposed that movement occurs

in two phases, under control of somewhatdifferent factors


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The first phase

movement across the abdomen to the

entrance of the inguinal canal appears

controlled (or at least greatly influenced) by

anti-mllerian hormone (AMH.)


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The second phase, in which the testes move

through the inguinal canal into the scrotum, is

dependent on androgens

( most importantly testosterone .)


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In many infants with inguinal testes, further

descent of the testes into the scrotum occurs

in the first 6 months of life. This is attributed

to the postnatal surge of gonadotropins and

testosterone that normally occurs between

the first and fourth months of life.


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The tissue in undescended testes becomes

more markedly abnormal ("degenerates") in

microscopic appearance between 2 and 4

years after birth .

There is some evidence that early orchiopexy

reduces this degeneration.


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Epidemiology

The most common congenital anomaly of the

male genitalia. There is a higher incidence in premature

babies (up to 30%.)

It affects almost 1% of all full-term male

infants at the age of1 year.

Unilateral cryptorchidism is four times more

likely than bilateral


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4* Environmental risk factors

5* Familial6* Genetic

7* Iatrogenic

1* Prematurity

2* Low birth weight3* environmental chemical


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Causes:


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1-Arrested testis:

1-abdominal :

*lumber fossa

*iliac fossa

2-extraabdominal :

*inguinal canal (commonest)

*near pubic tubercle


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2-ectopic testis:

LOCKWOOD theory

Sites of ectopic testis:

*superficial inguinal

pouch( commonest )*femoral

*penile

*perineal


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3-asending testis:

4-Atrophied testis:

*history of normal descend .

*unilateral hidden

impalpable testis.

*contra lateral oversized

testis

*equal well developed

scroutum halves.


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5-testicular agenesis : rare

6-Associated with otherabnormalities:

Prune belly syndrome


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*HISTORY

*Physical examination * Examination should take place while the child

is supine and in a cross-legged position, and cover the following steps:


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* Imaging or ultrasound ..

* Abdominal and pelvic ultrasonography may be required if intersexuality is suspected.

* US and CT scan are much less accurate in showing intra-abdominal testes.and..does not

add any benefit to differentiating between palpable and non-palpable testes.

* Diagnostic laparoscopy:

is the only way to confirm or rule out an intra-abdominal, inguinal or absent/vanishing testis

(non-palpable testis).

*A karyotype can confirm or exclude forms of dysgenetic primary hypogonadism,

such as Klinefelter syndrome or mixed gonadal dysgenesis.

.*.Hormone levels {human chorionic gonadotropin}


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The main goals of hormonal or surgical treatment are :

1- to allow for a normal anatomic position of the testicle

2- the preservation of fertility

3- hormonal production and the diagnosis of potential testicular malignancies.

4- correction of associated hernias

5- prevention of testicular torsion.

Orchiopexy should be considered after 4 months of life, as the rate of descent

diminishes considerably after this point.


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In patients who are not candidates for surgical intervention.

hCG or LH-releasing hormones (LHRH) are mainly used.


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The approach chosen is determined by the position of the testis and the surgeon's

expertise.

The palpable testis can be approached from a scrotal, sub-inguinal, inguinal, orsupra-inguinal approach.

The non-palpable testis can be approached using an inguinal, supra-inguinal, or

laparoscopic approach.

1. Look for the testis

2. Divide all attachments, including the gubernaculum, the cremasteric fibers, and

the lateral spermatic fascia.

3. Identify the patent processus vaginalis and separate it from the cord structures,and perform a high ligation; be careful not to trap the vas or vessels.

4. Place the testis in a subdartos pouch.


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1. Look for the testis

2. Divide all attachments, including the

gubernaculum, the cremasteric fibers, and the

lateral spermatic fascia.3. Identify the patent processus vaginalis and

separate it from the cord structures, and

perform a high ligation; be careful not to trap

the vas or vessels.

4. Place the testis in a subdartos pouch.


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Diagnostic laparoscopy versus inguinal exploration.


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The Fowler-Stephens principle involves dividing the testicular vessels to allow the

blood supply to the vas deferens to keep the undescended testis viable. The testicular

vessels should be divided away from the testis.

Testicular auto-transplantation can be performed by transecting the testicular vessels

and by performing a micro-vascular anastomosis to the inferior epigastric vessels


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An undescended testicle isn't in a cooler environment. This might increase the

risk of complications later in life. These complications include:

Fertility problems Testicular cancer


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Other complications related to the abnormal location of the undescended testicle

include:

1. Trauma If a testicle is located in the groin, it may be damaged from pressureagainst the pubic bone.

2. Inguinalhernia

Inguinal hernia


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3. Testicular torsion


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