GUS2 - K8 - Scrotal Swelling

8/11/2019 GUS2 - K8 - Scrotal Swelling

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م ي ح ر ل ن ح ر ل م Scrotal Swellingsس

Div. of Urology, Dept.of Surgery Medical Faculty,

University of Sumatera Utara



Common Causes of Scrotal Swellings

HydroceleEpididymal CystVaricoceleEpididymo-orchitis

Testicular Tumour



Hydrocele

• Fluid collections within the tunica vaginalisof the scrotum or along spermaticcord.

• Persistent developmental connections alongthe spermatic cord or Imbalance of fluidproduct versus absorption.

• Little risk of clinical consequence.



Pathogenesis

The fluid collects because of an imbalancebetween production and absorption.

The tunica vaginalis normally produces around0.5ml of fluid a day.Pathophysiology

– Proc. Vaginalis is a diverticulum of theperitoneal cavity.– It descends with the testis into the

scrotum (28 th gestational week).





History & ExaminationHistory: A painless swelling in the scrotum.

Onset may be gradual or sudden.

Examination: A scrotal swelling which you can get aboveThe testis cannot be palpated separate to theswellingThe lump transilluminates



Investigation

Because one of the causes of a hydrocele istesticular tumour, it is important to arrange a

scrotal ultrasound to rule out this as anunderlying pathology



Treatments

• Conservative management if the hydrocele issmall and causing little in the way of symptoms

• Aspiration +/- injection of a sclerosing agent• Surgery: Ligation of PPV in children

Jaboulay

LordsBoth the Jaboulay and the Lords procedure involve

incising the tunica vaginalis to allow the hydrocelefluid to be absorbed by the scrotal lymphatics.



Differentials– Orchitis– Testicular torsion– Indirect inguinal hernia– Traumatic injury to the testical



Epididymal Cyst



Definition

“ A cystic swelling arising from the epididymis”





Management

Simple surgical excision of the cyst

Aspirating will not work because the cyst ismultiloculated

As for hydroceles, conservative management isperfectly reasonable if the patient is asymptomatic



Varicocoele



Definition

“A varicocoele is a dilatation of the veins of the pampiniform plexus”



Symptoms & Signs

Symptoms: Scrotal swellingFar more common on left than on right

Dragging / aching sensation in the groin /scrotum

Signs: Scrotal swelling which you can get above

Swelling feels like a “Bag of worms”



Significance of Varicocoele

A left sided-varicocoele may arise as a result ofobstruction to venous drainage caused by a renal

tumour

Therefore all patients with a varicocoele shouldundergo imaging (usually ultrasound) of theirkidneys



Methods of Treatment

The two main methods are:

1 Surgical ligation

2 Embolisation under X-Ray control



Epididymo-Orchitis



Definition

“An inflammation of the tissues of theepididymis and testis”





Treatment

An appropriate broad-spectrum antibiotic isused, such as ciprofloxacin.



Ciprofloxacin

This is a fluoroquinolone antibiotic

It acts by inhibiting an enzyme called DNA gyrase inreproducing bacteria. This is one of the enzymesresponsible for unwinding DNA during replication



Testicular Tumours



Classification

You might sensibly start classifying testicular tumours intobenign and malignant. In fact benign solid tumours ofthe testis are extremely rare.

The classification of malignant tumours is complicated bythe fact that there are different classification systems

used in the UK and USA and consequently it’s easy to getconfused if you read textbooks from the differentcountries.



divided into:

1 Germ Cell Tumours2 Other tumours, the commonest of which is

lymphoma, which is the commonesttesticular malignancy in the older patient.



Germ cell tumours can be divided into

1 Seminomas2 Non-seminomatous germ cell tumours



But Remember

40% of testicular tumours are mixed, i.e.they have both seminomatous and non

seminomatous elements



Peak Age Incidence

Seminomas 40 yearsNSGCTs 30 years



Symptoms & Signs

Symptoms: Painless scrotal swellingChance discoveryTestis feels “heavier”

Signs: Scrotal swelling which you can get aboveThe lump is craggy & does nottransilluminate

May be associated with hydroceleMay have palpable liver due tometastases



InvestigationsRadiology: Ultrasound of testis

CT of abdomen to assess spreadChest X Ray for metastases

Blood Tests: AFP (alpha feto-protein)b-hCG (human chorionic

gonadotrophin)LDH (lactate dehydrogenase)

The blood tests are known as tumour markers.



SurgeryAn inguinal orchidectomy is performed

i.e. the testis is taken out through an incisionin the groin

This is because the lymphatic drainage of the

testis is to the para-aortic nodes. An incisionin the scrotum risks spreading the tumour tothe superficial inguinal lymph nodes whichdrain the scrotal skin



Other Treatments

If the tumour has metastasised, otheroptions for treatment include:

Radiotherapy for seminomaChemotherapy for NSGCTs

Sometimes a combination of the two isrequired



THANK YOU

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GUS2 - K8 - Scrotal Swelling