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