Ministry of Higher Education and Scientific Research

Medical University of Jabir Ibn Hayyan

Department of Surgery 2017

Scrotum
Scrotal pathology is a common cause of referral to the urologist.
Patients will either present with a mass in the scrotum, with or without
pain, or with an empty scrotum (cryptorchidism).

Differential Diagnosis
Painful Scrotal Mass Painless Scrotal Mass
Testicular torsion Testicular tumor
Epididymitis Hydrocele
Inguinal hernia Inguinal hernia
Testicular tumor (rapidly growing ) Spermatocele
Trauma (testicular rupture) Varicocele

Trans- Blood
Pathology Pain illumination Urinalysis Ultrasound Flow
Testicular torsion Yes No ± Solid Negative
Testicular tumor No No Negative Solid Normal
Epididymitis Yes No Positive Complex Increased
Hydrocele No Yes Negative Cyst Normal
Inguinal hernia ± ± Negative Complex Normal

‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
Dr. Muthanna H. Al- Athari, Ass. Professor, F.I.B.M.S. (Urology)
‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
Web Site: http://med.kufauniv.com/dr/muthanna
E-mail: muthanna.alathari@uokufa.edu.iq

1
 Varicocele
A varicocele is an abnormal dilatation of the veins of the pampiniform
plexus and internal spermatic vein of the spermatic cord. Left-sided
varicocele is most common, occurring in approximately 15% of normal
adult men and in up to 40% of patients with male infertility.
Pathophysiology
Varicocele formation has been attributed to one of three primary factors:
increased venous pressure in the left renal vein, collateral venous
anastomoses, and incompetent valves of the internal spermatic vein.
Unilateral right-sided varicoceles are rare (noted in only 2% of cases) and
should suggest the possibility of compression or obstruction of the
inferior vena cava (e.g., tumor or thrombus). Physical examination makes
the diagnosis. Dilated veins are best palpated with the patient standing
and aided by a Valsalva maneuver. Varicocele has been described as
feeling like a "bag of worms''.
Subclinical varicocele only diagnosed by imaging. The significance of a
varicocele is its association with infertility. Indications for
varicocelectomy include oligospermia, decreased sperm motility, and a
painful symptomatic varicocele, and in adolescents when there is reduced
testicular size.
Pathology of Testicular Dysfunction
It has been attributed to one or a combination of several mechanisms,
including: reflux of adrenal metabolites, hyperthermia, hypoxia, local
testicular hormonal imbalance, and intratesticular hyperperfusion injury.
Types of surgery for varicocele:
Open inguinal/subinguinal.
Microscopic inguinal/subinguinal.
Retroperitoneal mass ligation (Palomo).
Retroperitoneal artery sparing.
Laparoscopic.
Embolization.

NJ HYDROCELE
Types:
 Congenital or infant hydrocele: either; simple hydrocele,
hydrocele of the cord, or communicating hydrocele.
 Acquired or adult hydrocele: which is either:
 Idiopathic (usually)
 Secondary to: ** tumor (testicular).
** infection.
2
Congenital Hydrocele:
A simple (scrotal) hydrocele is an accumulation of fluid within the
tunica vaginalis. All hydroceles in infants and children result from
persistence or delayed closure of the processus vaginalis.
Clinically; are commonly seen at birth, and frequently bilateral, and may
be quite large. They transilluminate and may appear quite tense but are
not painful.
Management; Scrotal U\S is mandatory to exam the testes.
Most simple scrotal hydroceles found at birth deserve long-term
observation, and most resolve during the first 2 years of life. Aspiration
of infant hydroceles is contraindicated because of the risk for infection,
which in the case of a patent processus, would extend into the peritoneal
cavity. If surgical repair of an infant hydrocele is elected, an inguinal
approach should be used in case a patent processus is encountered.

Communicating hydrocele and Inguinal Hernia: :

Persistence of the processus vaginalis allows peritoneal fluid to freely
communicate with the scrotal limits of the processus, and a
communicating hydrocele results. .
Clinically; Communicating hydroceles may be diagnosed by history or
by physical examination. If a scrotal hydrocele can be compressed and
the fluid within the scrotum evacuated into the abdomen, a patent
processus must be present.
All communicating hydroceles should be explored through an inguinal
incision.
Surgical Treatment;
High-resolution scrotal ultrasonography should be performed in all men
with hydrocele.
Hydrocelectomy;
--Inguinal Approach.
--Scrotal Approach.
Scrotal hydrocelectomy may be safely performed when ultrasonographic
examination of the testis is normal.
Excisional Techniques: are most certain to result in permanent
elimination of the hydrocele, the (Jaboulay) bottleneck operation.
Plication Techniques: (Lord' s plication) can be employed for thin sacs.
Sclerotherapy;
Sclerotherapy is most useful in older men in whom fertility is no longer
an issue. It can be associated with substantial postoperative pain, and
recurrence is not uncommon.

3
 THE UNDESCENDED TESTIS
Definition; It refers to an abnormally positioned testicle,
cryptorchidism literally means “hidden testis.” An undescended testis
can be located anywhere between the abdominal cavity and just outside
the anatomic scrotum. Less commonly, the testis can also migrate to
ectopic positions outside the scrotum, not along the normal path of
descent. Eighty percent of undescended testes are palpable and 20% are
non-palpable.

Incidence; Isolated cryptorchidism is one of the most common

congenital anomalies found at birth and affects upward of 3% of full-term
male newborns. Unilateral cryptorchidism is more common than bilateral
cryptorchidism. Approximately 70% to 77% of cryptorchid testes will
spontaneously descend, usually by 3 months of age.

Epidemiology; birth weight alone is the principal determinant of

cryptorchidism at birth and at 1 year of life, independent of the length of
gestation.

Classification;
The term “nonpalpable testis” implies that the testis cannot be detected
on physical examination and therefore is either intra-abdominal, absent
(vanishing), atrophic, or missed on physical examination.

A “retractile testis” withdraws spontaneously out of the scrotum toward

the inguinal canal by an active cremasteric reflex but can easily be
brought down into a dependent position within the scrotum and remains
there after traction has been released.
Consequences of Cryptorchidism:
1. Infertility;
2. Neoplasia; The most common tumor that develops from a
cryptorchid testis is seminoma. It is yet inconclusive whether
orchidopexy performed at an early age will protect against the
development of malignancy.
3. Hernia ; A patent processus vaginalis is found in more than 90%
of patients with an undescended testis.
4. Testicular Torsion

4
 Management of Cryptorchidism:
Definitive treatment of an undescended testis should take place
between 6 and 12 months of age.
The overall accuracy of radiologic testing (U|S, MRI) for an
undescended testis is 44%.
Surgical Treatment; ''Standard orchiopexy'' with dartos pouch.
Hormonal Therapy; the overall efficacy of hormonal treatment is
less than 20% for cryptorchid testes and is significantly dependent on
pretreatment testicular location. Therefore, surgery remains the gold
standard for the management of undescended testes.
Laparoscopic Management of an Undescended Testis.

EPIDIDYMO-ORCHITIS (EO)
Acute Epididymo-Orchitis:
Pathology; In sexually active men younger than 35 years, C. trachomatis
and N. gonorrhoeae are the most common organisms. In children and
men older than 35 years, E. coli is the most common pathogen.
Pathogenesis; Most cases of EO in men older than 35 years are
associated with UTI caused by gram-negative enteric bacteria. EO
associated with urinary infection is more common among men who have
anatomic abnormalities or those who have recently had urinary tract
instrumentation.
Clinically; Patients present with heaviness and a dull, aching discomfort
in the affected hemiscrotum that can radiate up to the ipsilateral flank.
The epididymis will be markedly swollen and exquisitely tender to touch,
eventually becoming a warm, red, enlarged, scrotal mass,
indistinguishable from the testis. Fever and chills may develop, and
patients usually have urethral discharge or irritative voiding symptoms.
Elevation of the scrotum may decrease the patient's pain (positive Prehn's
sign). An inflammatory hydrocele may develop within a few days.
Fixation of the testicle to the scrotal wall suggests abscess formation.
Diagnosis; usually made from history, physical examination, and positive
urinalysis.
Color-flow Doppler testicular ultrasound can help make the diagnosis by
demonstrating increased blood flow. Testicular flow scan using 99mTc-
pertechnetate shows increased perfusion to the involved side and a
crescent of increased activity corresponding to the inflamed epididymitis.
Diagnostic recommendations include a Gram-stained smear for
evaluation of urethritis and for presumptive identification of gonococcal
infection, diagnostic testing for N. gonorrhoeae and C. trachomatis, urine
5
Gram stain and culture, syphilis serology and HIV testing (if sexually
transmitted epididymo-orchitis is likely).
Treatment
Outpatient management is appropriate for most patients with EO.
Hospitalization should be considered when severe pain suggests other
possible diagnoses, such as testicular torsion, testicular infarction, or
testicular abscess; when patients are febrile; or when noncompliance with
medication regimens is likely. Empiric antimicrobial regimens are
recommended as follows:
Gonococcal or chlamydial infection likely:
Ceftriaxone, 250 mg in a single IM dose, plus doxycycline 100 mg
orally twice a day for 2-3 wks.
Enteric infection likely:
Ofloxacin, 300 mg orally twice a day for 2-3 wks, or levofloxacin
500 mg orally once a day for 2-3 wks.
Adjunctive measures include bed rest, scrotal elevation, and analgesics
until fever and local inflammation subside.
Routine follow-up is recommended. Failure to respond within 3 days
requires reevaluation of both the diagnosis and treatment; and in such
circumstances, other possible diagnoses should be considered which
include: Testicular tumor, abscess, infarction, TB, fungal epididymitis, or
collagen-vascular disorders.
Chronic Epididymo-orchitis;
Chronic epididymitis can be the result of several recurrent episodes of
acute epididymitis producing chronic induration and pain. Treatment
consists of long-term antibiotics or epididymectomy.

Testicular torsion
Torsion refers to a twisting of the testis and spermatic cord around a
vertical axis, resulting in venous obstruction, progressive swelling,
arterial compromise, and eventually testicular infarction. Torsion must
be considered in the initial diagnosis of any scrotal pathology because
without immediate detorsion, the testis will be lost. Two types of torsion
occur: extravaginal and intravaginal.
Extravaginal Torsion:
Extravaginal torsion occurs in neonates (and occasionally in utero)
because of incomplete attachment of the gubernaculum and testicular
tunics to the scrotal wall. Extravaginal torsion accounts for fewer than
10% of all cases of testicular torsion. Removal of the infarcted testis has
been recommended because of the theoretic concern for autoimmune

6
damage to the contralateral testis, with resultant fertility problems in the
adult.
Intravaginal Torsion:
This condition can occur at any age but is most common among
adolescents. It is the result of an abnormally narrowed testicular
mesentery, with the tunica vaginalis almost completely surrounding the
entire testis and epididymis. This narrowed mesentery facilitates twisting
of the testis within the tunica vaginalis about its vascular pedicle and
gives an appearance termed the ''bell-clapper'' deformity.
Diagnosis; The typical patient presents with sudden onset of pain and
swelling, occasionally associated with some minor trauma. The testis will
be tender, is often high in the scrotum because of shortening by the
twisted cord, and may have a transverse lie or an anteriorly positioned
epididymis. Urinalysis is usually negative. Elevation of the scrotum will
not relieve the pain (negative Prehn's sign). Color-flow Doppler
ultrasonography should be obtained without hesitation and has become
the test of choice. Surgical exploration is the best diagnostic test and
should not be delayed if this diagnosis is seriously considered.

Treatment;
Treatment consists of immediate detorsion. Correction within 6 hours of
onset of pain usually results in a normal testis. Manual detorsion can be
attempted by either lifting the scrotum or rotating the testicle about its
vascular pedicle. Successful manual detorsion must still be followed by
surgical orchiopexy. An unsuccessful attempt at manual detorsion
requires immediate surgical exploration. The clearly infarcted testis
should be removed; however, if viability is in doubt, it should be left in
situ because Leydig cell function may be preserved. After detorsion, the
testis should be fixed to the scrotal wall with two to three non-absorbable
sutures to prevent repeated torsion. The contralateral testis must also be
fixed because of the high incidence of its subsequent torsion.