Inguinoscrotal Swellings

And Undescended Testis

Nurfariha | Ameer | Ruqoyyah
Content
1. Anatomy of the inguinal and scrotal region that is of surgical importance
2. Definition of a hernia
3. Clinical features of a hernia
4. Distinguish an inguinal hernia from a scrotal and inguinal region swellings
5. Distinguish a femoral hernia from an inguinal hernia
6. Distinguish a direct from an indirect inguinal hernia
7. Pre-disposing factors causing a hernia and a recurrent hernia
8. Surgical management of a hernia
9. Distinguish a scrotal swelling into testicular and extra testicular swelling
10. Clinical features of a solid and cystic testicular swelling
11. Clinical features of inflammatory (acute and chronic) testicular conditions
12. Clinical features and presentations of malignant testicular swelling
13. Surgical management of scrotal swelling
 Anatomy Of
The Inguinal And
Scrotal Region
RECALL – LAYERS OF THE ANTERIOR ABDOMINAL WALL
 INGUINAL REGION

Surface Markings

● ASIS
● Pubic symphysis
● Pubic tubercle

Inguinal ligament: ASIS to Pubic tubercle

Mid-inguinal point: midpoint between ASIS
to pubic symphysis
 INGUINAL CANAL
● Above and parallel to medial half of inguinal
ligament
● Directed downward and medially / lying obliquely
● Extending from deep to superficial inguinal ring
● The canal serves as a pathway by which
structures
can pass from the abdominal wall to the
external genitalia
● 1.5 - 2 inches / 4-6 cm long
● It is of clinical importance as a potential
weakness in the abdominal wall, and thus a
common site of herniation
 OPENINGS

The inguinal canal has 2 openings:

1. Deep (internal) inguinal ring

2. Superficial (external) inguinal ring
 Deep Inguinal Ring

● Entrance to the inguinal canal

● Oval opening in the transversalis fascia
● Lateral to the inferior epigastric vessels that
lies about 1.5 cm above mid-inguinal point
● From the margin of the ring. “Internal
spermatic fascia”
extends into the spermatic cord
 Superficial Inguinal Ring

● Triangular opening in the external oblique

aponeurosis
● Above and medial to the pubic tubercle
● From the margin of the ring, external
spermatic fascia extends into the
spermatic cord
 BOUNDARIES OF INGUINAL CANAL

Superior ● Internal oblique muscle

wall/ roof ● Transversus abdominis muscle

Anterior wall ● External oblique aponeurosis

● Internal oblique aponeurosis
(lateral 2/3rd)
Inferior wall/ ● Inguinal ligament
floor ● Lacunar ligament (medially)

Posterior wall ● Transversalis fascia (entire length)

● Conjoint tendon (medial 3rd)
 CONTENT OF INGUINAL CANAL

Males

● Spermatic cord (with the genital branch of

the genitofemoral nerve)
● Ilioinguinal nerve (passes through the
superficial ring but does not completely
run through the entire inguinal canal)
Females

● Round ligament of the uterus

● Genital branch of the genitofemoral nerve
● Ilioinguinal nerve
 HESSELBACH’S TRIANGLE

It is described as the area where a direct

inguinal hernia will extrude from posterior to
anterior

Boundaries

● Medially: lateral border of rectus abdominis

● Laterally: inferior epigastric vessels
● Inferiorly: Inguinal ligament

Surgical importance:

● Not reinforced by conjoint tendon

● Potentially weak area
● Direct inguinal hernia protrudes through it
FEMORAL TRIANGLE

Femoral triangle consists of three borders

● Superior border: inguinal ligament

● Lateral border: medial border of the sartorius muscle
● Medial border: medial border of the adductor
longus muscle

Content ( lateral to medial)

● Femoral Nerve (landmark is midpoint of inguinal
ligament)
● Femoral Artery (landmark is at the mid- inguinal
point, inferiorly)
● Femoral Vein
● Femoral canal - contains loose connective tissue,
lymphatic vessels, and lymph nodes of cloquet
 FEMORAL CANAL
● It is an anatomical compartment, located in the
anterior thigh
● It is the innermost compartment of the three
compartments on the femoral sheath
● Extends from the femoral ring above to the
saphenous opening
● 1.25 cm long, 1.25 cm wide
● Contains fats, lymphatic vessels, and lymph
nodes

Clinical significance

The entrance to the femoral canal is the femoral ring,

through which
bowel can sometimes enter, causing femoral hernia
 FEMORAL RING

It is the abdominal opening of the femoral

canal
Boundaries
● Anterior: inguinal ligament
● Posterior: Ligament of Astley cooper
● Medial: Lacunar ligament
● Lateral: Femoral vein
In cases of femoral hernia, part of the
bowel pushes into the femoral canal
 SPERMATIC CORD
● The cord passes through the
inguinal canal, entering the
scrotum via the superficial inguinal
ring
● It continues into the scrotum,
ending at the posterior border of
the testes
● Here, its contents disperse to
supply the various structures of the
testes and scrotum
 COVERINGS OF THE SPERMATIC CORD

There are three layers of fascia derived from the layers of

the anterior abdominal wall.

Each covering is acquired as the processus vaginalis descends

into the scrotum through the layers of the abdominal wall.

1. External spermatic fascia derived from the external

oblique aponeurosis
2. Cremasteric fascia derived from the internal oblique
muscle
3. Internal spermatic fascia derived from transversalis
fascia and attached to the margins of the deep inguinal
ring

The cremasteric muscle forms the middle layer of the

spermatic cord fascia. It is a discontinuous layer of striated
muscles that is orientated longitudinally
CONTENTS OF SPERMATIC CORD
 SCROTUM

• Sacs of skin and fascia out-pouching of the

lower part of the anterior abdominal wall
• It contains
 testes,
 epididymis, and
 lower end of spermatic cord
 SCROTUM

Arterial supply ● External pudendal branch of femoral artery

● Internal pudendal artery
Venous drainage ● Veins accompany the corresponding arteries

Lymphatic ● Superficial inguinal nodes (medial group)

drainage
Nerve supply ● Ilioinguinal nerve
● Genital branch of genitofemoral nerve
● Perineal nerves
● Posterior cutaneous nerves of thigh

The dartos muscle is supplied by the genital branch of genitofemoral nerve

 TESTES

● Male gonad
● Homologous with ovary of the female
● Suspended in the scrotum by the spermatic
cord
● Lies obliquely, so that its upper pole is tilted
forwards and medially
● The left testes is slightly lower than the right
● Function:-
○ Production of spermatozoa
○ Secretion of testosterone
● Shape: oval/ellipsoid
● Measurements: 4 cm x 3 cm x 2.5 cm
● Weight (adult): 10 -15 g
 EXTERNAL FEATURES OF THE TESTES

● Two poles (upper and lower)

● Two surfaces (medial and lateral)
● Two borders (anterior and posterior)
● Epididymis
Coverings of the testes
1. Tunica vaginalis
2. Tunica albuginea
3. Tunica vasculosa
 TESTES

Lymphatic drainage

● Drains into the pre aortic and

para aortic groups of lymph
nodes at the level of second
lumbar vertebra
 EMBRYOLOGICAL DEVELOPMENT OF THE TESTES

A. 5th week: Testes begins its primary

descent; kidney ascends
B. 8th - 9th week: Kidney reaches
adult position
C. 7th month: Testes at internal inguinal
ring; gubernaculum (in inguinal fold)
thickens and shortens

D. Postnatal life.
Hernia
 WHAT IS A HERNIA?
A hernia is a protrusion of a viscus or part of a viscus through an
abnormal opening in the wall of its containing cavity (Bailey & Love)
The external abdominal hernia is the most common form, the most
common frequent varieties being the inguinal, femoral, and umbilical,
accounting for 75% of cases.
 COMPOSITION OF HERNIA

Hernia consists of 3 parts

The sac ● The sac is a diverticulum of peritoneum, consisting of
mouth, neck, body, and fundus
The covering ● Coverings are derived from the layers of the
abdominal wall through which the sac passes
The contents ● Omentum = omentocele
● Intestine = enterocele;more commonly small bowel but
may be large intestine or appendix
● A portion of the circumference of the intestine =
Richter's hernia
● A portion of the badder (or a diverticulum)
● Ovary with or without the corresponding fallopian tube
● A Meckel’s diverticulum = Littre’s hernia
● Fluid = as part of ascites
 CLASSIFICATION OF HERNIA

Reducible ● The hernia either reduces itself when

the patient lies down or can be reduced
by the patient or the surgeon
Irreducible ● The contents cannot be returned to the
abdomen but there is no evidence of
other complications
Obstructed ● Irreducible hernia associated with
intestinal obstruction
● There is no interference to the blood supply
to the bowel
● The symptoms (colicky abdominal pain
and tenderness over the hernia site) are
less severe and the onset is more
gradual than in strangulated hernias
 CLASSIFICATION OF HERNIA

Strangulated ● Blood supply to the content is impaired

Incarcerated ● Lumen of the portion of the colon occupying
the hernia sac is blocked with faeces
Distinguish an inguinal hernia from a
scrotal and inguinal region swellings
■ 4 questions:
1. Can you get above the swelling?
2. Can you identify the testis and the epididymis
3. Is the swelling transilluminable?
4. Is the swelling tender?
Cannot get above the • Cough impulse Hernia
swelling • Reducible
• Testis palpable
• Opaque
• No cough impulse Infantile hydrocoele
• Not reducible
• Testis not palpable
• Transilluminable
Can get above Testis not definable Opaque Non-tender Chronic
swelling from epididymis haematocoele
Tumour
Gumma
Tender Torsion
Epididymo-
orchitis
Acute
haematocoele
Transilluminable Hydrocoele
Testis definable Opaque Non-tender Tumour
from epididymis Swelling of
testis
Non-tender TB epididymis
Swelling of epididymis

Tender Epididymo
- orchitis
Transilluminable Cyst of
epididymis
Femoral hernia

• Protusion of extraperitoneal fat, peritoneal sac and sometimes

abdominal contents through femoral canal
• It is most liable to get strangulated because of narrowopening
Femoral hernia
• Uncommon, but more common in females
• A marble shaped lump below the inguinal ligament and medial to femoral pulse
- Usually irreducible: narrow neck – high risk for strangulation
- Usually does not have cough impulse
• Local symptoms:
- Pain (if adhered to greater omentum)
- Swelling (apparent on standing and straining, disappear when lying down)
• General symptoms:
- If obstructed: abdominal colic, vomiting, distension, constipation
- If strangulated: sudden pain at local side immediately spreads all over the
abdomen with vomiting
Femoral hernia

• Differential diagnosis:
- Skin / soft tissue: cyst, lipoma
- Vascular masses: saphena varix, femoral aneurysm, inguinal lymphadenopathy
- Hernia: inguinal hernia, obturator hernia
- Other: psoas bursa, ectopic testis
 Distinguish an inguinal hernia from a
femoral hernia
INGUINAL HERNIA FEMORAL HERNIA

Appear through Appear through femoral

superficial ring above canal below inguinal
inguinal ligament and ligament and lateral
medial topubic tubercle topubic tubercle
Usually reducible Usually not reducible
Cough impulse present Cough impulse absent

Low risk of strangulation High risk of strangulation

■ Management of Femoral Hernia
• 3 classical approach
1. Inguinal approach (Lotheissen’s operation)
 Through inguinal canal: advantage being the sac can be removed flush
with the parietal peritoneum and this method can help prevent inguinal
hernia as well
2. High approach of Mc Evedy
 Incision made over femoral canal and continued above to inguinal canal
 Useful for strangulated and irreduciblehernia
3. Low approach of Lockwood
 Below the inguinal ligament via groin crease incision
 Indicated in uncomplicated cases
 Does not prevent inguinal hernia
Distinguish a direct from
an indirect inguinal
hernia
Indirect inguinal hernia
• Most common – 65%
• Hernia sac enters the inguinal canal
with the spermatic cord via the deep
inguinal ring, then emerges from the
superficial ring and descends into
the scrotum
• Male more than female, 20%
bilateral, children more than adults
• Congenital; patent processus
vaginalis + weekened fascia at deep
inguinal ring
Direct inguinal hernia
• Bulges directly through a weekend
fascia Hesselbach’striangle
• Hernia sac is not with the spermatic
cord
• Rare in women, usually occur
bilaterally in men with; weak
abdominal muscles and
comorbid conditions causing
increase intraabdominal
pressure
 CRITERIA DIRECT HERNIA INDIRECT HERNIA
Course Via transversalis fascia Via deep inguinal ring and
(within Hasselbach’s along inguinalcanal (out of
triangle) Hasselbach’s triangle)

Etiology Weak abdominal Patent or reopen

wall/muscle processus vaginalis

Relation to the inferior Lies medial to inferior Lies lateral to inferior

epigastric artery epigastric artery epigastric artery

Neck Wide - rarely causes Narrow - may cause

strangulation strangulation

Site Bilateral Unilateral – mostly on

right side (right testis
descend later thanleft)

Common in Old men Young adults andinfants

Position: Ask patient to stand, then lying down and examine both side of the inguinal regions
CRITERIA DIRECT HERNIA INDIRECT HERNIA
Shape Oval Pyriform (when
(always complete – descend
incomplete) into scrotum), oval
(incomplete)
Descend into scrotum No Yes
Reduce on lying down Yes (automatically) No (manually)
How to reduce Reduces upwards Reduces upwards,
and straight laterally and
backwards backwards
How to control Controlled after Controlled after
reduction by reduction by
pressure over the pressure over the
superficial ring deep ring
Deep ring occlusion test Bulge out Do not bulge out
Complications
• Irreducible: Tight inguinal ring
• Obstructed: Lumen of hollow viscera is blocked
• Strangulated: The blood supply to the content of hernial sac is cut off – gangrene – perforation –
peritonitis
• Incarcerated: The block of the lumen of hollow viscera is due to thick fecal matter / adhesions)
• Reduction-en-mass: Taxis is normal maneuver to reduce (if forcibly reduce)
Pre-disposing factors
(pre, post and operative)
causing a hernia and a
recurrent hernia
 PRE-DISPOSING FACTORS
(New Hernia)
• Increase Intra-abdominal Pressure

• Chronic Cough, Constipation, Mass

• Weakness Of Abdominal Muscle

• Past Abdominal Surgery, Smoking, Abdominal Injury

• Other Factors : Old Age, Male Sex, Family History

 PRE-DISPOSING FACTORS
(Recurrent Hernia)
• Preoperative factors
• Straining factor not corrected before surgery

• Operative factors
• Failure to ligate sac at neck, tension stitches especially in Basini repair, use of absorbable
stitches in repairing inguinal canal.

• Post operative factors

• Infection, lifting heavy things within 3 months of operation, predisposing factors not
corrected
Surgical management
of a hernia
 SURGICAL MANAGEMENT

1. Herniotomy
- Removal Of Hernial Sac
- In Children With Indirect Hernias, Persistent Processus
- In Adult: High Recurrence Rate
2. Herniorrhaphy
- Strengthening Of The Posterior Wall Of Inguinal Canal By
Repair
- Bassini
- Shouldice
Bassini repair
Shouldice repair
3. Hernioplasty

- Reinforcement Of Posterior Wall Of Inguinal Canal With A

Synthetic Mesh
- Tension Free
Open: Lichtenstein
Laparoscopic:
Totally Extraperitoneal Approach (TEP)
Transabdominal Preperitoneal (TAPP)
LAPAROSCOPIC SURGERY

Laparoscopic
indication:
-Bilateral inguinal
hernia
-Recurring hernia after
open surgery
- - More rapid return to
full activity
 COMPLICATIONS OF SURGERY

• Bleeding ( May Due To Accidental Damage To Inferior Epigastric Or Iliac Vessel)

• Urinary Retention
• Seroma (Due To Excessive Inflammatory Response To Sutures Or Mesh)
• Wound Infection
• Recurrence
• Chronic Pain (Pain Present Three Moths After Surgery)
• Testicular Infarction Due To Damage To Testicular Artery (Rare, Most Serious
Complication)
Undescended testis
 Undescended Testis

• Incomplete descent of the testis

occurs when the testis is arrested
in some part of its normal path to
the scrotum
 Incidence
• 4% of boys: born with unilateral or bilateral undescended
testes
• 2/3 of these: reach scrotum during the first 3 months of life
• Testicular maldescent at the age of 1 year is around 1%.
• Missed in neonatal period and only discovered later in life.
• Higher incidence in preterm infants because the testis
descend through the inguinal canal during the third trimester.
EMBRYOLOGICAL DEVELOPMENT OF TESTIS

Testes develop in the retroperitoneum

below the kidneys at around the 10th
thoracic level.
• A, 5th week: Testis begins its primary
descent; kidney ascends.
• B, 8th-9th weeks: Kidney reaches adult
position.
• C, 7th – 9th month: Testis at internalinguinal
ring; gubernaculum thickens and shortens.
• D, Postnatal life.
 PATHOLOGY
• More common on right side.
20% cases are bilateral
• The testis may be:
- Intrabdominal: lying extraperitoneally just inside internal inguinal
ring
- Intracanalicular: may or may not be palpable
- Extra- canalicular : at scrotal neck
- Ectopic: the most common site is superficial inguinal pouch.
Femoral triangle, root of penis and perineum (rare)
Comparison Between Undescended And
Ectopic Testis
Undescended Testis
• Testis arrested in its normal pathway
• Usually, testis undeveloped
• Undeveloped &empty scrotum
• Associated with indirect inguinal
hernia
Ectopic Testis
• Testis deviates from its normal path
• Fully developed testis
• Empty but usually fully developed
scrotum
• Never associated with indirect
inguinal hernia
 CLINICAL FEATURES
1. Symptoms
-parents seek advice for the baby because of empty scrotum
-patient notice during adolescence / in adult life-infertility
2. Local examination
-If both testes are undescended→ the scrotum is small and hypoplastic
-If only one testis→ markedly asymmetrical
-Palpate for testis→ may be impalpable or palpable(below superficial inguinal ring)
-In undescended testis, testis is smaller in size and soft. In retractile and ectopic
testis, size is normal and lying superficially.
-If the testis can be felt, it is small and does not remain in the scrotum after
manipulation
Investigation

• Ultrasound –
identifying
intracanalicular
testis
• Laparoscopy – to differentiate between abdominal testis and truly absent
testis

• Hormonal- in cases of bilateral impalpable testes, the presence of

testicular tissue can be confirmed by recording a rise in serum
testosterone in response to intramuscular injections of human chorionic
gonadotrophin (require specialist endocrine review)

Laparoscopic view of
a right-sided intra-
abdominal testis
visible at the
internal ring.
 SURGICAL TREATMENT
1.Orchidopexy
▪ Usually performed before 12
months of age.
▪ The testis and spermatic cord are
mobilised and the testis is
repositioned in the scrotum.
▪ Testis is placed in a pouch
constructed between the dartos
muscle and the skin
 Three maneuvers help to gain the length required to
bring the testis down into the bottom of the scrotum

1st : identify, separate and ligate patent processus vaginalis

2nd : divide the coverings of spermatic cord + cremastic muscle
3rd : divide the lateral fibrous bands just inside the internal
inguinal ring
* Although effective, tiny vas and testicular vessels are
vulnerable to injury.
• Palpable undescended testes undergo a single stage
orchidopexy
• Impalpable undescended testes usually require a two stage
 Benefits
• Fertility. To optimise spermatogenesis, the testis needs to be
in the scrotum below body temperature at a young age.
• Reduce the risk of malignancy because it is histologically
abnormal.
• Cosmetic and psychological – a prosthetic testis can be
inserted to replace an absent one
2. Orchidectomy
(surgical removal of one or both testicles )

- Should be considered if the incompletely descended

testis is atrophic, particularly in post pubertal boy if the
other testis is normal
 COMPLICATIONS
▪ Infertility
▪ Malignancy
-cancer risk for adults is 5-10 times greater. Most common cancer
is seminoma.
▪ Hernia
- 90% boys with undescended testis have patentprocessues
vaginalis.
▪ Testicular torsion
- Due to developmental abnormality between testis and its
mesentry
Scrotal swelling
Varicocele
Hydrocele
Testicular Torsion
Epididymo-orchitis
Testicular Tumour
 Varicocele
• Varicose dilatation of the veins draining the
testis
• Common (15-20% of males)
• 90% left-sided
–Left vein is more vertical, connect to left renal vein
–Longer than the right
–Lack a terminal valve
 Causes
• Idiopathic in younger males around puberty
• In older man with retroperitoneal disease:
–Exclude renal cell carcinoma
 Signs and symptoms
• Mostly C/F:
asymptomatic Dragging discomfort that
is worse on standing at
the end of the day
Aching pain in scrotum
and groin

Examination shows
typical “bag of worms”
 Clinical features
Inspection Single/ multiple Usually unilateral

Cough impulse May be positive

Site Scrotal area below inguinal ligament ,usually

left side, testis hang lower than unaffected
side (in longstanding cases)

Skin Dilated tortuous vein ( look like a bag of worm)

Palpation Relation to inguinal Able to get above the mass

Relation to testis Testis can be felt separately

Surface Feels like a bag of worm

Consistency Soft
Trans-illuminable None
 Management
• Conservative (risk of infertility)
• Transfemoral radiological embolization
–In significant discomfort
• Surgical ligation of testicular vein
–Can recur
 Hydrocele
• Abnormal collection of serous fluid in part of
processus vaginalis, usually the tunica vaginalis
Classification

(a) Vaginal hydrocele: fluid in tunica vaginalis not extending up to

cord
(b)Infantile hydrocele: distal part of processus vaginalis is
obliterated, does not connect to peritoneum
(c)Congenital hydrocele: processus vaginalis is patent and
connects with the peritoneal cavity. Often intermittent (fluid may
drain into peritoneal cavity when lying down). Ascites should be
considered if bilateral.
(d) Hydrocele of the cord: fluid accumulates around the cord.
 Aetiology
1. By excessive production of fluid within the sac

2. By defective absorption of fluid. Seems to be the

cause of most of the primary hydrocele.

3. By interference with lymphatic drainage of

scrotal structures.

4. By connection with peritoneal cavity via a patent

processus vaginalis.
 Clinical Features
• It is translucent.

• Can get above the swelling.

• Primary vaginal hydrocele is most common in middle and

later life.

• Being painless, it may reach a bigger size before patient

seek treatment.

*An ultrasound scan may be necessary to visualise the testis

if the hydrocele sac is tense to exclude testicular tumour
 Complications
• Rupture (rare)
• Transformation into a haematocele occurs
after trauma or if there is spontaneous
bleeding into the sac
• The sac may calcify
 Management
• Conservative
• Aspiration of hydrocele (for those unfit for
surgery)
–Fluid always reaccumulate
• Congenital – herniotomy
• Surgical
–Lord’s operation
–Jaboulay’s procedure
TESTICULAR
TORSION
Pathophysiology
• Testicular torsion is a condition whereby the testicle twists in
such a way that its blood supply becomes compromised
• If left untreated, the blood flow to the testicle ceases and
the testicle dies.
• Torsion of the testis is uncommon
because the normal testis is
anchored and cannot rotate. For
torsion to occur, one of several
abnormalities must be present:
• Inversion of the testis is the
most common predisposing
cause.
• The testis is rotated so that it
lies transversely or upside down.
• High investment of the tunica
vaginalis causes the testis to
hang within the tunica like a
clapper in a bell (Figure 79.4).
• Separation of the epididymis
from the body of the testis
permits torsion of the testis on
the pedicle that connects the
testis with the epididymis
(Figure 79.5).
Precipitating Factors
• Straining at stool
• Lifting of a heavy weight
• Coitus
• May develop spontaneously
during sleep
Clinical Features
• Most common between 10 and 25 years of age,
although a few cases occur in infancy.
• Typically, sudden agonising pain in the groin and the
lower abdomen.
• Nauseated and may vomit.
• Torsion of a fully descended testis is usually easily
recognised.
• The testis seems high and the tender twisted cord can be
palpated above it.
• The cremasteric reflex is lost.
Investigations
The management of the case should be determined
primarily on clinical grounds.
• If there is any doubt as to the diagnosis, then urgent
scrotal exploration is indicated.
• Doppler ultrasound scanning
• Confirm the absence of the blood supply to the affected
testis.
Management
Exploration for torsion should be performed through
a scrotal incision.
• If the testis is viable when the cord is untwisted it
should be prevented from twisting again by fixation
with nonabsorbable sutures between the tunica
vaginalis and the tunica albuginea.
• The other testis should also be fixed because the
anatomical predisposition is likely to be bilateral.
• An infarcted testis should be removed – the patient
can be counselled later about a prosthetic
replacement.
EPIDIDYMO-
ORCHITIS
Inflammation confined to the epididymis is epididymitis;
infection spreading to the testis is epididymo-orchitis.
Pathophysiology
1. Primary infection of the urethra and prostate
2. Infection reaches the epididymis via vas deferens
3. Infection spreads to the testis
Causes
• In young sexually active men:
• Chlamydia trachomatis
• Neisseria gonorrhoea

• In older men:
• Urinary tract infection
• Secondary to an indwelling urethral catheter
Clinical Features
• The development of an ache in the
groin and a fever can herald the
onset of epididymitis.
• Epididymis and testis
• Swell and become painful.
• The scrotal wall
• Red, oedematous and shiny, may
become adherent to the epididymis.
Investigations
• Urinalysis
• Show leukocytes and may show a formal urinary tract
infection.
• Ultrasound
• Initial assessment of epididymitis and will identify abscess
formation.
• Urethral swabs
• In young men, should be taken for chlamydial testing.
• In adolescents the differential diagnosis is testicular
torsion and if there is any clinical doubt as to the
diagnosis then testicular exploration should be
performed.
Management
• Either doxycycline (100–200 mg daily) or a quinolone should
be the initial treatment in young men.
• Contact tracing of the partner and treatment if necessary.
• In older men, quinolones are the usual initial treatment but
if there is evidence of systemic sepsis, then intravenous
antibiotics directed at urinary pathogens may be valuable.
• If an organism is isolated from the urine, this simplifies the
choice of antibiotic.
• All patients should drink plenty of fluid.
• Local measures including scrotal support and analgesia are
helpful. Antibiotic treatment should continue for at least 2
weeks or until the inflammation has subsided.
• If suppuration occurs, drainage is necessary.
Complications
• Resolution may take 6–8 weeks to complete.
• Occasionally, an abscess can form that needs
surgical drainage.
• Other complications
• Testicular atrophy,
• Development of a chronic epididymitis
• Infertility.
TESTICULAR
TUMOUR
Introduction
• Testicular cancer represents around 1–1.5 per cent
of male neoplasms.
• The peak incidence of seminomas is in the fourth
decade of life with the non-seminomatous germ cell
tumours being more common in the third decade of
life.
• They are the most common form of tumour in
young men.
• Risk factors include:
• History of testicular maldescent
• History of a contralateral testicular tumour
• Klinefelter’s syndrome (47, XXY)
Classification
• Germ cell tumors (90-95%)
• Seminoma
• Embryonal cell carcinoma
• Yolk sac tumor
• Teratoma
• Choriocarcinoma
• Interstitial tumors (1-2%)
• Leydig cell tumors
• Lymphoma (3-7%)
• Other tumors (1-2%)
Seminoma
• Metastasise: mainly via
lymphatics (hematogenous is
uncommon)
• Lymphatic drainage of testis is to
para-aortic lymph nodes.
• The contralateral para-aortic
lymph nodes are sometimes
involved by tumour spread, but
the inguinal lymph nodes are
affected only if the scrotal skin is
involved.
• A seminoma typically has a cut
surface which is homogeneous
and pinkish cream in colour. It
appears to compress
neighbouring testicular tissue
(Figure).
Non-seminomatous Germ Cell
Tumor (NSGCTs)
Embryonal carcinoma
• Highly malignant tumours that occasionally invade cord
structures.
Yolk sac tumour
• Tumours with this component secrete alpha fetoprotein
(AFP).
Choriocarcinoma
• Often produces human chorionic gonadotrophin (HCG). This
is a highly malignant tumour that metastasizes early via both
the lymphatics and the bloodstream.
Teratoma
• These tumours contain more than one cell type with
components derived from ectoderm, endoderm, and
mesoderm. Tumour can be mature or immature
(undifferentiated primitive tissue)
Interstitial Cell Tumours
Origin: Leydig cell or Sertoli cell
• A Leydig cell tumour masculinises; a Sertoli cell tumour feminises.

Gross appearance:
• Small and well-circumscribed
• Yellow cut surface

Most prepubertal tumours produce androgens, which cause:

• Sexual precocity including prominent external genitalia
• Suprapubic hair growth
• Deep masculinised voice.

Most post-pubertal interstitial cell tumours produce feminising hormones

leading to
• Gynaecomastia
• Erectile dysfunction
• Loss of libido
• Azoospermia.
Clinical Features
Symptoms
• Painless testicular lump
• Sensation of heaviness (2-3 x normal size)
• Metastasis;
• Intra-abdominal disease: abdominal pain, epigastric mass
• Lungs: chest pain, dyspnea, hemoptysis (late stage)
Signs
• Intra-testicular solid mass
• Gynaecomastia (in 5% of cases)
• Epididymis difficult to palpate when it is flattened
or incorporated in the growth.
• Vas never thickened
• Normal rectal examination
 Investigations
1. In suspected cases:
• Ultrasound of testis (mandatory investigation in all
cases of suspected testicular tumour)
2. In confirmed cases:
• Aim: staging for management
(orchidectomy)
• Before orchidectomy done;
• Measure tumor markers (AFP & HCG)
• After orchidectomy;
• Monitor tumor markers to monitor response to
treatment
1. Chest x-ray: will occasionally demonstrate the
‘classical’ cannon ball metastases (Figure 79.19)
2.CT of chest and abdomen; detecting metastatic
disease and for monitoring the response to therapy
Staging
STAGE I The tumour is confined to the testis
STAGE II Nodal disease is present but is confined to
nodes below the diaphragm
Stage III Nodal disease is present above
the diaphragm
Stage IV Non-lymphatic metastatic disease
(most typically within the lungs)
 Treatment
• Scrotal exploration and orchidectomy for suspected
testicular tumour
• The orchidectomy is undertaken via an inguinal incision.
• Management by staging(after orchidectomy)
Stage 1 Seminoma • Adjuvant radiotherapy to para-aortic nodes
(radiosensitive) • Platinum-based chemotherapy:
relapsed cases
NSGCTs (non- • Chemotherapy: chemotherapy combined
radiosensitive) with bleomycin, etoposide, cis-platinum
(combination BEP chemotherapy)
Stage 2- 4 Seminoma & • Chemotherapy (combination BEP
NSGCTs chemotherapy)
• Retroperitoneal lymph nodes
dissection: if retroperitoneal masses
remain after chemotherapy.
Prognosis
• Seminomas:
• Without metastasis: 90-95% 5 years survival
• Poor prognostic features: survival rate drop to 70%
• NSGCTs:
• Good prognosis tumors: >90% 5 years survival
• Advanced tumor: 60% 5 years survival
THANK
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