Testis & Scrotum237 CHAPTER -30 TESTIS AND SCROTUM Dr. H. Shircore sio List the causes of scrotal swellings. Varicocele 1. Define varicocele. 2. Describe the aetiok varicocele. Describe the clinical features of varicocele. 4. Describe the management of varicocele, Hydrocele I. Define hydrocele. 2. Describe the classification of hydrocoele. 3. Describe the aetiology of hydrocele. 4, Describe the diagnosis and treatment of hydrocele. 5. Describe the complications of hydrocele. Neoplasms of the testis, 1. Describe the types of the neoplasins of the testis. 2. Describe the pathology of testicular tumour. 3. Describe the clinical features of testicular tumour. 4. Describe the diagnosis and treatment of testicular tumour. Imperfect descent of testis 1. Classify imperfect descent of the testis Describe the pathology and clinical features of the imperfect descent of the testis, 3. Describe the hazards of imperfect descent of the testis. 4. Describe the diagnosis and treatment of imperfect descent of the testis. Scrotal swelling is a common surgical problem, Because of laxity, the contents of the scrotum can be examined easily on standing and lying, Patient needs to be warm, comfortable, and relaxed during the examination It is important to exclude inguino-scrotal swelling, by attempting to get above the scrotal swelling, reducing the mass and performing the cough impulse. The scrotal swelling can arise from the scrotal skin such as sebaceous cyst and lipoma or from the contents of the serotum,238 Testis & Scrotum Scrotal swelling from contents of scrotum Firm)/ Hard Soft / Cystic A bag of worms t ; Pain / Tenderness Is testis palpable? \ $ 1 1 1 | No Yes Yes No | \ t t | 1/0 of trauma “ test | Yes No Positive Le “esos Seroum } Pain te Testicular aema-_Epididymo vem cede Hydfocele 1 Haematocele Varico Tumour tocele orchitis torsion 2.Chylocele cele Thick wally‘TUMOURS OF THE TESTIS One of the most common forms of cancer in the young male adult They make up only about 1-2% of malignant tumours in men About 99% of testicular neoplasms are malignant Classification 1 2. 3 Seminoma (40%) Teratoma (32%) Combined Seminoma & Teratoma (14%) 4. 5, 6. |. Interstitial rumours (1.5%) Lymphoma (7%) Other tumours (5.5%) Seminoma enlarged testis is smooth and firm cut surface is homogenous and pinkish cream in colour occasionally lobulated appearance there may be area of necrosis spread via lymphatics blood-borne metastasis is uncommon . Teratoma arises from totipotent cells in the rete testis, yellowish in colour with cystic spaces containing gelatinous fluid nodules of cartilage are often present Histologically, teratoma can be classified into (a) Teratoma differentiated (TD) uncommon os ee (b) Malignant teratoma intermediate, teratocarcinoma (MTI_A & B) most common (c) Malignant teratoma anaplastic (MTA) (4) Malignant teratoma trophoblastic (MTT) 4, Interstitial cell tumours arise from Leydig or Sertoli cells Leydig cell tumour masculinises Sertoli cell tumour feminizes Clinical features sensation of heaviness about 30% of patients experience pain history of trauma to the affected side in over 10% the testis is enlarged, smooth, firm and heavy complete loss of testicular sensation secondary hydrocele in 10% of patients secondary retroperitoneal deposits may be palpable enlarged supractavicular node may be the presenting sign of testicular tumour chest pain, dyspnoea and haemoptysis in cases of lung metastases hurricane tumour is a ferocious malignancy which kills in a matter of weeks240 Treatment = staging is an essential first step - detection of tumour markers — human chorionic gonadotrophin (hCG) - alpha fetoprotein (AFP) - lactate dehydrogenase (LDH) = chest radiograph for pulmonary deposits - CT. MRI for detection of i abdominal and intrathoracic secondaries - Orchidectomy is essential to remove primary tumour and for histological diagnosis Staging of testicular tumours Stage | : testis lesion only — no spread. Stage 2 : nodes below diaphragm only Stage 3 : nodes above diaphragm Stage 4 : pulmonary or hepatic metastases Management by staging and histological diagnosis (after orchidectomy) (1) seminomas are radiosensitive ~ excellent results by irradiating stage 1 and stage 2 tumours highly sensitive to cisplatin (2) teratomas are less sensitive to radiation = stage 1 tumours by level of serum markers and repeated CT ~ stage 2-4 tumours by chemotherapy (cisplatin, Testis & Scrotum methotrexate, bleomycin, vincristine) Prognosis Seminoma ~ if'no metastases, 5 years survival rate is 95% after orchidectomy and radiotherapy or chemotherapy = if there is metastasis. survival drops to 75% Teratomas — in stage 1 or 2 teratomas. 5 years survival rate is more than 85% in stage 3 and 4 teratomas, 5 years survival rate is about 60% EPIDIDYMO-ORCHIT S ~ may be secondary to urinary tract infection (UTI) or urethritis - isa complication of catheterization or instrumentation of the urinary tract - chlamydial and gonococeal epididymitis is still prevalent = blood-borne infections of the epididymitis are less common - in Myanmar, filariasis is one of the common causes Clinical features (a) Acute disease ~ ache in the groin - fever = the epididymis and testis swell rapidly = exquisitely painfulscrotal wall is oedematous and shiny = occasionally, the infection may go ‘on to abscess formation (b) Chronic cases = typically, there is a firm discrete ling of the lower pole of the epididymis ~ epididymis is firm and craggy + there is a lax secondary hydrocele in 30% - the seminal vesicles feel indurated and swollen > tuberculous cold abscess forms in neglected cases Treatment ~ bed rest while acute symptoms persist ~ appropriate antibiotics which cover the urinary tract pathogens = scrotal support + if suppuration occurs, drainage is necessary ~ in tuberculous epididymo-orchitis, treat with antituberculous drugs for 2 months ~ if resolution does not occurs within 2 months, epididymectomy or orchidectomy is advisable TORSION OF THE TESTIS Predisposing causes: ~ inversion of testis (most common) ~ high investment of the tunica vaginalis Testis & Scrotum241 ~ separation of the epididymis from the body of testis ~ most common between 10 and 25 years of age ~ afew cases occur in infancy ~ _ sudden agonizing pain in the groin and the lower abdomen - vomiting ~ thickening of the tender twisted cord ~ elevation of the testis reduces the pain of epididymo-orchitis but makes it worse in torsion = occasionally, it can be mimicked by a small tense strangulated inguinal hernia compressing the cord ~ Doppler ultrasound sean will confirm the absence of the blood supply to the affected testis, Treatment If there is any doubt about the diagnosis, the scrotum should be explored without delay. ~ Untwist the testis by gentle manipulation in the first hour. ~ Early operative fixation is required to avoid recurrent torsion, - Fixation by non-absorbable sutures between the tunica vaginalis and the tunica albuginea242 HYDROCELE BILATERAL HYDROCELE Definition; Hydrocele is an abnormal collection of serous fluid in any part of the processus vaginalis, usually the tunica. Types of hydrocele (a) Vaginal hydrocele (b) Infantile hydrocele (c) Congenital hydrocele (d) Hydrocele of the cord Aetiology - by excessive production of fluid within the sac - by defective absorption of fluid = by interference with lymphatic drainage of scrotal structures - by connection with a hernia of the peritoneal cavity in the congenital variety Testis & Scrotum Clinical features invariably translucent it is possible to ' get above the swelling’ it is usually inseparable from the and uniformly enlarged firm in consistency ~ may be tense or lax Complications of hydrocele testi Rupture usually occurs as a result of trauma but may be spontaneous - Herniation of the hydrocele sac through the dartos muscle - Transformation into a hematocele The sac may calcify Treatment A variety of surgical procedures are available, Most commonly following procedures are done. No rule for aspiration. 1. Lord's operation Jaboulay’s procedure . Radical cure OTHER TESTICULAR SWELLINGS Filarial hydrocele and chylocele = 80% of hydrocele in some tropical countries where parasite Wucheria. bancrofti is endemic= fluid contains liquid fat which is, rich in cholesterol = this is due to rupture of lymphatic varix with drainage of chyle into the hydrocele = treatment is by rest and aspiration = chronic cases are treated by excision of the sac Haematocele = result from damage to a small vessel during tappingofa hydrocele - prompt refilling of the sae, pain, tenderness and poor or absent transillumination leave no doubt about the diagnosis = sometimes result from testicular trauma - clotted haematocele may result from a slow spontaneous ooze of blood into the tunica vaginalis = itis usually painless = tumour may present as a haematocele = treatment is by orchidectomy Epididymal cysts = represent the cystic degeneration of the epididymis = filled with crystal-clear fluid = usually multiple ~ usually found in middle age and often bilateral Testis & Scrotum243 - clusters of tense thin-walled cysts feel like a tiny bunch of grapes on palpation = they are brilliantly transilluminable = are separate from the testis on palpation = treatment is excision of the cysts Spermatocele = unilocular retention cyst - nearly always lies in the head of the epididymis = itis usually soften and laxer than other cystic lesions in the scrotum = itis transilluminable = fluid contains spermatozoa and resembles barley water in appearance = small spermatoceles can be ignored = larger ones should be aspirated or excised through a scrotal incision Encystic hydrocele of the cord = fluid accumulates around the spermatic cord = therefore mass appears around the ductus deferens - very difficult to distinguish from an irreducible inguinal hernia - traction on the testis causes a hydrocele of the cord to be pulled downwards244 Varicocele Definition: A varicocele is a varicose dilatation of the veins draining the testis Aetiology ~ occurs in adolescence or early adulthood + left side is affected in 95% ~ dilated vessels are cremasteric veins = obstruction of the left testicular vein by a renal tumour or afteg nephrectomy is an occasional cause of varicocele in middle age Clinical features = more frequent in hot climate - tall, thin men with pendulous scrota are frequently affected Testis & Scrotum there may be vague and annoying dragging discomfort the scrotum on the affected side hangs lower than normal the varicose plexus feels like a bag of worms there may be a cough impulse testicular atrophy may present in longstanding cases Treatment ligation of the spermatic vein through extraperitoneal approach (Paloma) this may be done surgically at internal inguinal ring through the inguinal approach radiologically by embolization laparoscopic ligation at deep ring extraperitoneally