SURGRY LECTURE FOR MEDICAL

STUDENTES
BY: SHITAHUN A
MALE GENITALIA DISORDER
 CONTENTES
• HYDROCELE
• HEMATOCELE
• UNDESCENDED TESTIS
• TESTICULAR TORSION
• EPIDIDYMO ORCHITIS
• HYPOSPADIA
• EPISPADIA
• BANATOPHSTHITIS
 Hydrocele
• A hydrocele is an abnormal collection of
serous fluid in a part of the processus
vaginalis, usually the tunica.
• Acquired hydroceles are primary or idiopathic,
or secondary to testicular disease.
 Etiology

A hydrocele can be produced in four different ways

• by excessive production of fluid within the sac, e.g. secondary
hydrocele;

• by defective absorption of fluid; this appears to be the

explanation for most primary hydroceles

• by interference with lymphatic drainage of scrotal structures;

• by connection with the peritoneal cavity via a patent processus

vaginalis (congenital).
• Hydrocele fluid contains albumin and
fibrinogen.
• If the contents of a hydrocele are allowed to
drain into a collecting vessel, the liquid does
not clot;
• the fluid coagulates if mixed with even a trace
of blood that has been in contact with
damaged tissue.
 Clinical features

• Hydroceles are typically translucent and

• it is possible to ‘get above the swelling’
• Primary vaginal hydrocele is most common in middle and later
life
• common in hot countries.
• swelling is usually painless
• The testis may be palpable within a lax hydrocele, but an
ultrasound scan is necessary to visualise the testis if the
hydrocele sac is tense.
• an acute hydrocele in a young man may be due to a testicular
tumor
• About 5% of inguinal hernias are associated
with a vaginal hydrocele on the same side.
• In congenital hydrocele, the processus
vaginalis is patent and connects with the
peritoneal cavity.
• The communication is usually too small to
allow herniation of intra-abdominal contents.
• fluid may drain into the peritoneal cavity when
the child is lying down
• Ascites should be considered if the swellings
are bilateral.
 Complications of hydrocele

• Rupture is rare.
• Transformation into a hematocele occurs after
trauma or if there is spontaneous bleeding into
the sac.
• The sac may calcify.
 Treatment

• Congenital hydroceles are treated by

herniotomy if they do not resolve spontaneously
• Cannula drainage of the hydrocele fluid
• It may be suitable for men unfit for scrotal
surgery
• Injection of sclerosants such as tetracycline is
effective
• Secondary hydrocele is most frequently associated
with acute or chronic epididymo-orchitis.
• A secondary hydrocele is usually lax and of
moderate size: the underlying testis is palpable.
• If a tumor is suspected, the hydrocele should not
be punctured for fear of needle-track implantation
of malignant cells.
• A secondary hydrocele subsides when the primary
lesion resolves.
 Secondary causes of hydrocele
• Post-herniorrhaphy hydrocele is a relatively
uncommon complication of inguinal hernia repair.
• Hydrocele of a hernial sac occurs when the neck
of the sac is occluded by adhesions or an omental
plug.
• Filarial hydroceles and chyloceles account for up
to 80% of hydroceles in tropical countries where
the parasite Wucheria bancrofti is endemic.
• Filarial hydroceles follow repeated attacks of filarial
epididymo-orchitis.
• They vary in size and may develop slowly or very rapidly.
• This is caused by rupture of a lymphatic varix with
discharge of chyle into the hydrocele.
• In longstanding chyloceles there are dense adhesions
between the scrotum and its contents.
• Treatment is by rest and aspiration.
• The chronic cases are treated by excision of the sac.
 Haematocele

• Haematocele usually results from vessel damage

during needle drainage of a hydrocele.
• Prompt refilling of the sac, pain, tenderness and
reduced transillumination confirm the diagnosis.
• Acute hemorrhage into the tunica vaginalis
sometimes results from testicular trauma with or
without testicular rupture.
• If the haematocele is not drained, a clotted
haematocele usually results.
 Clotted haematocele

• Clotted hydrocele may result from a slow

spontaneous ooze of blood into the tunica
vaginalis.
• It is usually painless and may be mistaken for
a testicular tumor.
• Treatment is by orchidectomy
• The testis is often compressed and relatively
useless
 TORSION OF THE TESTIS

• Predisposing causes
• Inversion of the testis is the most common predisposing
• High investment of the tunica vaginalis
• Separation of the epididymis from the body of the
testis
• contraction of the abdominal muscles,
• Straining at stool, lifting a heavy weight and coitus are
all possible precipitating factors.
• torsion may develop spontaneously during sleep.
 Clinical features

• Testicular torsion is most common between 10

and 25 years of age
• Most commonly there is sudden agonizing
pain in the groin and the lower abdomen.
• The patient feels nauseated and may vomit.
• The testis seems high and the tender twisted
cord can be palpated above it.
• The onset of redness of the skin and a mild
pyrexia may present.
• Elevation of the testis makes it worse in
torsion but reduces the pain in epididymo-
orchitis.
 Diagnosis
• Doppler ultrasound scan will confirm the
absence of the blood supply to the affected
testis,
• If there is any doubt about the diagnosis, the
scrotum should be explored without delay.
• An empty edematous hemiscrotum suggests
that a tender lump at the external inguinal ring
is a torted testis rather than a strangulated
hernia.
 Treatment

• In the first hour or so it may be possible to untwist the testis

by gentle manipulation.
• If manipulation is successful, pain subsides and the testis is
out of danger.
• Arrangements should be made for early operative fixation to
avoid recurrent torsion.
• Exploration for torsion can 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 non-absorbable
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

 Epididymo-orchitis
• bacterial infection originating in the urinary tract.
• most men will not show evidence of urinary tract
infection.
• Symptoms are unilateral painful swelling of the
epididymis and/or testis, often with fever.
• The scrotum may be erythematous on the side of
involvement.
• The white blood cell (WBC) count often is elevated.
• The onset is fairly rapid, but not as sudden as torsion
• An ultrasound may show increased blood flow to the
epididymis.
• A reactive hydrocele may be present.
• Intratesticular infection can result in ischemic
orchitis, and reduced testicular blood flow can be
seen on ultrasound.
• scrotal exploration is necessary when blood flow is
reduced to rule out torsion unless other signs such as
pyuria, elevated WBC count, or fevers are present.
• Treatment is with oral antibiotics if the patient
is not markedly febrile and is otherwise stable.
• Hospitalization and parenteral antibiotics are
required if the patient has high fevers,
significantly elevated WBC, or hemodynamic
instability
• Intratesticular abscesses may form, and
usually result in orchiectomy.
 Undescended testis
• Cryptorchidism is a congenital condition in which one or
both testicles are not appropriately positioned in the
scrotum at birth.
• Cryptorchidism may be unilateral or bilateral, and the
undescended testicles may be palpable or nonpalpable.
• The undescended testicles may be present in the abdomen
or the groin area or misplaced in the scrotum.
• The undescended testicles may be functional or atrophied.
• Some individuals have no testicles at all (anorchia).
• The etiology of cryptorchidism is not well understood.
• Cryptorchidism affects an estimated 3 percent of full-term
male neonates and up to 30 percent of premature infants.
• About 70 percent of cryptorchid testicles spontaneously
descend within the first year of life.
• However, the number of boys whose condition persists
after this period remains constant at approximately 1
percent.
• Long-term consequences of cryptorchidism may include
testicular malignancy and infertility/subfertility.
• The appropriate evaluation and treatment strategy for
cryptorchidism may be influenced by many factors including:
• Whether or not the testicle is palpable
• Whether the condition is present unilaterally or bilaterally
• The age at presentation
• Comorbid conditions
• The majority of undescended testicles (UDTs) can be located
on physical examination.
• For locating nonpalpable UDTs, exploratory laparoscopic
surgery is routinely used in clinical practice.
• Treatment for cryptorchidism is usually initiated
between the ages of 6 months and 1 year.
• There are three key surgical options commonly used
to treat cryptorchidism.
• Surgical options depend on the location and
appearance of the undescended testicle and include:
• Orchidectomy
• Single-stage Fowler-Stephens orchiopexy
• Two-stage Fowler-Stephens orchiopexy
 Hypospadias

• Hypospadias occurs in one in 200–300 boys

• the most common congenital malformation of the urethra.
• The external meatus opens on the underside of the penis or the perineum, and
the ventral aspect of the prepuce is poorly developed
• Hypospadias is classified according to the position of the meatus:

Glanular hypospadias

common and does not usually require treatment.

external meatus is marked by a blind pit

connects by a channel to the ectopic opening on the underside of the glans.

Coronal hypospadias

meatus is placed at the junction of the underside of the glans and the body of the penis.

 Penile and penoscrotal hypospadias

 opening is on the underside of the penile shaft

 Perineal hypospadias

most severe abnormality. scrotum is bifid and the urethra opens between its two halves.

There may be testicular maldescent, which may make it difficult to determine the sex of
the child.
 Treatment

• Glanular hypospadias does not need treatment unless the

meatus is stenosed, in which case a meatotomy is
performed.

• Surgery is indicated for other forms of hypospadias to

improve sexual function, to correct problems with the
urinary stream and for cosmetic reasons.

• Most procedures use preputial skin and so circumcision

should be avoided until the hypospadias has been repaired.
 Epispadias

• Epispadias is very rare.

• In penile epispadias, the opening on the dorsum

is associated with upward curvature of the penis

• Epispadias usually coexists with bladder

exstrophy and other severe developmental
defects.
 Paraphimosis

• A tight foreskin once retracted may be difficult to return

and a paraphimosis results.
• the venous and lymphatic return from the glans and distal
foreskin is obstructed and these structures swell, causing
even more pressure within the obstructing ring of prepuce
• Icebags, gentle manual compression and injection of a
solution of hyaluronidase in normal saline may help to
reduce the swelling.
• Such patients can be treated by circumcision if careful
manipulation fails.
 Balanoposthitis

• Inflammation of the prepuce is known as posthitis;

• inflammation of the glans is balanitis.
• The opposing surfaces of the two structures are
often involved, hence the term balanoposthitis.
• Skin conditions such as lichen planus and psoriasis
affect the penis
• Drug hypersensitivity reactions can affect the skin
of the penis.
 Clinical features
• In mild cases, the only symptoms are itching and some
discharge.
• In more severe inflammation, the glans and foreskin
are red-raw and pus exudes.
• Balanoposthitis is associated with penile cancer,
diabetes and phimosis.
• Monilial infections are quite common under the
prepuce.
• Treatment is by broad-spectrum antibiotics and local
hygiene measures.
END