surgery

• Scrotum


  An outpouching of the lower part of the anterior abdominal wall that contains the testis, epididymides, and lower end of the spermatic cord
• Structure of the spermatic cord


  • Vas deferens
  • Testicular artery
  • Testicular veins (pampiniform plexus)
  • Testicular lymph vessels
  • Autonomic nerves
  • Processus vaginalis
  • Cremasteric artery
  • Artery of the vas deferens
  • Genital branch of the genitofemoral nerve

  
• Types of scrotal swellings


  • Cystic
  • Solid
  • Neither tumor (benign/malignant)
  • Varicocele
  • Hernia
  • Hydrocele
  • Epididymal cyst/spermatocele
  • Haematocele
• Characteristics of scrotal swellings


  • Painful
  • Painless
• Causes of painful scrotal swellings


  • Epididymitis/epididymorchitis
  • Hydrocele
  • Torsion of spermatic cord
  • Inguinoscrotal (total) hernia
  • Torsion of testicular appendages
  • Epididymal cysts/spermatocele
  • Haematocele
  • Varicocele
  • Incarcerated inguinoscrotal hernia
  • Testicular tumors
• Testicular tumors account for 10% of scrotal swellings
• Hydrocele


  A collection of abnormal quantity of serous fluid in the tunica vaginalis. If it contains pus or blood it is called pyocele or haematocele respectively.
• Congenital communicating hydrocele


  Incomplete obliteration of the processus vaginalis allowing fluid collection within tunica vaginalis
• Hernia


  A large opening of the processus vaginalis which may allow abdominal contents to enter the scrotal sac
• Causes of hydrocele


  • Primary (cause unknown, associated with patency of processus vaginalis)
  • Secondary (fluid accumulation secondary to pathology inside the testis like epididymo-orchitis, testicular tumor, and trauma)

  
• Symptoms of hydrocele


  • Painless swelling
  • Embarrassment
  • Frequent and painful micturition (if secondary to epididymo-orchitis)
• Hydrocele does not affect fertility
• Examination findings in hydrocele


  • Unilateral or bilateral swelling
  • Normal colour and temperature
  • Tender (if secondary)
  • Fluctuant with fluid thrill
  • Not reducible
  • Testis impalpable and transilluminate

  
• Management of hydrocele


  • In children: most neonatal hydroceles resolve in first 2 years, persistent ones treated with herniotomy
  • In adults: surgical (subtotal excision, Jabouley's operation, Lord's operation, Chinese operation)
  • Secondary hydrocele: treat underlying condition
• Epididymal cyst


  Cystic degeneration of the epididymis, filled with crystal-clear fluid, found in middle age, better to leave it as excision may cause obstruction
• Spermatocele


  A unilocular retention cyst derived from some portion of the sperm-conducting mechanism of the epididymis, typically lies in the epididymal head, contains spermatozoa, small ones can be ignored, larger ones can be aspirated or excised
• A child or adolescent with acute scrotal pain, tenderness, or swelling should be looked on as an emergency situation requiring prompt evaluation, differential diagnosis, and potentially immediate surgical exploration
• Causes of painful scrotal swellings


  • Testicular torsion
  • Epididymo-orchitis
• Testicular torsion


  The most urgent problem, high risk of loss due to infarction (90%), may have torsion of cord or appendages, more common in undescended testes due to absence of fixation
• Types of testicular torsion


  • Extravaginal (exclusive to perinatal)
  • Intravaginal (90% of adolescent age group)

  
• History and physical exam findings in testicular torsion


  • Sudden onset of pain
  • Past history of similar pain in 50%
  • Cremasteric reflex may be absent
  • Prehn's sign: Elevation of testes does not relieve pain
  • Angel sign: Transverse or oblique testicular lie

  
• Diagnosis and management of testicular torsion


  • If certain, emergent surgery
  • If uncertain, nuclear scan or ultrasonography to document blood flow
  • < 6 hours, 90% salvage, detorsion and orchiopexy bilaterally
  • > 24 hours, 100% loss and atrophy, orchidectomy
  • Attempt manual detorsion - outward, "open the book"

  
• Torsion of testicular appendages


  Rarely seen after puberty, presents with pain, may develop scrotal swelling & erythema, "blue dot sign" seen early, treat symptomatically
• Epididymitis


  Most common acute scrotum post-pubertal, gradual onset of pain, fever in 40%, dysuria in 50%, urinalysis may show pyuria in 50%
• Epididymo-orchitis


  Inflammation confined to the epididymis is epididymitis, infection spreading to the testis is epididymo-orchitis, the most common cause of acute scrotum
• Modes of infection in epididymo-orchitis


  • Infection reaches the epididymis via the vas from a primary infection of the urethra, prostate or seminal vesicles
  • Blood-borne infections of the epididymis are less common
• Clinical features of epididymo-orchitis


  • Initial symptoms are those of urinary tract infection
  • The epididymis and testis swell and become painful
  • Fever
  • The scrotal wall, at first red, oedematous and shiny, may become adherent to the epididymis
  • Resolution may take 6–8 weeks to complete
  • Occasionally, an abscess may form and discharge of pus through the scrotal skin
• Acute epididymo-orchitis develops in about 18% of males suffering from mumps
• The main complication of epididymo-orchitis is testicular atrophy, which may cause infertility if the condition is bilateral
• Investigations for epididymo-orchitis


  • GUE: pyuria
  • Urine C&S: positive
  • WBC count: leukocytosis
  • Scrotal ultrasound + Doppler: hyperperfusion
• Differentiating features between testicular torsion and epididymo-orchitis

  • Teenagers vs adulthood
  • Sudden onset vs gradual onset
  • No fever vs fever present
  • High testis level vs normal
  • Abnormal lie vs normal
  • Scrotal elevation increases pain vs pain decreased
  • Normal urine exam vs GUE show pus cells
  • Duplex US: avascular vs hypervascular
  • Cremasteric reflex absent vs present

  
• Epididymitis management


  Confirm that torsion of testis does not exist, treat with scrotal elevation, antibiotics (keflex, septra), refer for persistence of pain/swelling

  
• Treatment of epididymo-orchitis


  • Broad spectrum antibiotics for 2 weeks (3rd generation cephalosporin or quinolones)
  • Scrotal support
  • Supportive therapy (analgesics, antipyretics, anti emetics, IVF)
  • If suppuration occurs (abscess): drainage is necessary
• Testicular injuries


  Blunt or penetrating trauma can cause contusion and rupture of the testis, associated with a collection of blood around the testis, ultrasound is the investigation of choice, haematocele should be drained and the tunica albuginea repaired, severely damaged testis may have to be removed

  
• Cryptorchidism


  Almost 1% of all full-term male infants are affected at the age of one year, categorisation into palpable and non-palpable testis is most appropriate
• Complications of cryptorchidism


  • Cancer (25-30 times increased risk, not affected by orchiopexy)
  • Infertility (50% abnormal semen in unilateral, 70% in bilateral)
  • Testicular torsion
  • Trauma
  • Hernia
• Assessment of cryptorchidism


  • Physical examination is the only method to differentiate palpable or non-palpable testes
  • Radiological imaging is only 44% accurate
  • Diagnostic laparoscopy is required to confirm intra-abdominal, inguinal and absent/vanishing testis

  
• In cases of bilateral non-palpable testes and any suggestion of sexual differentiation problems, urgent endocrinological and genetic evaluation is mandatory
• Treatment of cryptorchidism


  • Medical therapy using hCG or GnRH has a maximum success rate of 20%
  • Palpable testis: surgery includes orchidofuniculolysis and orchidopexy, with success rates of up to 92%
  • Non-palpable testis: inguinal surgical exploration with the possibility of orchidectomy
• There is no reliable examination to confirm or rule out an intra-abdominal, inguinal and absent/vanishing testis (nonpalpable testis), except for diagnostic laparoscopy