Inguinoscrotal Conditions
This Lecture Collected By Omer Ahmed Al-Samrrai, 5th Grade of T.U.C.O.MTesticular 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. 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. A radionuclide testicular scan may be useful in equivocal cases if performed early after the onset of symptoms and before significant reactive hyperemia of the scrotal skin occurs. 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 4-6 hours of onset of pain usually results in a normal testis. Delay for more than 12 hours results in poor testicular salvage (~20%). Manual detorsion can be attempted by either lifting the scrotum or rotating the testis 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. The contralateral testis must also be fixed because of the high incidence of its subsequent torsion.
Inguinal Hernia
An inguinal hernia often is first seen as a scrotal mass secondary to loops of bowel within the scrotum. Indirect inguinal hernias may be secondary to a patent processus vaginalis or protrusion of a new peritoneal process following the same path along the cord into the scrotum. Direct inguinal hernias result from weakness of the transversalis fascia at Hesselbach's triangle, with peritoneal outpouching into the area of the external ring only, rarely descending into the scrotum. An inguinal hernia that cannot be reduced is said to be incarcerated. If the vascular supply of the herniated organ (usually bowel) is compromised, it is said to be strangulated surgical emergency. Treatment is usually surgical.Hydrocele
A hydrocele is a fluid collection within the tunica vaginalis surrounding the testis or the processus vaginalis ( hydrocele of the cord) . It presents as a painless swelling of the scrotum that transilluminates. It often makes testicular palpation difficult and can conceal an underlying testicular tumor.Congenital or Infant Hydroceles
Congenital or infant hydroceles are usually the result of peritoneal fluid accumulation within the scrotum via a patent processus vaginalis and occur in 6% of full-term boys. Their size often changes from day to day or with recumbency. Treatment should be delayed during the first year of life because normal spontaneous closure of the processus vaginalis may occur. After 1 year, surgical ligation of the processus vaginalis should be undertaken.
Acquired or Adult Hydroceles
Acquired or adult hydroceles are usually idiopathic but may be secondary to tumor, infection, trauma or systemic disease. An imbalance in fluid secretion and absorption by the tunica vaginalis has been suggested as a possible cause. Treatment is generally indicated to allow easy palpation of the testis or because of symptomatic discomfort or disfigurement. Definitive therapy is surgical drainage and excision of tunica vaginalis.
Spermatocele
A spermatocele is an epididymal cyst that arises from the efferent ductules and holds a cloudy fluid containing spermatozoa. It presents as a painless, cystic mass that lies above and anterior to the testis. Ultrasound can confirm the diagnosis if doubt exists. Treatment consists of spermatocelectomy for extensive involvement. Therapy should be avoided in young male patients concerned with fertility.
Varicocele
DefinitionDilatation and tortuosity of the veins of the pampiniform plexus of the spermatic cord.
Prevalence
Found in 15% of men in the general population and 40% of males presenting with infertility. Bilateral or unilateral (left side affected in 90%).
Aetiology
Incompetent values in the internal spermatic veins lead to retrograde blood flow, vessel dilatation, and tortuosity of the pampiniform plexus. The left internal spermatic vein enters the renal vein at right angles, and is under a higher pressure than the right vein, which enters the vena cava obliquely at a lower level. As a consequence, the left side is more likely to develop a varicocele.
Pathophysiology
Testicular venous drainage is via the pampiniform plexus, a meshwork of veins encircling the testicular arteries. This arrangement normally provides a counter-current heat exchange mechanism which cools arterial blood as it reaches the testis. Varicoceles adversely affect this mechanism, resulting in elevated scrotal temperatures and consequent deleterious effects on spermatogenesis ( loss of testicular volume).
Varicocele grading system
GradeSizeDefinition1SmallPalpable only with Valsalva manoeuvre2ModeratePalpable in a standing position3LargeVisible through the scrotal skin
Presentation
The majority of varicoceles are asymptomatic, although large varicoceles may cause pain or a heavy feeling in the scrotal area. Examine both lying and standing, and ask patient to perform Valsalva manoeuvre (strain down). A varicocele is identified as a mass of dilated and tortuous veins above the testicle (described as feeling like a bag of worms), which decompress on lying supine. Examine for testicular atrophy.Investigation
Scrotal Doppler ultrasound scan is diagnostic.
Semen analysis: varicoceles are associated with low or absent sperm counts, reduced sperm motility, and abnormal morphology, either alone or in combination (oligoasthenoteratospermia (OAT) syndrome).
Management
The significance of a varicocele is its association with infertility. Indications for varicocelectomy include oligospermia, decreased sperm motility, and a painful symptomatic varicocele.
Embolization
Interventional radiological technique where the femoral vein used to access the spermatic vein for venography and embolization (with coils or other sclerosing agents).Surgical ligation
Retroperitoneal approach: a muscle-splitting incision is made near the anterior superior iliac spine, and the spermatic vessels are ligated at that level.Inguinal approach: the inguinal canal is incised to access the spermatic cord, and the veins are tied off as they exit the internal ring.
Subinguinal approach: veins are accessed and ligated via a small transverse incision below the external ring.
Laparoscopic: veins are occluded high in the retroperitoneum.
Undescended testes
The testes descend into the scrotum in the 3rd trimester (passing through the inguinal canal at 24-28 weeks). Failure of testicular descent results in cryptorchidism (or undescended testes).Incidence
3% at birth (unilateral > bilateral). ~75% will spontaneously descend by 3 months. The incidence at 1 year is 1%.Classification
testis may be intra-abdominal, intra-inguinal, or pre-scrotal.
Risk factors
Pre-term infants; low birth weight; small for gestational age; twins.
Aetiology
Abnormal testis or gubernaculum (tissue which guides the testis into the scrotum during development); endocrine abnormalities (low level of androgens, human chorionic gonadotrophin (HCG), luteinizing hormone (LH)); decreased intra-abdominal pressure (prune-belly syndrome).Pathology
Degeneration of Sertoli cells; loss of Leydig cells; atrophy and abnormal spermatogenesis.Long-term complications
Relative risk of cancer is 40-fold higher in the undescended testis. Majority are seminomas; carcinoma in situ represents a small percentage (~2%). There is a slightly increased risk of cancer in the contralateral, normally descended testis.Reduced fertility.
Increased risk of testicular torsion.
Increased risk of direct inguinal hernias (due to a patent processus vaginalis).
Management
Full examination to elucidate if testis is palpable and to identify location. Assess for associated congenital defects. If neither testis is palpable, consider chromosome analysis (to exclude an androgenized female), and hormone testing (high LH and FSH with a low testosterone indicates anorchia).
Treatment should be performed within the first year. Hormone therapy (HCG, LHRH) stimulates testosterone production. Surgery consists of inguinal exploration, mobilization of spermatic cord, ligation of processus vaginalis, and securing the testis into a dartos pouch in the scrotal wall (orchidopexy). Laparoscopy can be used in planning surgery and for treatment. Intra-abdominal testes may require division of spermatic vessels to provide extra length (relying on collateral blood flow from vas), 2-stage procedures, or microvascular autotransplantation.
Tikrit Medical College, Urology, Fifth year, Oct. 2008
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Hydrocele with HerniaHydrocele of the Cord
Spermatocele