INCOMPLETELY DESCENDED TESTIS:
The testis develop in the retroperitoeum below the kidneys in early
fetal life.
The testis is arrested in some part of its path to the scrotum
4% incidence, half of them descend during the first month of life, after
that is uncommon.10% family history.an incompletely descend testis
tend to atrophy as puberty approaches .early operation in early
childhood can preserve function of the testis.
Secondary sexual character are normal .may be:
Intra-abdominal, inguinal, or in superficial inguinal pouch (should
differentiated from retractile testis)
Retractile testis
: is normal descend but retract up ward, and can milk it
to the bottom of the scrotum and need no treatment.
Hazard of incomplete testis:
*sterility, especially in bilateral.
*pain due to trauma.
*associated with inguinal hernia
*torsion.
*infection, epididyo-orchitis.
*atrophy.
*increase liability to malignant disease (orchidopexy may or may not
change the incidence, but help early diagnosis).
Treatment:
By surgical procedure named orchidopexy that should be done early
after one year age.
Orchidectomy (removal): if atrophied, or after puberty. When the other
testis normal.
INJURIES TO THE TESTIS:
Rapture by blow is uncommon cause, because of mobility,
contusion and rapture associated with blood collection around
the testis. Scrotal exploration, should be considered when
there is massive swelling and pain after scrotal trauma, either
evacuation of hematoma. Or repair of tunica, or orchidectomy.
TORSION OF THE TESTIS
:
Is uncommon, unless there is abnormality:
*inversion of the testis.
*high investment of tunica.
*separation of epididymis.
Due to contraction of cremaster muscle with its spiral
attachment, favors rotation of testis around the vertical axis,
due to straining,, lifting a heavy weight and coitus, are possible
predisposing factors. Sometime spontaneously during sleep.
Clinical feature:
Age: 10-25 years age, and infancy.
Sudden onset agonizing pain in the groin or lower abdomen.
Testis high and tender, twisted cord .elevation of the testis
worse the pain ,elevated testis and change in polarity(the testis
lies transvers and epididymis become anteriorly. )
Diagnosis by Doppler ultrasound of the testes where there is
diminish its vascularity.
Treatment:
1. In early few hours de-torsion can be done. And arrange for
surgery for fixation later.
2. Prompt surgical exploration, untwisting and fixation .but, If
infarcted or gangrenous orchidectomy performed.
3. The anatomical abnormality is bilateral and the other
testis should also be fixed.
VARICOCELE
:
Is varicose dilatation of the veins draining the testis Present in
adolescence or early adulthood, usually on the left side.
Usually symptomless, may annoying dragging discomfort .the
testes with varicocele hangs lower than normal .on palpation
feels like a bag of warms., may cough impulse, in long standing
cases the testis become smaller and softer (atrophy) . It believe
to cause infertility but the evidence is inconclusive, it may
interfere with temperature of the testis.
Treatment:
Varicocelectomy not always indicated for Asymptomatic.
HYDROCELE:
Is abnormal collection of serous fluid in some part of processus
vaginalis usually the tunica .may be:
1. Acquired: primary (idiopathic), or secondary to testicular
disease.
2. Congenital (vaginal, infantile, congenital and encysted
types).
Clinical feature:
Can get above it, translucent (Trans illumination test is
positive), usually painless unless complicated.
Rarely secondary to testicular malignancy.
May associated with inguinal hernia.
Diagnosed by ultrasound.
Complication: include bleeding (hematocele), rapture (rare),
and calcification.
Treatment:
Surgery by hydrocelectomy.
HAEMATOCELE:
Hemorrhage to hydrocele, due to trauma or manipulation,
there is pain and tenderness, reduce Trans illumination, treated
by surgical drainage.
CYST ASSOCIATED WITH EPIDIDYMIS
:
Epididymal cyst
: cystic degeneration of the epididymis
Spermatocele
: retention cyst derived from some portion of the
sperm conducting mechanism of the epididymis.
Cyst of testicular appendage
: on upper pole of the testis. These
cysts mostly painless, no need for excision unless complicated.
EPIDIDYMO-ORCHITIS
:
Inflammation of the epididymis” if spreading to the testis is
epididymo-orchitis.source of infection:
*ascending infected urine via the vas.
*blood born infection, less common.
Clinical feature:
Symptoms of urinary infection, groin pain and fever,, pain and
swelling of the epididymis, scrotal wall first red ,edematous,
then shiny .by exam. Elevation of the testis cause relive of pain.
It may complicate urethral manipulation as cystoscopy. It take
6-8 week to resolve.it may complicated by abscess.
TB epididymitis
may conceder if not response to antibiotic.
Also
mumps epididymo orchitis
may complicate 18% of patient
with mumps that may cause atrophy.
Treatment:
Bed rest
Testicular support
Proper antibiotic ma parenteral may need 2 week or till the
inflammation subside.
TUBERCULOUS EPIDIDYMITIS:
Usually it is part of genito urinary tract TB. Which is usually
secondary to TB in the body.
There is swelling, induration on the pole of testis, with little
ach, not responding to antibiotics may complicated as
discharging sinus .also bedded vas.
Treated by systemic anti TB drugs part of treatment of primary
focus in the body.
TUMOUR OF THE TEST
Most testicular tumor are malignant, scrotal lump that cannot
be felt separately from the testis may be malignant tumor
.lymphatic spread to retroperitoneal and intrathoracic lymph
node. Not invade inguinal LN unless involvement of scrotal skin.
If there is pulmonary metastasis suggest the tumor is teratoma.
Classification:
According to their predominant cellular type:
*
seminoma.
*
teratoma
(include variant histological variant:
teratoma differentiated which is not malignant.
Malignant teratoma intermediate, teratocarcinoma: common,
malignant.
Malignant terato anaplastic, embryonal carcinoma which is
malignant and not always radio sensitive.
Malignant terato trophoblastic, uncommon most malignant.
*
combined seminoma and teratoma
.
|*
intrestitial tumor
: leyding cell tumor masculinizes, a sertoli
cell tumor feminizes (post pubertal interstitial cell tumor arise
from sertoli cell leading to gynecomastia, the tumor is benign,
and orchidectomy cures.)
*
lymphoma
.
*
others.
Teratoma peak age 20-35, while seminoma age 35-45,
seminoma rare before puberty.
Clinical feature:
Painless, testicular lump, larger size, may present with sing of
metastasis as abdominal mass (enlarge lymph node).
Or in chest X ray as metastases (chest pain, dyspnea, and
hemoptysis).
May simulate epidydmo orchitis.
Rarely sever pain because of hemorrhage into neoplasm.
May gynecomastia in teratoma.
Diagnosis:
1. Tumor marker: HCG, Alpha-fetoprotein. , lactate
dehydrogenase.
2. Ultra sound of scrotum.
3. CXR.
4/ CT scan, MRI: for monitoring of metastasis and follow up of
treatment.
Management:
Staging is essential.
Surgical exploration and orchiectomy.
STAGING:
1. Stage 1: testis lesion only no spread.
2. Stage 2: node below diaphragm only.
3. Stage3: node above the diaphragm.
4. Stage 4: pulmonary or hepatic metastases.
Treatment:
Seminoma are radiosensitive and excellent result, also
chemosensetive.
Teratoma: less sensitive to radiation, chemotherapy with great
result.
Retroperitoneal LN dissection is needed if persist after
chemotherapy
Prognosis:
Tumor marker help to make the diagnosis and follow the
effectiveness of treatment.
Prognosis is excellent when the patient is treated with
combination chemotherapy in cancer center.
IDIOPATHIC SCROTAL GANGREN (Fournier s gangrene.):
It is a vascular disaster of infective origin, characterized by:
*sudden scrotal inflammation.
*rapid onset of gangrene leading to exposure of scrotal
contents.
*the absence of any obvious cause in over half of the cases.
May follow minor surgical procedures in perineal area.
Clinical feature:
Sudden scrotal pain, prostration, pallor, cellulitis spread the
entire scrotum, slough, leaving the testis exposed,
Treatment:
Excision of gangrenous skin with cover antibiotic, many patient
may die.
Assist. Professor: Mohammed ridha Judi 2019