[1]
Disorders of the testis & spermatic cord
Ectopy &cryptorchidism
•
In ectopy the testis has strayed from the path of the normal
descent;
•
In cryptorchidism, it is arrested in the normal path of
descent.
Ectopy may be due to an abnormal connection of the distal end of
gubernaculum testis that leads the gonads to abnormal position
.
The ectopic sites are as follow
1- superficial inguinal (most common).
2- perineal (rare).
3- femoral or crural (rare).
4- transverse or paradoxic both testes descend the same inguinal
canal.
5- pelvic.
• Cryptorchidism is a condition in which the testicle is arrested
at some point in its normal descent anywhere between the
renal & scrotal areas.
[2]
• Unilateral arrest is more common than bilateral arrest
•
At the time of birth (9 months gestation) the incidence of
maldescent is 3.4% half of such testicle descend in the first
month of life
• The incidence of cryptorchidism in adults is 1%
• in premature infants, it is 30% .
• Categorisation : Palpable 80% and Non palpable 20%
Etiology
causes of maldescent testis is not clear may due to.
A –abnormality of the gubernaculum testis.
(cord like structure that extend from the lower pole of the testis
to the scrotum).
B –intrinsic testicular defect.
making the testicle insensitive to gonadotropins. Best explanation
for unilateral
C –deficient gonadotropic hormonal stimulation. Testicular
descent is androgen mediated event, Best explanation of bilateral
cryptorchidism, & more incidence of undescent testis in
premature infant
Pathogenesis & pathology.
The scrotum is an effective temperature regulator for the testis,
which are kept 1-2 `C cooler than body temperature.
[3]
• The spermatogenic cells are sensitive to body temperature.
•
Studies of the ultrastructure of the cryptorchid testis found
deleterious changes in the 1st year of life. By the age of 4 yr
massive collagen deposition was evident.
•
So the testis has to be in the scrotum by the age of 6
months. Fortunately, the leydig cells are not affected by
body temperature.
Clinical findings.
The cardinal feature is the absence of one or both testes from the
scrotum. So the scrotum on the affected side is under developed.
•
The testis either non palpable or felt external to the inguinal
ring.
•
The patient may also complain of pain from trauma to the
testis due to abnormal position.
•
Adult pt with bilateral cryptorchidism may present with
infertility.
Hormonal studies, ultrasound, MRI, & laparoscope aid in the
diagnosis.
Complications.
1- torsion of the spermatic cord.
2- tumor, cancer is 25-30 times more common in misplaced testis
than normal testis. orchiopexy facilitate early detection rather
than decrease the incidence of malignancy.
[4]
3- trauma,
4-Hernia
5- Subfertility
6- abnormal semen analysis.
Treatment.
Medical : success rate about 20% by using (hCG)or (GnRH) can
used in bilateral case
Surgery : should be as early as 6 months
Palpable testis then orchiopexy
Non palpable testis then Inguinal exploration with possible
laproscopy
• Microvascular autotransplantation
. Disorders of the spermatic cord
Varicocele
• Dilatation & tortuousity of veins within the pampiniform
plexus above the testis.
•
A left side Varicocele is found in 15% of young healthy men.
In contrast the incidence of Varicocele in subfertile men
approaches 40%.
• It un usual in boys under 10 but became more frequent at
beginning of puberty
• Ites adverse influence increase with the time
[5]
• Incompetent valves are more common in the left internal
spermatic vein &right angle insertion of the left spermatic
vein to the left renal vein
Presentation : mostly presenting asymptomatic or could be
scrotal pain and swelling ,fertility problems
Assessment :history an examination in up right position
Grading:
I. Non palpable
II. Palpable
III. Palpable &visible
If still there is suspicion so we do uls see
• If there is venous reflux by doppler
• Testicular size
• Sperm concentration & motility are significantly decreased
in 65-75% of subject.
• Infertility is often observed & can be reversed in high
percentage of patients by correction of varicocele.
[6]
• The effect of varicocele on testicle remain unclear several
theories have been postulated.
1- hormonal imbalance due to decrease testosterone
secretion by leydig cell
2- reflux of potentially toxic renal & adrenal metabolites.
3- increase hydrostatic pressure which reduce the efficiency of
blood return & testis hypoxia
4- increase scrotal temperature due to reflux of warm
corporeal blood into the pampiniform plexus
❖ Tratment
• Conservative if there no indication of surgery
Follow up
• During adolescent ,testicular size should be checked
annually .after adolescent ,repeated sperm analysis is to be
recommended.
Surgery Indication
❖ small testis
❖ Symptomatic varcocele
❖ Pathological spermiogram
❖ Additional testicular pathology like mass
❖ Bilateral palpable varcocele
[7]
Surgical ligation of the internal spermatic veins.
Percutaneous methods like injection of sclerosing fluid may
be of value.
Hydrocele
Collection of fluid within the tunica or processus vaginalis.
Although it may occur within the spermatic cord, its most
often seen surrounding the testicle.
Causes:-
1. Primary :cause unknown associated with patency of
processes vaginalis
It classified as follow
A-communicating :it connect with the peritoneal
B-Non-communicated :not connected with peritoneal
2- Secondary : the fluid accumulate secondary to the
pathological process like infection ,tumor ,trauma . clear &
yellow.
Clinical presentation : Sumptoms
1. Painless swelling
[8]
2. Embarrassment
3. Dysuria &frequency if due to infection
Examination
❖ Position: swelling usually unilateral but can be bilateral
❖ Colour &temperature normal
❖
Tenderness :primary not tender but seconadary may be
tender
❖ Composition :fluctuant and have fluid thrill if large enough
❖ Reducibility :can not reduced
❖ Testis impalpable and transillumenate
Management:-
❖ Primary
in children
✓ Most neonatal hydrocele resolve in first 2 year of live if
persist then repair
In adult
✓ Surgical excision
❖ Secondary
✓ Treat the underlying cause.
Acute secrotum in children
[9]
Achild or adolescent present with acute secrotal pain
swelling tenderness
Aetiology
1. Torsion testis
2. Torsion appendix testis
3. Epididymatis or epididmo-orchtis
4. Other like mumps orchitis,varcocele,secrotal odema or
hematoma
Torsion of the spermatic cord
Torsion of the testicle is a twist of spermatic cord leading to
strangulation of the blood supply it mostly occur between age of
10-30.
Unless treatment is given within 4 hr testicular atrophy may occur.
Causes.
1- undescend testis.
[10]
2- trauma.
3- congenital anomalies of the tunica vaginalis or spermatic cord.
Voluminous tunica vaginalis that insert well up on the cord. This
allow the testis to rotate within the tunica.
The initiating factor is spasm of the cremaster muscle which insert
obliquely on the cord.
Clinical findings.
•
Sudden onset of pain Followed by swelling, reddening of
the scrotal skin, lower abdominal pain, & nausea & vomiting.
• Past history of similar pain in 50%
❖ Examination usually reveals
• Absent cremastic reflex (most important)
• swollen, tender organ that is retracted upward
• Horizontal lie of testes.
•
Pain may increase by lifting the testis. This differentiate
torsion from epididimorchitis
Diagnosis
if certain :emergent surgery
if uncertain :uls with doppler study document
blood flow &anatomy if absent vascularity then indicate torsion.
D.Dx
[11]
Acute epididymitis,
acute orchitis,
trauma.
Treatment.
Early surgical detorsion + fixation of the affected testis & the
contralateral testis as prophylactic procedure should be done as
early as 1st 6 hours