Scrotal swellings

Prof Mostafa Sakr

• (A) Painful Scrotal Swellings• Testicular torsion• Epididymitis (chronic: specific or non-specific)• Hematocele• Rupture testis• Complicated Hernia• Some testicular tumors (10%)• Torsion of testicular appendix

• (B) Painless Scrotal Swellings• Testicular tumours• Varicocele• Hydrocele• Spermatocele• Hernia• Syphilitic gumma

• Diagnosis of scrotal swellings• To determine the nature of a scrotal swelling

aspects need to be assessed. – Can you get above the swelling? – Can the testis and epididymis be identified

separately? – Does the swelling transilluminate? – Is the swelling tender?

• A. Swellings not confined to the scrotum (inguinoscrotal)

• Hernias – May be reducible with cough impulse – Testis is palpable

• Infantile hydrocele – Irreducible – No cough impulse – Testis impalpable

•

• B. Swellings confined to scrotum• Testicular tumours:• Incidence: 2/100.000• Special characteristics:• Curable cancer• It has sensitive markers: (alpha-fetoproteins,

beta-HCG )• iii- Lymphatic drainage follows the blood supply

to para-aortic lymph nodes.

• Classification:• I- Germ cell tumor• -Seminoma 30% (Classic, Anaplastic, Spermatocytic)• -Embryonal carcinoma 30%• -Teratoma 35% (Differentiated, intermediate,

undifferentiated)• -Chorion epithelioma 1%• -Mixed tumor 15%• B- Non germ cell tumor: • Leydig-cell tumour, Sertoli-cell tumour and others.

• Etiology:• Premitive or immature cells (totipotential)

Abnormal differentiation spermeogensis, embryogensis, vetillogenesis.

• Predisposing factors:• l.Cryptorchidism• 7-10% of patients with testicular tumors have prior

testicular maldescent.• 2. Trauma• Repeated minor trauma was suggested as a predisposing

factor. • 3. Hormonal imbalance• 4. Atrophy• Post-mumps orchitis atrophy is a potential causative factor

• Pathology:• The tumor starts as in situ growth, spread

locally to peritubular tissue, then destroy testicular structure and lately the tumor invades the tunica albuginea which resists the malignant invasion.

• Metastasis:• Tumor of the testis proper spread along the

lymphatic vessels to paraaortic lymph nodes..

• Seminoma:• Differentiation into line of spermeogensis. • Cell of origin:• The germinal epithelium of seminiferous tubules. • Gross description:• Cut surface is grayish white, lobulated homogenous without hemorrhage or

necrosis. The tumor has no capsule. However, the tumor is distinct from the normal tissue.

• Microscopic:• Monotonus sheets of uniform cells with delicate connective tissue. The cells

have clear or granular cytoplasm with large central hyperchromatic nucleus. Malignant foreign body giant cells or syncytiotrophoblast are common, granulomatous reaction may be present, (the degree of anaplasia differentiate anaplastic from classic type.

Cut section in Seminoma.

• Spermatocytic type (4-8%):• The tumor is large yellowish soft slightly

mucoid. The cells are variable in size, the cytoplasm is more deeply stained. The nucleus is deeply granular with condensed chromatin-like spermatogonia. Stroma is scanty, lymphatic infiltration and granulomatous reaction are present. This tumor has better prognosis.

• Teratoma• Cell of origin: Totipotential cells. It gives elements of

more than one germ layer.• Gross: Large swelling, its cut surface reveals cysts with

mucinous material. Solid tissue, muscle, cartilage, bone are interposed between cysts.

• Microscopicaly:• Ectoderm—squamous epith, normal tissue• Endoderm—gastrointestinal, respiratory tissue• Mesoderm—bone, cartilage and muscle tissue.

• Chorion epithelioma• Cell of origin: Totipotential cell Differentiation into the

line of vetillogensis• It is highly malignant tumor.• Gross: Testis is hemorrhagic• Microscopically: cytotrophoblast, uniform medium sized

cells, distinct cell border and single uniform nucleus. Around these cells, the syncytiotrophoblast form its cap in villous-like structures. There are multinucleated cells with many hyperchromatic irregular nuclei in vaculated eosinophillic cytoplasm.

• Embryonal carcinoma• Differentiation into line of embryogenesis• Cell of origin:Totipotential cells.• Gross description:• It is the smallest germ cell tumr. Cut surface is variegated

appearance with grayish white smooth or granular bulging soft tissue, it has no capsule. There are extensive hemorrhage and necrosis.

• Microscopic:• Cells are of variable size and arrangement. Some are large

pleomorphic with distinct cell borders. Nuclei are also pleomorphic, mitotic figures are common.

• Embryonal carcinoma• Differentiation into line of embryogenesis• Cell of origin:Totipotential cells.• Gross description:• It is the smallest germ cell tumr. Cut surface is variegated

appearance with grayish white smooth or granular bulging soft tissue, it has no capsule. There are extensive hemorrhage and necrosis.

• Microscopic:• Cells are of variable size and arrangement. Some are large

pleomorphic with distinct cell borders. Nuclei are also pleomorphic, mitotic figures are common.

• Clinical manifestations (common to all tumors):• The earlier the diagnosis and treatment, the better is

the prognosis. • Symptoms and signs:• 1. Painless testicular swelling• 2. Dull aching pain in the testis or in 10% acute pain• 3. 10% manifest with metastasis; e.g. neck mass,

respiratory problems, gastrointestinal, bone fractures, CNS manifestations etc.

• 4. Gynecomastia 5% (hormonal imbalance).

• Examination:• Start with the normal side, tumor is usually

painless, hard, and heavy or the testis is expanded. It may spread to epididymis. Small hydrocele may be present (secondary). Sonography is accurate, examination of the abdomen is essential.

• Diagnosis:• -It is based on clinical examination and

ultrasound showing heterogenous vascularized or huge mass. No preoperative biopsy needed to avoid soiling of scrotal skin with malignant cells.

• -Preoperative tumor markers.

• Staging system: • Stage l: confined to testis • Stage ll: spread to regional node• Stage lll: beyond retroperitoneal area.• Metastatic Survey:• Chest X-ray CT scan Tumor

marker

• Marker Oncofetal:• Alpha-Fetoprotein• Beta-HCG• CEA (carcinoembryonic antigen)• Cellular enzymes (LDH, PLAP)

• Treatment:• Urgent high inguinal orchiectomy • Followed by:• 1- Seminoma—irradiation 2500 rads in 3

weeks• 2- Nonseminomatous germ cell tumor +

retroperitoneal lymph nodes dissection.

D. D.• Epididymo-orchitis

– Testis and epididymis definable – Testis tender

• Testicular tumour – Testis and epididymis definable – Lump within testis – Testis non tender

• Epididymal cysts – Testis and epididymis definable – Lump separate – Testis non tender

• Vaginal hydrocele • - Testis and epididymis not definable • - Transilluminates brightly • Torsion testis • - Testis and epididymis not definable • - Testis tender • Gumma • - Testis and epididymis not definable • - Irregular non-tender lump

• Testicular torsion• Definition• It is a surgical emergency due to twisting of

the cord, leading to obstruction of venous blood supply to the testes leading to secondary edema and congestion which will cause arterial obstruction and necrosis and gangrene of the testes.

• Etiology• If the testis has a narrow mesentery, it will move freely

around its axis like a clapper bell thus being liable to torsion. The abnormality is usually bilateral. It occurs usually at puberty or if a tumor develops in the testis due to increase in the testis size.

• • Differential diagnosis• Strangulated inguinal hernia, acute epididymoorchitis,

scrotal abscess, hematocele and mump's orchitis.

• Types• I. Neonatal Testicular torsion• (Extravaginal torsion, Torsion of the cord)• • Mechanism• In neonates, the gubernaculum has still not

completely been attached to the scrotal wall, and the testes and the gubernaculum freely rotate inside the scrotum, thus the entire testes, epididymis and tunica vaginalis twist together in a vertical axis on the spermatic cord above.

• Clinical picture• The infant is restless, reluctant to feeding.• Hard, large scrotal mass, -ve transillumination.• – Treatment: It is controversial

• No treatment the testis is already necrotic.• Surgical orchiectomy with contra lateral

orchiopexy to avoid sympathetic orchipathia of the other side and protect against its delayed torsion.

• II. Pubertal testicular torsion• (Intravaginal torsion)• • Age of incidence12—18 years• • Precipitating factors of torsion• Contraction of the cremasteric muscle.• Straining or lifting heavy objects.• Coitus or masturbation.•

• • Clinical picture• Sudden onset acute testicular pain and swelling.• Severe tenderness.• Nausea and vomiting.• Transverse lie of the testis.• Scrotal elevation will increase pain.• Secondary hydrocele may develop.

• Treatment• Manual detorsion (done from medial to lateral)

is not recommended as it is not a final solution and torsion may recur, also may be incomplete so the pain is relieved but the testis is still ischemic.

• Surgical exploration• Affected testis if viable detorsion and orchiopexy, if not

viable do orchiectomy.• Contralateral testis orchiopexy.

• III. Torsion of testicular appendages• The most common appendage susceptible to torsion is the

appendix testes.• Clinical picture• Similar to pubertal testicular torsion.• The twisted appendix may be palpable before scrotal swelling

development as a 3—5 cm tender mass above the upper pole of the testis with a characteristic blue dot sign on the overlying skin.

• Local anesthesia may be given for proper examination. • Treatment Surgical excision.

• Hydrocele• It is abnormal quantity of peritoneal fluid

between the visceral layers of the tunica vaginalis.

• Procesus vaginalis obliterated except around testis.

• Usually painless, unless underlying disease is painful.

• Types– Communicating– Encysted– Funnicular– scrotal

• May be primary or secondary.• Diagnosis:

– Testis not felt.– Can get above it.– Transluminant.– U/S.

• Treated by Excision and Eversion

• Epididymitis– Uncommon in adolescents - be wary about

making the diagnosis – Usually has a more prolonged history than torsion,

less pain and with urinary symptoms – Tenderness is greatest over the epididymis

• Idiopathic scrotal oedema– Usually occurs in boys less than 10 years old – Presents with scrotal redness and oedema – Pain is slight and testis feels normal.