Abnormalities of the Testes and Scrotum

8/17/2019 Abnormalities of the Testes and Scrotum

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Abnormalities Of The Testis And Scrotum

Ahmed Al-Sayyad


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Embryology

Testicular differentiation is initiated in the 7th

week of gestation by the SRY gene

At 4 to weeks! gestation" the genital ridgesorgani#e$ This is followed by migration of

%rimordial germ cells

At 7 to & weeks! both sertoli and leydig cells ha'e

de'elo%ed


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Embryology

(uring the &th week" the fetal testis begins to secretetestosterone and )*S inde%endent of %ituitary hormonalregulation

)*S is secreted by the Sertoli cells and causesdegeneration of the m+llerian structures after the &th weekof gestation

The gubernaculum a%%ears at the 7th week of embryologic

de'elo%ment where its cranial as%ect en'elo%s the caudae%ididymis and lower %ole of the testis and e,tendscaudally into the inguinal canal" where it maintains a firmattachment


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ry%torchidism

./ of full-term male newborns and .0$./ incidence in

%remature infants

)ore %re'alent among %reterm" small-for-gestational-age"

low-birth-weight" and twin neonates

A%%ro,imately 70/ to 77/ of cry%torchid testes will

s%ontaneously descend by . months of age

1y 2 year of age" the incidence of cry%torchidism declinesto about 2/ and remains constant throughout adulthood


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(escent 3actors

ormonal5 androgens")*S"estrogen"descendin

6ubernaculum

63 and 6R8

E%ididymis

*ntra-abdominal %ressure


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Terminology

9ndescended

Ascended

6liding

Retractile

Ecto%ic


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on%al%able testis

*ntra-abdominal

:anishing

Atro%hic

)issed on e,amination

1ilateral non%al%able work-u%


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onse;uences of ry%torchidism

*nfertility

eo%lasia

ernia

Torsion

Trauma

osmetic


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*n'estigations

ormones

9S

T

)R*

=a%arosco%y


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ormonal Thera%y

6 or 6nR can be used

The lower the %retreatment %osition the better the

results Self limiting side effects

O'erall success rate > ?0/

=imited indications if any


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Surgical *nter'ention


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ydrocele

ormally" the %rocessus 'aginalis is obliterated

from the internal inguinal ring to the u%%er

scrotum" lea'ing a small %otential s%ace in thescrotum that %artially surrounds the testis

Embryologic misad'entures may occur and results

in @hydrocele" hydrocele of the cord" and

communicating hydrocele$


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Sim%le ydrocele

Sim%le @scrotal hydrocele is an accumulation of fluid

within the tunica 'aginalis

Results from %ersistence of or delayed closure of the

%rocessus 'aginalis

ommonly seen at birth" fre;uently bilateral" may be ;uite

large$ They transilluminate and may seem ;uite tense but

not %ainful

)ost resol'e during the first ? years of life

*f surgical re%air is elected" an inguinal a%%roach should be

used


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ommunicating ydrocele

8ersistence of the %rocessus 'aginalis whichallows %eritoneal fluid to communicate with thescrotum

The classic descri%tion is that of a hydrocele thatchanges in si#e

*t can be com%ressible during e,amination

All should be fi,ed using an inguinal a%%roach (o it bilateral if %atient got :8 shunt or on

%eritoneal dialysis


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ydrocele of the cord

Segmental closure of the %rocessus" which lea'es

a loculated hydrocele of the cord

8resents as a %ainless groin mass which is mobileand transilluminates

*nguinal e,%loration and high ligation is curati'e


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Acute Scrotum


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(ifferential (iagnosis

Torsion testis

Torsion a%%endi, testis

Torsion a%%endi, e%ididymis E%ididymo-orchitis

ernia

Trauma :asculitis

(ermatological


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Testicular Torsion

True surgical emergency of the highest order

*rre'ersible ischemic inBury may begin as soon as

4 hours after occlusion of the cord *ntra'aginal torsion" result from lack of normal

fi,ation of the testis and e%ididymis to the fascialand muscular co'erings that surround the cord

This creates an abnormally mobile testis thathangs freely within the tunical s%ace @a Cbell-cla%%er deformityC


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Testicular Torsion

a%%ens in any age but most commonly in

%re%ubertal males

8resentation5 8ain"D:"8oor a%%etite"%re'iouse%isodes

E,amination5Swelling"Tenderness"igh

riding"trans'erse orientation"=oss of cremasteric

refle,


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Testicular Torsion

(o%%ler 9S may hel% in the diagnosis

)anual detorsion may be attem%ted in ER

Scrotal e,%loration is mandatory (etorte the affected testis and %e, the other side

while waiting for the testis to %ink u%

*f the testis is still ali'e %e, it " if not do anorchiectomy


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*ntermittent Torsion

Recurrent e%isodes of acute" self-limited scrotal

%ain

ormal %hysical e,amination will be found in- between

*f the sus%icion is strong " electi'e scrotal

e,%loration and bilateral orchio%e,y should be

%erformed


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Torsion A%%endi, Testis

%resentation is e,tremely 'ariable" from an

insidious onset of scrotal discomfort to an acute

%resentation identical to torsion testis E,am5Tenderness or mass in the u%%er %ole"1lue

dot sign"cremasteric refle, usually %resent

(o%%ler 9S may hel% in diagnosis

)anagement5conser'ati'e"%ain meds"limit acti'ity


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E%ididymitis

Rare in %ediatrics

8resentation5%ain"swelling"erethyma"=9TS"fe'er"

urethral discharge"ST(s *n'estigations5%yuria" bacteriuria" %ositi'e urine

culture" increased flow on do%%ler

*: Ab, gi'en if systematically ill then oral for

total of 20-24 days Screening 9S usually indicated

:96


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:aricocele

(ilated and tortuous 'eins of the %am%iniform

%le,us

3ound in a%%ro,imately 2F/ of male adolescents"with a marked left-sided %redominance

Etiology5increased 'enous %ressure in the left

renal 'ein" incom%etent 'al'es of the internal

s%ermatic 'ein


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'aricocele

9nilateral 'aricocele may affect testicular function

bilaterally

To,ic effect of 'aricocele may manifest as testicular

growth failure" semen abnormalities" =eydig cell

dysfunction" and histologic changes

8ossible mechanisms5reflu, of adrenal metabolites"

hy%erthermia" hy%o,ia" local testicular hormonal

imbalance" and intratesticular hy%er%erfusion inBury


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'aricocele

8resentation5asym%tomatic"%ain"scrotal

mass"infertility"atro%hy

6rading on %hysical e,amination Obtain scrotal 9S

Treat if there is loss of 'olume @G ? mls or G ?0/


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Treatment Alternati'es

*nguinal =igation and Subinguinal =igation

Retro%eritoneal and =a%arosco%ic =igation

Trans'enous Occlusion om%lications5hydrocele"recurrence"testicular

atro%hy

Abnormalities of the Testes and Scrotum

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