Gus156 Slide Scrotal Swellings

8/12/2019 Gus156 Slide Scrotal Swellings

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Scrotal Swellings

Dr. Syah Mirsya Warli, SpU Dr. Zahri A. Ranie, SpU

Dr. Bungaran Sihombing, SpU Div. of Urology, Dept.of Surgery

Medical Faculty, University of North Sumatera


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Common Causes of Scrotal Swellings

HydroceleEpididymal Cyst

Epididymo-orchitisTesticular Tumour


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Hydrocele

Fluid collections within the tunica vaginalis of the scrotum or a long spermaticcord. Persistent developmental connections a long the

versus absorption. Little risk of clinical consequence.


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Pathogenesis

The fluid collects because of an imbalance betweenproduction and absorption.

The tunica vaginalis normally produces around

0.5ml of fluid a day.Pathophysiology

Proc. Vaginalis is a diverticulum of theperitoneal cavity.

It descends with the testis into the scrotum(28th gestational week).


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Common Causes

Congenital Patent processus vaginalis (PPV)

Ac uired Idio athicTumourTraumaInfection


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History & Examination

History: A painless swelling in the scrotum.Onset may be gradual or sudden.

The testis cannot be palpated separate to theswellingThe lump transilluminates


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Investigation

Because one of the causes of a hydrocele istesticular tumour, it is important to arrange ascrotal ultrasound to rule out this as an

un er ying pat o ogy


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Treatments

Conservative management if the hydrocele issmall and causing little in the way of symptoms Aspiration +/- injection of a sclerosing agent

Surgery: Ligation of PPV in children JaboulayLords

Both the Jaboulay and the Lords procedure involveincising the tunica vaginalis to allow the hydrocelefluid to be absorbed by the scrotal lymphatics.


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Differentials

Orchitis Testicular torsion Indirect inguinal hernia

Traumatic injury to the testical


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Epididymal Cyst

Definition :


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History & Examination

History: Painless scrotal swellingOnset usually gradual

Examination : Scrotal swelling which you can getaboveTestis palpable separate from the lesion

The cyst transilluminates


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Management

Simple surgical excision of the cyst

multiloculated

As for hydroceles, conservative management isperfectly reasonable if the patient is asymptomatic


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Varicocoele

Definition

pampiniform plexus


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Symptoms & Signs

Symptoms: Scrotal swellingFar more common on left than on rightDragging / aching sensation in the groin /scro um

Signs: Scrotal swelling which you can get aboveSwelling feels like a Bag of worms


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Significance of Varicocoele

A left sided-varicocoele may arise as a result of obstruction to venous drainage caused by a renaltumour

Therefore all patients with a varicocoele shouldundergo imaging (usually ultrasound) of their

kidneys


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Methods of Treatment

The two main methods are:

1 Surgical ligation2 Embolisation under X-Ray control


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Epididymo-Orchitis

Definition

n n ammat on o t e t ssues o t eepididymis and testis


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Symptoms & Signs

Symptoms: Painful scrotal swelling

Signs: A scrotal swelling which you can get above

an w ic is- hot- tender

- erythematous


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Treatment

An appropriate broad-spectrum antibiotic isused, such as ciprofloxacin.


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Ciprofloxacin

This is a fluoroquinolone antibiotic

It acts by inhibiting an enzyme called DNA gyrase inreproducing bacteria. This is one of the enzymesresponsible for unwinding DNA during replication


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Testicular TumoursClassification

You might sensibly start classifying testicular tumoursinto benign and malignant. In fact benign solid

tumours of the testis are extremely rare.

The classification of malignant tumours is complicatedby the fact that there are different classificationsystems used in the UK and USA and consequentlyits easy to get confused if you read textbooks fromthe different countries.


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Divided into :

1 Germ Cell Tumours2 Other tumours the commonest of which is

lymphoma, which is the commonesttesticular malignancy in the older patient.


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Germ cell tumours can be divided into

1 Seminoma2 Non-seminoma


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Classification of Non-Seminomatous Germ Cell TumoursUK USA

Malignant teratomadifferentiated

Teratoma

a gnan era omaundifferentiated

m ryona arc noma

Malignant teratomaintermediate

Teratocarcinoma

Malignant teratomatrophoblastic

Choriocarcinoma

Yolk Sac Tumours Yolk Sac Tumours


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Remember

40% of testicular tumours are mixed, i.e.they have both seminomatous and non


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Peak Age Incidence

Seminomas 40 yearsNSGCTs 30 years


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Symptoms & Signs

Symptoms: Painless scrotal swellingChance discoveryTestis feels heavier

gns: cro a swe ng w c you can ge a oveThe lump is craggy & does not transilluminateMay be associated with hydroceleMay have palpable liver due to metastases


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InvestigationsRadiology : Ultrasound of testis

CT of abdomen to assess spreadChest X Ray for metastases

Blood Tests : AFP al ha foeto- rotein b-hCG (human chorionic

gonadotrophin)LDH (lactate dehydrogenase)

The blood tests are known as tumour markers.


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SurgeryAn inguinal orchidectomy is performedi.e. the testis is taken out through an incision inthe groin

This is because the lymphatic drainage of the testisis to the para-aortic nodes. An incision in thescrotum risks spreading the tumour to thesuperficial inguinal lymph nodes which drainthe scrotal skin


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Other Treatments

If the tumour has metastasised, otheroptions for treatment include: Radiothera for seminoma Chemotherapy for NSGCTs

Sometimes a combination of the two is

required


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