The Testicle and The Testicle and ScrotumScrotum

Suks Minhas,Suks Minhas,Consultant UroConsultant Uro--andrologist,andrologist,University College Hospital,University College Hospital,

LondonLondon

Areas of Surgical ExpertiseAreas of Surgical Expertise

Male InfertilityMale Infertility

Vasectomy and microsurgical reversal of Vasectomy.Vasectomy and microsurgical reversal of Vasectomy.

Genital OncologyGenital Oncology

Sexual DysfunctionSexual Dysfunction

Ejaculatory disordersEjaculatory disorders

Testicular Pain.Testicular Pain.

Peyronies DiseasePeyronies Disease

Penile ReconstructionPenile Reconstruction

Other Surgery of the testis and scrotumOther Surgery of the testis and scrotum

Other Surgery of the penisOther Surgery of the penis

The ScrotumThe Scrotum

Types of problem;Types of problem;

Diseases of the scrotumDiseases of the scrotum

Referred pain from the abdomen/spineReferred pain from the abdomen/spine

‘‘Chronic testicular PainChronic testicular Pain’’

Trauma

Penile Fracture due to vigorous intercourse

Infection

EpididymitisEpididymitis

CausesCausesMen less than 35Men less than 35-- Chlamydia and Chlamydia and GonorrhoeaGonorrhoea

Men greater than 35Men greater than 35-- Gram negative BacilliGram negative Bacilli

Full Urological evaluationFull Urological evaluation

Tender, swollen, red or warm scrotum Tender, swollen, red or warm scrotum Testicle pain and tendernessTesticle pain and tendernessDysuria and Frequency and UrgencyDysuria and Frequency and UrgencyPainful intercourse or ejaculation Painful intercourse or ejaculation Chills and a fever Chills and a fever Testicular lump Testicular lump Pain or discomfort in the lower abdomen Pain or discomfort in the lower abdomen or pelvic area or pelvic area Discharge from the penis Discharge from the penis Blood in the semenBlood in the semen

ComplicationsComplications

Scrotal abscessScrotal abscess

Chronic epididymitisChronic epididymitis

Testicular atrophyTesticular atrophy

Infertility Infertility

Specimen- Necrosis due to testicular torsion

Adult Testicular TorsionAdult Testicular TorsionSurgical EmergencySurgical EmergencyEpidemiologyEpidemiology

Commonest 12Commonest 12--18 years18 years1/4000 males less than 25 years of age1/4000 males less than 25 years of age

TypesTypesIntraIntra--vaginalvaginalExtraExtra--vaginalvaginal

Testicular TorsionTesticular Torsion

Clinical Features (Eaton, J Urol 2005)Clinical Features (Eaton, J Urol 2005)Painful recurrent episodes (50%)Painful recurrent episodes (50%)Severe pain of rapid onset Severe pain of rapid onset Nausea and/or vomiting (25%)Nausea and/or vomiting (25%)Horizontal lie of the testes Horizontal lie of the testes Other symptomsOther symptoms--Abdominal pain (20Abdominal pain (20--30%)30%)

Fever (16%)Fever (16%)Urinary frequency (4%)Urinary frequency (4%)

Previous history of trauma and pain attacks, presence of Previous history of trauma and pain attacks, presence of nausea and vomiting, and absence of urinary complaints are nausea and vomiting, and absence of urinary complaints are the main predictors of TT (Ciftci 2004)the main predictors of TT (Ciftci 2004)

Testicular TorsionTesticular Torsion

Differential DiagnosisDifferential Diagnosis

Torsion of testicular appendage Torsion of testicular appendage

EpididymoEpididymo--orchitisorchitis

Testicular TorsionTesticular Torsion

InvestigationsInvestigationsMSU/DipstickMSU/Dipstick

?US sensitivity of 69.2%, specificity of 100%, ?US sensitivity of 69.2%, specificity of 100%, positive predictive value of 100% and negative positive predictive value of 100% and negative predictive value of 97.5%. predictive value of 97.5%.

?Tc?Tc--99m radionuclide imaging 99m radionuclide imaging Sensitivity of 90Sensitivity of 90--100% 100%

Testicular TorsionTesticular Torsion

Surgical ManagementSurgical Management

A salvage rate of 80A salvage rate of 80--100% is found in patients 100% is found in patients who present within 6 hours of painwho present within 6 hours of pain

After 6After 6--8 hours, the salvage rates decrease to 8 hours, the salvage rates decrease to almost 0% at 12 hours.almost 0% at 12 hours.

cocele

SymptomsSymptoms

Pain (abdominal/groin/testicular)Pain (abdominal/groin/testicular)

LumpLump

InfertilityInfertility

VaricoceleVaricocele

Dilatation of the Dilatation of the pampiniformpampiniform plexus of plexus of spermatic veinsspermatic veinsIncidence Incidence 12% of men in the general 12% of men in the general population population 2525--35% with infertility35% with infertility90% left sided, 10% on right90% left sided, 10% on rightNBNB-- renal cell carcinomarenal cell carcinoma

Grading ofGrading of varicocelevaricocele

I palpable during I palpable during valsalvavalsalvaII palpable on standingII palpable on standingIII visible on standingIII visible on standing

Bag of wormsBag of worms

Incidence of Varicocele in Incidence of Varicocele in 9034 infertile couples9034 infertile couples

Normal semen qualityNormal semen quality11.7%11.7%

Abnormal semen qualityAbnormal semen quality 25.4%25.4%

WHO, Fertil Steril 1992; 57:1289

Varicocele grade and semen qualityVaricocele grade and semen quality

Varicocele Grade n Total sperm count ( mil)

Not present 5841 115Grade 1 434 86Grade 2 548 67Grade 3 271 60

WHO, Fertil Steril 1992; 57:1289

Editorial, BMJEditorial, BMJ 2004;328:9672004;328:967--968968 (24(24 April), April),

Only studies with status as randomised clinical trials Only studies with status as randomised clinical trials No evaluation of methodology was performed No evaluation of methodology was performed Three studies exhibited methodological problems Three studies exhibited methodological problems Inherent selection bias (many couples for ART rather than Inherent selection bias (many couples for ART rather than enter the study).enter the study).

““Most studies show improvement in postoperative sperm Most studies show improvement in postoperative sperm density and motility. The natural pregnancy rates varies, but density and motility. The natural pregnancy rates varies, but the overall average is 37%, a clearly higher figure than any the overall average is 37%, a clearly higher figure than any reported for nonreported for non--treatment. Although many of these studies treatment. Although many of these studies suffer from the flaws of nonsuffer from the flaws of non--randomised trials, these results randomised trials, these results would be difficult to explain on the basis of chance alonewould be difficult to explain on the basis of chance alone””

Hydrocele

Causes of Acute/Chronic testicular Causes of Acute/Chronic testicular painpain

Idiopathic in 25% of cases Idiopathic in 25% of cases Intermittent Intermittent Testicular TorsionTesticular TorsionPostPost--genitourinary surgery genitourinary surgery Sperm Sperm granulomagranuloma (post(post--VasectomyVasectomy) ) VaricoceleVaricoceleTesticular CancerTesticular CancerGenitourinary infection (e.g. STD) Genitourinary infection (e.g. STD)

Causes of Chronic testicular Causes of Chronic testicular PainPain

Acute on ChronicAcute on ChronicAssess for referred pain Assess for referred pain

NephrolithiasisNephrolithiasis in the midin the mid--ureter (most common) ureter (most common) Prostatitis/Chronic Pelvic Pain SyndromeProstatitis/Chronic Pelvic Pain SyndromeRadiculopathy Radiculopathy

GenitofemoralGenitofemoral and and ilioinguinalilioinguinal nerves (T10nerves (T10--L1) L1) Causes Causes

Inguinal HerniaInguinal HerniaRadiculitis Radiculitis Entrapment Entrapment NeuropathyNeuropathy after after Hernia RepairHernia RepairSperm Sperm granuloma granuloma