Scrotal Abnormalities

Question 1

What is cryptochidism?

Answer 1

Failure of one or both testicles to descend to their natural position in the scrotum

Question 2

Epidemiology of criptochidism?

Answer 2

most common congenital anomaly of the genitourinary tract

Question 3

Etiology of cryptochidism?

Answer 3

unknown, possibly multifactorial

Question 4

Risk factors of cryptochidism?

Answer 4

Prematurity
Low birth weight

Question 5

Clinical features of cryptochidism?

Answer 5

1. Palpable (in 80% of cases)
   - testicle cannot be manually manipulated into the scrotum
2. Non-palpable
   - may be intra-abdominal or absent

Question 6

What are possible variations in cryptochidism?

Answer 6

1. inguinal testis
2. intra-abdominal testis
3. ascending testes

Question 7

What is an inguinal testis?

Answer 7

The testicle is located between the external and internal inguinal ring, preventing adequate mobilization (90% of cases).

Question 8

What is an intra-abdominal testis?

Answer 8

The testicle is located proximal to the internal inguinal ring

Question 9

What is an ascending testes?

Answer 9

Testicular retraction into the scrotal pouch is possible; however, the testes immediately retract into the groin after manipulation.

Question 10

Treatment fo cryptochidism?

Answer 10

Orchidopexy
- exposure and fastening of the testicle to the scrotum
Note: Non-palpable testes - potentially therapeutic open or laparoscopic orchidopexy
> Surgery is recommended between 6–18 months of age

Question 11

Complications of cryptochidism?

Answer 11

1. Testicular cancer
2. Testicular torsion
3. Inguinal hernia
4. Infertility

Question 12

What is an ectopic testis?

Answer 12

The testicle is located outside the normal path of descent.
- Close urological monitoring is necessary, as the risk of testicular cancer and infertility is increased!

Question 13

What is a retractile testis?

Answer 13

Temporary displacement of the testicle in the inguinal canal by the cremasteric reflex.
- The testis may be easily repositioned back into the scrotal pouch.
Note: No treatment is necessary.

Question 14

What is a varicocele?

Answer 14

Abnormal enlargement and tortuosity of the pampiniform plexus in the scrotum due to proximal obstruction of the spermatic vein

Question 15

Epidemiology of varicocele?

Answer 15

Most common cause of scrotal enlargement in men
Incidence: 20–30% of the male population

Question 16

Etiology of a varicocele?

Answer 16

• Idiopathic/primary
• The cause of primary varicocele is not fully understood.
• The left testicle is most commonly affected (85% of cases)
• The longer course of the left spermatic vein and its insertion at a 90° angle into the left renal vein predisposes to slower drainage and increased hydrostatic pressure.

Question 17

How does a varicocele form?

Answer 17

1. Left renal vein passes between the aorta and superior mesenteric artery → ↑ susceptibility of the renal vein to compression (nutcracker phenomenon) → increased intravascular pressure in the left spermatic vein
2. The longer course of the left spermatic vein and its insertion at a 90° angle into the left renal vein predisposes to slower drainage and increased hydrostatic pressure
   → varicocele formation

Question 18

What is symptomatic/secondary varicocele?

Answer 18

Caused by a mass in the retroperitoneal space obstructing venous drainage into inferior vena cava (right-sided varicocele) or left renal vein (left-sided varicocele) or a thrombotic event
- Persist in the supine position due to a physical obstruction to blood flow within the spermatic vein

e.g. Ormond disease [Idiopathic retroperitoneal fibrosis], lymphoma, renal cell carcinoma

Question 19

Symptoms of varicocele?

Answer 19

1. A painless enlargement may be present
2. Dull, aching pain of the hemiscrotum (typically left-sided)
3. Heaviness of the affected scrotum
4. Soft bands/strands are palpable in the upper pole of the affected scrotum (“bag of worms”)
5. Symptoms worsen when standing or when performing the Valsalva maneuver.
6. Negative transillumination
7. In rare cases, paresthesia is possible

Question 20

Diagnosis of varicocele?

Answer 20

Ultrasound
- dilated (> 2 mm) hypoechoic pampiniform vessels
Note: Always perform an ultrasound of both testicles when varicocele is suspected, as the condition may occur bilaterally

Question 21

Complications of varicocele?

Answer 21

Infertility
In a varicocele, blood stasis within the scrotum increases local temperature, resulting in a suboptimal environment for spermatogenesis
> Sperm is produced in the testicles at 2°C below the average body temperature

Question 22

Treatment of varicocele?

Answer 22

1. scrotal support
2. Invasive treatment

Question 23

Indications for treatment of varicocele?

Answer 23

1. Testicular atrophy or delayed growth of the affected testicle in children and adolescents
2. Pain
3. Infertility (confirmed with an abnormal sperm analysis)

Question 24

Name and describe the procedures to correct varicoceles?

Answer 24

1. Laparoscopic varicocelectomy
   - affected dilated testicular veins (pampiniform plexus) are occluded by ligation
2. Percutaneous embolization
   - Young men without testicular atrophy, pain, or evidence of infertility should receive follow-ups (regular assessment of testicle size and/or semen analyses every 1–2 years).

Question 25

Presence of a unilateral right-sided varicocele indicates?

Answer 25

is uncommon and should raise suspicion of a mass in the retroperitoneal space blocking the spermatic vein.
e.g. Ormond disease, lymphoma, renal cell carcinoma

Question 26

What is a hydrocele?

Answer 26

Painless accumulation of fluid in a sac around one or both testicles which derives from the tunica vaginalis, a tissue covering the testes

Question 27

Etiology of hydrocele?

Answer 27

1. Idiopathic (most common)
2. Congenital hydrocele
3. Communicating hydrocele
   Occurs due to the failed closure of the processus vaginalis during development (Usually discovered in infancy)
4. Non communicating hydrocele: no connection to the peritoneal cavity present

Question 28

What is an acquired hydrocele?

Answer 28

Secondary to underlying pathology
e.g., trauma, tumor, torsion, infection
- Wuchereria bancrofti infection is the most common cause worldwide, but virtually nonexistent in the US (lymphatic filariasis).

Question 29

Clinical features of a hydrocele?

Answer 29

1. Fluctuant, painless swelling of affected scrotum
2. May be present since infancy or childhood
3. May or may not be reducible
4. Palpation above the swelling is possible: a normal spermatic cord and inguinal ring are present.
5. Positive transillumination

Question 30

How to diagnose a hydrocele?

Answer 30

Usually a clinical diagnosis
Ultrasound: Hypoechoic fluid confirms the diagnosis

Question 31

Treatment of a hydrocele?

Answer 31

Congenital hydrocele usually resolves spontaneously within 6 months of birth

Question 32

Indications for surgery in a hydrocele?

Answer 32

1. If spontaneous resolution does not occur by 1 year of age
2. Excessive discomfort and/or if scrotal skin integrity is compromised
3. An underlying pathology is suspected
4. Testicle not palpable
5. If infertility is a concern

Question 33

Describe procedures to correct hydroceles?

Answer 33

1. Surgical excision of the hydrocele sac
2. Percutaneous aspiration of the hydrocele fluid combined with instillation of a sclerosing promoter into the sac
   Note: A hydrocele must be differentiated from an inguinal hernia!