Scrotum Flashcards
Age ranges scrotal pathology
Torsion
Infancy and puberty less than 3 and from beginning of puberty
Hydatid
7-10 years
Idiopathic scrotal oedema
5-9 years
Infection
Infancy and puberty
Mumps
Rare before 10
HSP
3-15 years of age
Retraction foreskin and age ranges
Oster Danish study 1965 1968 danish schoolboys 8% 6-6 year olds 6% 10-11 year olds 1% 16-17 year olds
Testicular descent embryology
At inguinal ring
In scrotum
Transabdominal descent week 10-15
Inguinoscrotal week 25-35
UDT prevalence
Right vs bilateral
3% newborns 1% at 6 months 30% premature Right 70% Bilateral 30%
UDT impalpable locations
80% palpable 20% impalpable of which 50% in canal 40% abdomen 10% absent
Ascending testicle risk if retraction and all testes
50 % retraction and 2% all testes May ascend
Age of orchidopexy
Complications
6 months- 18 months At 1 year risk of anaesthetic lower Complications BAUS Groin scrotal swelling pain 10-50% 2-10 % Infection Removal High riding position
0.004-2% Bleeding Atrophy Fertility Chronic pain Repeat procedure
Risks of hydrocele PPV repair
Recurrence 1-3% for neonate, 1% older kids Iatrogenic UDT 1% Injury to vas 0.33% Atrophy up to 10% No change swelling almost all Bleeding requiring treatment 2-10% Infection 0.004-2%
Testicular survival with orchidopexy procedures
Groin 98%
One stage 70%
Two stage 90%
Risk malignancy UDT General RR % of testicular cancer with UDT RR if fixed 0-6 years old RR if fixed over 13 years
Testicular cancer of which 10-15 % have UDT
RR is 3
RR is 2 if fixed 0-6 years old
RR 5 if fixed over 13
Circumcision complications
Bleeding 1.5% Local sepsis 8.5% Oozing 36% Discomfort more than 7 days 26% Meatal scabbing or stenosis Removal of too much or too little skin Urethral injury Amputation of glam Inclusion cyst
Testicle development MIH secretion week
Week 7 by pre sertoli cells
Regression of Müllerian ducts begin week 8 in response to MIS and complete by 10-12 weeks
Testosterone allows each mesoneprhic duct develop into epididymis, vas and seminal vesicles
incidence of UDT
3-5% at term
born less than 37 weeks 30% incidence of UDT
2 nd stage descent of testes
25-35 weeks
risk factors for UDT
maternal smoking
dad or brother - family history first degree relative
low birth weight or IUGR
when will testes not descend further
% of boys at 6 months with UDT
6 months of age
most likely to descend within first 3 months
premature babies descent can occur any time 1st year of life
1% of boys at 6 months have UDT
1.5% of 3 months have UDT, not much change in this figure by 1 year
ectopic locations
penile contralateral scrotum pre prenile superficial inguinal pouch perineum femoral region anterior abdominal wall
incidence bilateral UDT
right vs left
25%
right more common than left
right 70%
left 30%
semen parameters with UDT
paternity rate with unliat and bilat UDT
Oligospermia or azoospermia occurs in 75% of patients with bilateral UDT and 40% of unilateral UDT
Paternity in patients with unilateral UDT is similar to general population
Paternity rates 80-90% with history of unilateral UDT
Paternity rate 45-65% with history of bilateral UDT
Prospects fertility enhanced by early orchidopexy under 2 years
UDT and risk malignancy
RR 2 x to 10x vs normally descended testicle
higher risk if intrabdominal
early orchidopexy may reduce risk malignancy but not eliminate entirely
Nordic concensus and SRs - advise into scrotum 6-12 months
Fowler stephens success rate
when to do second stage
complications
60%
at 6 months, either open or with laparoscopic assitance
Atrophy 5% for inguinal up to 27% of two stage
Reascent
Injury Vas 1-2%
Testicular atrophy – 8% when testis lay beyond the external ring, 13% when in inguinal canal, 27% two stage fowler stphens, 5% for inguinal orchidopexy
Reascent of testis
Injury vas 1-2% - post ichaemic obliteration vas resulting from damage to blood supply likely unrecognised
Testicular volume influenced by initial position of gonad rather than age at surgery performed
surgery for UDT NICE, EAU
BAPS 6-18 months
EAU by 12 months
Nordic consensus statement 6-12 months
retractile testes age range most common
In clear-cut cases parents may be reassured that retractile testes are common, particularly between the ages of 3 and 7 years, and that surgical intervention is rarely required.
testicular descent
transadbominal
abdomen week 10-15
inguinoscrotal week 25-35
co existing conditions with UDT
hypospadias, SB 100% prune belly CP exomphalos
causes of maldescent of testicle 4
Physical ob to descent
Lack of intrabdominal pressure
Hypopituitarism
Mesenchymal defects
most common ectopic location
where is this
superficial inguinal pouch
between scarpa fascia and external oblique fascia
normal size pre pubertal testes
smaller than a malteaser sweet
definition retractile testicle
Retractile testes are those that move spontaneously out of the scrotum on a regular basis and or on initial examination but will return either spontaneously or with manipulation to a dependent scrotal position and remain there for a finite but ill defined period
cremasteric reflex and testosterone
reflex suppressed by T so absent in first six months due to perinatal T surge
risk of ascending testicle with retractile testes
follow up of retractile testicle
50% of retractile may ascend
2% of all testes may ascend
Arrange yearly review until puberty is established as significant risk of ascent by urology or GP if willing
May have 50% ascend
anaesthetic concern under age 1
Anaesthetic risk under 1 year equal to those over 70s should be undertaken by paediatric anaesthetist
Testicular survival concerns before age of 1 have not been realised
benefits of early orchidopexy for UDT (5)
Reduced distance testes have to move outweighs risk to delicate vessels
Early orchidopexy improves testicular growth
cosmesis
higher risk torsion
malignancy (before 13) Pettersson NEJM
fertility (before 2)
risk hernia
management bilateral impalpable testes
20 times more common to have bilateral intra ab testis than bilateral absent testes
Recommended to have laparoscopy than trying to assess whether testicular tissues with GnRH stimulation test
inguinal orchidopexy success rate
98%
Single stage Fowler stephens 70%
Two stage 60%
malignancy outcomes UDT
7/100,000 testicular cancer so still uncommon
5-10% in those with UDT
RR = 3,
Influence by syndromes, position, and dysplasia
Maybe increased risk in CL testis
Responsibility not to cause undue anxiety
Reassure risk small
Encourage monthly examination both testis from adolescence
malignancy paper age before or after 13
Pettersson NEJM 2007 Swedish
The relative risk of testicular cancer among those who un-derwent orchiopexy before reaching 13 years of age was
2.23 (95% confidence inter-val [CI], 1.58 to 3.06), as compared with the Swedish general population;
for those treated at 13 years of age or older, the relative risk was 5.40 (95% CI, 3.20 to 8.53)
fertility outcomes UDT
Historical data unilateral UDT does not affect paternity rates
But is reduced for bilateral UDT
Time to conception equal 3 gourps
Sperm densities different but morphology and motility similar
Early orchidopexy allows neonatal gonadocytes to adult dark spermatogonia which may improve sperm density in adulthood
96% normal semen parameters if orchidopexy under 12 months
66% if 12-24 months
differentiation of gonads
testicular descent phase 1 and 2 hormones
6th weeks undifferentiated
6-7 weeks under influence of SRY genes testes differentiate
testicular descent under MIH occuring by 12 weeks from urogenital ridge to internal inguinal opening
then
second phase from 25-30 weeks under T, inguingal canal to scrotum
differentiation of gonads
testicular descent phase 1 and 2 hormones
6th weeks undifferentiated
6-7 weeks under influence of SRY genes testes differentiate
testicular descent under MIH occuring by 12 weeks from urogenital ridge to internal inguinal opening
then
second phase from 25-30 weeks under T, inguingal canal to scrotum
stages of spermatogenesis draw diagram growth phase multiplication phase maturation phase
in neonatal gonocytes
ages of 3 and 12 months give rise adult dark spermatogonia
these then develop adult pale spermatogonia
meiosis I transform into primary spermatocytes
then meiosis II into secondary spermatocytes
progress to spermatids then rise to spermatozoa
complications inguinal orchidectomy
10-50%
Swelling of the groin and scrotum lasting several days
2-10%
1/10 to 1/50
Infection, removal, lie high in scrotum
0.004-2%
1/50 to 1/250
Bleeding No guarantee or reduced fertility Atrophy Repeat procedure Chronic pain Anaesthetic risk
Fowler stephens laparoscopy
risk of testicular loss with 2 stage procedure
air flow 2 pressure 10
20%
patency of PPV at birth
90% patent at birth
in up to 80% of males and 60% of females, the process vaginalis is still present at birth
when does PPV obliterate
By 8 weeks of age, 63% of males will have a persistent processus vaginalis with obliteration occurring any time up until the age of two years.
After this age, up to 40% of males continue to have a persistent process vaginalis with around half remaining asymptomatic throughout life.
incidence of neonatal hernia
when is risk of obstruction highest
1-5% of children
in neonate
management of incarcerated hernia
resuscitate,
Analgesia
Try to reduce hernia
Try to control ext ring, put pressure on swelling and feel hernia reduce
If unable to reduce despite maximal morphine analgesia, then proceed to emergency repair
If hernia is reduced, quite common to wait 48 hours, let oedema settle and then expediated basis
rate of resolution of hydrocele
when to do surgery
90% resolve in 1st year spontaneously
fix over 2 years old
complications PPV ligation
Complications Recurrence in older child 1% Neonate 1-3% recurrence rate UDT in 1% iatrogenic Testicular atrophy more common in neonate up to 10% Injury to vas 0.33%
peak times testicular torsion
incidence torsion
<3 and shortly after puberty 13-15
incidence 4.5 per 100,000 in age 1-25 years
contralateral bell clapper deformity
A recent study of 27 pubertal TT cases indicated that the contralateral testis was affected in 78% of the boys
testicular appendage torsion age group
7-10 years
mumps orchitis
usually after puberty
rare before 10
4-5 days after mumps infection parotitis
affects scrotum in 10-30% of patients who have mumps
conservative treatment
can result in testicular atrophy, reduced size seen in half of post pubertal patients with abnormalities of semen in a quarter, may be as a result of pressure necrosis
effect on endocrine difficult to establish
idiopathic scrotal odema age range
association
5-9 YEARS
testicle not tender, skin may be tender
association with worms treat child and family
when do second stage fowler stephens
6 months later
HSP
3-15 years
May rarely cause acute scrotum
Painless rash, weals blotches petechiae,
May get joint pain, VH, abdominal pain, can get intussepction, vasculitis of scrotum
No need explore
Conservative will get better
what are salvage rates of torsion after time frame
study
what is it called when near internal ring at laparoscopy
peeping testicle
examination of scrotum in UDT
look for underdeveloped scrotum if testicle never was there
when would do next stage of FS procedure
risk of need to remove testicle
6 months
liklihood of survival 70% successful
20% risk removal
mumps orchitis percentage after mumps infection
time interval
rate testicular atrophy and semen abnormality
15-30% will get mumps orchitis in post pubertal boys occurs 4-8 days after parotitis
half will have testicular atrophy
quarter abnormal semen analysis
sterility is rare
incidence UDT
2-4% of boys at full term
30% premature
incidence 1 month
incidence 1 year
1% at 1 month
0.8.% at 1 year
UDT familial risk
father affect 4.6 x RR
brother affected 6.9 x RR
principle of fertility in fixing UDT
Early orchidopexy allows neonatal gonadocytes to adult dark spermatogonia occuring at 3-6 months which may improve sperm density in adulthood
96% normal semen parameters if orchidopexy under 12 months
66% if 12-24 months
extravaginal torsion
neonatal torsion
testis and coverings twist entirely within the scrotum
intravaginal torsion
children and older adults
within the TA
resolving PPV by 1 year %
90% resolve by 1 year
surgery if persists over 2 yo
when intervene varicocele
if more than 20% size difference on US
