Testes and scrotum Flashcards
Differential diagnosis of unilateral testis (5)
Undescended testis (true cryptorchidism ) Retractile testis Ectopic testis Unilateral orchidectomy Agenesis
Main 2 causes of bilateral empty scrotum
Children: bilaterally undescended testes
Adults: bilateral orchidectomy (prostate ca metastasise here)
Explain normal testicular descent (7)
- Transabdominal migration:initiated by gubernacular swelling. Hormone = mullerian inhibiting substance
- Inguinoscrotal descent: preceded by protrusion of gubernaculum and process vaginalis into scrotum. Hormone = NB testosterone
Usually completed by 32 weeks.
Treatment of undescended testes (3)
Re-examine at 6 months of age. ( ideally desc by 12-18 months )
If still not descended:
If impalpable, do laparoscopy to localise testes(intra-abdominal/inguinal) or diagnose with anorchia.
If palpable =orchidopexy.
3 causes of undescended testes
Intrinsically abnormal testes causing incomplete descent.
Hormonal: “surge” of testosterone during first 3 months of life absent
Mechanical: prune belly syndrome (bilateral)
Treatment of retractile testis
Most are normal. Examine annually to inspect for ascending testes or “stuck” testes in upper scrotum inguinal region (will need orchidopexy)
Clinical findings of retractile testis (2)
Normal scrotal development
Can “ milk” testes out of inguinal canal and replace in scrotum
Classification of UDT (3)
Abdominal (prox to int inguinal ring)
Inguinal (between internal and external inguinal ring - most common)
Upper scrotal
Clinical findings of undescended testes
Hypoplastic scrotum with less rugae
Impalpable or palpable outside of scrotum
What needs to be investigated if bilateral impalpable testes?
Intersex disorders. Especially if associated with hypospadias, micropenis.
5 complications of undescended testes
- Malignancy (especially intra-abdominal )
- Infertility (spermatogenesis affected more than hormone prod)
- Inguinal hernia (95 % patent process vaginalis)
- Testicular torsion
- Trauma
Most common site of ectopic testis
Superficial inguinal pouch (just lat to external inguinal ring)
Treat ectopic testes?
Always orchidopexy
Clinical feature ectopic testis
Always palpable, because has passed through inguinal canal.
How is hydrocoele diagnosed clinically (6)
- Trans-illuminates
- Painless cystic scrotal swelling
- Testes impalpable if large hydrocoele
- . Fluid thrill
- Fluctuates (unlike enlarged testes)
- Normal spermatic cord palpated above hydrocoele (differentiate from indirect inguinal hernia)
Clinical features of varicocoele (6)
Pain when erect, otherwise painless
“ bag of worms” appearance above testis when patient stands
Valsalva makes it more obvious and palpable, pulsates
Cough impulse (venous thrill)
May have ipsilateral testicular atrophy
Disappear when lie down
90% left sided, 10% bilat
Complications varicocoele
Infertility due to increased intrascrotal temp and venous anoxia (oligospermia, asthenospermia, teratospermia - “stress pattern” on semenalysis)
Prevention varicocoele
Wear loose underwear
Grading of varicocoele
O venous noise on Doppler with Valsalva
1 palpated with Valsalva
2 palpated
3 observed bag of worms
Differentials acute scrotum (8)
- Testicular torsion
- Epididymitis
- Orchitis (mumps)
- Fournier ‘s gangrene
- Scrotal wall cellulitis/abscess
- Trauma - haematocele, ruptured testis
- Strangulated indirect inguinal hernia
- Testicular tumour (but usually painless)
- torsion of the appendix of the testis
- idiopathic lyphoedema of genitals
- insect sting
Which scrotal conditions have cough impulse (2)
NB hernia
Varicocoele
Clinical features of acute epididymitis (4)
- Pyrexia, dysuria, urinary frequency, urethral discharge
- Swollen tender epididymis posteriorly with normal testis anteriorly
- Pain relieved by elevation testes (positive phren test!)
- Positive cremasteric reflex!
- May have tender prostate on DRE - associated prostatitis
- 50% uti.
What is a varicocoele
Varicose veins (swelling ) of pampiniform plexus of spermatic cord. 90% left sided, 10% bilat
What kind of incontinence is included in LUTS
Urge incontinence (failure to store bladder) ( irritative /storage LUTS) NOT stress/total incontinence (urethral) or overflow incontinence.
Testicular torsion clin signs (7)
- NEGATIVE Phren test (pain not relieved by elevating scrotum, unlike epididymo-orchitis)
- Ischaemic pain (unlike epididymo-orchitis- inflammatory pain) often radiating to ipsilateral iliac fossa, nausea vomiting
- . Acutely tender unilateral scrotal swelling
- Unable to distinguish testis and epididymis ( unlike epididymo- orchitis)
- Cremasteric reflex NEGATIVE (unlike…)
- ,”Clapper-in-bell” sign - OPPOSITE testis lie transversely (means that redundant tunica vaginalis with high investment on spermatic cord- risk factor)
- high riding testis
- In neonates: painless scrotal mass
- Late = redness and oedema scrotal wall diffuse, small hard testis
- no urinary symptoms (unlike epidydimo- orchitis)
Clinical signs of indirect inguinal hernia (7)
- Cough impulse
- Bowel sounds
- Reducible
- Testes palpable and separable from hernia, cord not palpable.
- No pain, unless strangulated
- no transillummation
- to differentiate from direct: when reduced and apply pressure to deep inguinal ring (midway from ASIS to pubic tubercle ) hernia will remain reduced.
Causes epididymitis
E. coli!
Sexually active: chlamydia and gonorrheoea
What is a hydrocele?
Collection of fluid between visceral and parietal layers of tunica vaginalis of testis
Describe the classification of hydrocoele (3)
Congenital
• communicating (“fluid hernia”, due to patent processus vaginalis)
• hydrocele of cord
Acquired (no communication with peritoneal cavity)
. Primary - normal testis and epididymis, most common, due to decreased fluid absorption
• secondary - scrotal pathology associated eg acute epididymitis, testicular tumour, testicular torsion, scrotal trauma
What is an epididymal cyst?
- arise from epididymis thus fluid posterior or superior
* clear fluid
What is a spermatocoele?
- abnormal cyst that arise from epididymis thus fluid posterior or superior
- cloudy fluid, “barley water” (contain sperm)
Treatment communicating hydrocele?
- Patent processus vaginalis may close spontaneously 1-2 years after birth
- if persist, herniotomy.
Treatment primary hydrocoele? (2)
- Aspiration and sclerotherapy for small hydrocele - to get parietal and visceral layers tunica vaginalis to adhere
- hydrocelectomy: parietal layer tunica vaginalis everted or removed
Classification testicular torsion and major differences?
Extravaginal:
• less common <10%
• spermatic cord and tunica vaginalis undergo torsion together
• neonates, because tunica vaginalis not yet secured to guberbacalum
intravaginal:
• most common, > 90%
• spermatic cord rotate within tunica vaginalis
• adolescents, probably because increased weight testicle after puberty and sudden contraction of cremasteric muscles.
• more common on left side.
Testicular torsion special investigations? (2)
- If present within 24h, don’t delay treatment by doing investigations! If present later and in doubt, do:
- radio-isotope testicular scan: 90% accurate. Cold area of decreased perfusion. Late = “ring sign’ - cold area surrounded by increased activity due to scrotal hyperaemia
- colour Doppler ultrasound: detect pulsate flow via internal spermatic anlery
Testicular torsion treatment (3)
• Acute presentation- emergency surgery
• Manual detorsion: to relieve pain and buy time, but must follow with exploration. Twist laterally
• emergency surgery;
- scrotal incision
- detorsion: if testis viable do orchidopexy, if ischaemic do orchidectomy
- Contralateral orchidopexy in all cases!
What is an indirect inguinal hernia?
• Bowel herniate through inguinal canal (this is where testes descent too).
• after normal testicular descent, the deep inguinal ring closes and processus vaginalis obliterated. In these patients, this didn’t happen.
Through internal ring
Classification and etiology varicocoele?
Primary (mostly)
- congenital absence of valves in spermatic vein
- “nutcracker effect” (compression left renal vein between aorta and sup mesenteric a)
- R angled junction of L spermatic vein and renal vein versus oblique junction of R spermatic v and vena cava thus more common L side
Secondary (rare)
- neoplastic obstruction renal vein and IVC eg by tumour thrombus from RCC
- can be palpated supine unlike primary.
Treatment varicocoele?
- only if complications: pain, infertility, atrophy in young)
- principle = occlude spermatic vein to prevent retrograde flow
- open surgical ligation
- spermatic vein embolisation (antegrade sclerotherapy, retrograde embolization, laparoscopy)
Invasive treatment for erectile dysfunction who have failed oral therapy?
Intracavernous vasodilator injection (ici)
• prostaglandin e1 (alprostadil) or
• papaverine
Name 3 complications ICI
• Pain in penis, haematoma and other injection site injuries
• priapism!
• Peyronie’s plaque due to repeated injections
No systemic effects! Drug metabolised locally
Surgical last resort treatment for ED?
- Penile prosthesis/implant: malleable or inflatable
* penile artery reconstruction in young men with isolated vascular lesion
Identify pathology picture 7
Bell clapper deformity of testis. Risk factor for torsion.
Label picture 10
Left: normal
Middle: non-communicating hydrocoele
Right communicating hydrocoele
