Abnormalities Of The Testes And Scrotum by MikeJenny


									Abnormalities Of The Testis And Scrotum

     Ahmed Al-Sayyad

 Testicular differentiation is initiated in the 7th
  week of gestation by the SRY gene
 At 4 to 6 weeks’ gestation, the genital ridges
  organize. This is followed by migration of
  primordial germ cells
 At 7 to 8 weeks’ both sertoli and leydig cells have

   During the 8th week, the fetal testis begins to secrete
    testosterone and MIS independent of pituitary hormonal
   MIS is secreted by the Sertoli cells and causes
    degeneration of the müllerian structures after the 8th week
    of gestation
   The gubernaculum appears at the 7th week of embryologic
    development where its cranial aspect envelops the cauda
    epididymis and lower pole of the testis and extends
    caudally into the inguinal canal, where it maintains a firm

   3% of full-term male newborns and 30.3% incidence in
    premature infants
   More prevalent among preterm, small-for-gestational-age,
    low-birth-weight, and twin neonates
   Approximately 70% to 77% of cryptorchid testes will
    spontaneously descend by 3 months of age
   By 1 year of age, the incidence of cryptorchidism declines
    to about 1% and remains constant throughout adulthood
Descent Factors

   Hormonal: androgens,MIS,estrogen,descendin
   Gubernaculum
   GFN and CGRP
   Epididymis
   Intra-abdominal pressure

   Undescended
   Ascended
   Gliding
   Retractile
   Ectopic
Nonpalpable testis

   Intra-abdominal
   Vanishing
   Atrophic
   Missed on examination
   Bilateral nonpalpable work-up
Consequences of Cryptorchidism

   Infertility
   Neoplasia
   Hernia
   Torsion
   Trauma
   Cosmetic

 Maternal history including the use of gestational
  steroids, Perinatal history, including
  documentation of a scrotal examination at
 Examine in a warm room,supine,squatting etc
 Look for genital abnormalities,scrotal
  size,contralateral hypertrophy

   Hormones
   US
   CT
   MRI
   Laparoscopy
Hormonal Therapy

   HCG or GnRH can be used
   The lower the pretreatment position the better the
   Self limiting side effects
   Overall success rate < 20%
   Limited indications if any
Surgical Intervention

   When
   Inguinal orchiopexy
   Laparoscopic orchiopexy
   Fowler-Stephens orchiopexy
   Staged orchiopexy
   Microvascular autotransplantation

 Normally, the processus vaginalis is obliterated
  from the internal inguinal ring to the upper
  scrotum, leaving a small potential space in the
  scrotum that partially surrounds the testis
 Embryologic misadventures may occur and results
  in (hydrocele, hydrocele of the cord, and
  communicating hydrocele).
Simple Hydrocele

   Simple (scrotal) hydrocele is an accumulation of fluid
    within the tunica vaginalis
   Results from persistence of or delayed closure of the
    processus vaginalis
   Commonly seen at birth, frequently bilateral, may be quite
    large. They transilluminate and may seem quite tense but
    not painful
   Most resolve during the first 2 years of life
   If surgical repair is elected, an inguinal approach should be
Communicating Hydrocele

   Persistence of the processus vaginalis which
    allows peritoneal fluid to communicate with the
   The classic description is that of a hydrocele that
    changes in size
   It can be compressible during examination
   All should be fixed using an inguinal approach
   Do it bilateral if patient got VP shunt or on
    peritoneal dialysis
Hydrocele of the cord

 Segmental closure of the processus, which leaves
  a loculated hydrocele of the cord
 Presents as a painless groin mass which is mobile
  and transilluminates
 Inguinal exploration and high ligation is curative
Acute Scrotum
Differential Diagnosis

   Torsion testis
   Torsion appendix testis
   Torsion appendix epididymis
   Epididymo-orchitis
   Hernia
   Trauma
   Vasculitis
   Dermatological
Testicular Torsion

 True surgical emergency of the highest order
 Irreversible ischemic injury may begin as soon as
  4 hours after occlusion of the cord
 Intravaginal torsion, result from lack of normal
  fixation of the testis and epididymis to the fascial
  and muscular coverings that surround the cord
 This creates an abnormally mobile testis that
  hangs freely within the tunical space (a "bell-
  clapper deformity")
Testicular Torsion

 Happens in any age but most commonly in
  prepubertal males
 Presentation: Pain,N\V,Poor appetite,previous
 Examination:Swelling,Tenderness,High
  riding,transverse orientation,Loss of cremasteric
Testicular Torsion

   Doppler US may help in the diagnosis
   Manual detorsion may be attempted in ER
   Scrotal exploration is mandatory
   Detorte the affected testis and pex the other side
    while waiting for the testis to pink up
   If the testis is still alive pex it , if not do an
Intermittent Torsion

 Recurrent episodes of acute, self-limited scrotal
 Normal physical examination will be found in-
 If the suspicion is strong , elective scrotal
  exploration and bilateral orchiopexy should be
Prenatal testicular torsion

 Extravaginal torsion
 Presents at birth as a hard,nontender testis fixed to
  the scrotal skin which is usually discolored
 Doppler US may help in the diagnosis
 Management is controversial: observation Vs
Torsion Appendix Testis

 presentation is extremely variable, from an
  insidious onset of scrotal discomfort to an acute
  presentation identical to torsion testis
 Exam:Tenderness or mass in the upper pole,Blue
  dot sign,cremasteric reflex usually present
 Doppler US may help in diagnosis
 Management:conservative,pain meds,limit activity

   Rare in pediatrics
   Presentation:pain,swelling,erethyma,LUTS,fever,
    urethral discharge,STDs
   Investigations:pyuria, bacteriuria, positive urine
    culture, increased flow on doppler
   IV Abx given if systematically ill then oral for
    total of 10-14 days
   Screening US usually indicated
   ? VCUG

 Dilated and tortuous veins of the pampiniform
 Found in approximately 15% of male adolescents,
  with a marked left-sided predominance
 Etiology:increased venous pressure in the left
  renal vein, incompetent valves of the internal
  spermatic vein

   Unilateral varicocele may affect testicular function
   Toxic effect of varicocele may manifest as testicular
    growth failure, semen abnormalities, Leydig cell
    dysfunction, and histologic changes

   Possible mechanisms:reflux of adrenal metabolites,
    hyperthermia, hypoxia, local testicular hormonal
    imbalance, and intratesticular hyperperfusion injury

 Presentation:asymptomatic,pain,scrotal
 Grading on physical examination
 Obtain scrotal US
 Treat if there is loss of volume (> 2 mls or > 20%)
Treatment Alternatives

 Inguinal Ligation and Subinguinal Ligation
 Retroperitoneal and Laparoscopic Ligation
 Transvenous Occlusion
 Complications:hydrocele,recurrence,testicular

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