Abnormalities Of The Testis And Scrotum Ahmed Al-Sayyad

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Abnormalities Of The Testis And
Scrotum Ahmed Al-Sayyad
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Embryology

• 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 developed

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Embryology

• During the 8th week, the fetal testis begins to
  secrete testosterone and MIS independent of
  pituitary hormonal regulation
• 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 attachment

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Cryptorchidism

• 3 of full-term male newborns and 30.3 incidence
  in premature infants
• More prevalent among preterm, small-for-gestationa
  l-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

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Descent Factors

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

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Terminology

• Undescended
• Ascended
• Gliding
• Retractile
• Ectopic

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Nonpalpable testis

• Intra-abdominal
• Vanishing
• Atrophic
• Missed on examination
• Bilateral nonpalpable work-up

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Consequences of Cryptorchidism

• Infertility
• Neoplasia
• Hernia
• Torsion
• Trauma
• Cosmetic

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Work-UP

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

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Investigations

• Hormones
• US
• CT
• MRI
• Laparoscopy

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Hormonal Therapy

• HCG or GnRH can be used
• The lower the pretreatment position the better
  the results
• Self limiting side effects
• Overall success rate lt 20
• Limited indications if any

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Surgical Intervention

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

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Hydrocele

• 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).

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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 used

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Communicating Hydrocele

• Persistence of the processus vaginalis which
  allows peritoneal fluid to communicate with the
  scrotum
• 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

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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

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Acute Scrotum
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Differential Diagnosis

• Torsion testis
• Torsion appendix testis
• Torsion appendix epididymis
• Epididymo-orchitis
• Hernia
• Trauma
• Vasculitis
• Dermatological

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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")

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Testicular Torsion

• Happens in any age but most commonly in
  prepubertal males
• Presentation Pain,N\V,Poor appetite,previous
  episodes
• ExaminationSwelling,Tenderness,High
  riding,transverse orientation,Loss of cremasteric
  reflex

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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 orchiectomy

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Intermittent Torsion

• Recurrent episodes of acute, self-limited scrotal
  pain
• Normal physical examination will be found
  in-between
• If the suspicion is strong , elective scrotal
  exploration and bilateral orchiopexy should be
  performed

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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
  exploration

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Torsion Appendix Testis

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

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Epididymitis

• Rare in pediatrics
• Presentationpain,swelling,erethyma,LUTS,fever,
• urethral discharge,STDs
• Investigationspyuria, 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

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Varicocele

• Dilated and tortuous veins of the pampiniform
  plexus
• Found in approximately 15 of male adolescents,
  with a marked left-sided predominance
• Etiologyincreased venous pressure in the left
  renal vein, incompetent valves of the internal
  spermatic vein

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varicocele

• Unilateral varicocele may affect testicular
  function bilaterally
• Toxic effect of varicocele may manifest as
  testicular growth failure, semen abnormalities,
  Leydig cell dysfunction, and histologic changes
• Possible mechanismsreflux of adrenal
  metabolites, hyperthermia, hypoxia, local
  testicular hormonal imbalance, and
  intratesticular hyperperfusion injury

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varicocele

• Presentationasymptomatic,pain,scrotal
  mass,infertility,atrophy
• Grading on physical examination
• Obtain scrotal US
• Treat if there is loss of volume (gt 2 mls or gt
  20)

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Treatment Alternatives

• Inguinal Ligation and Subinguinal Ligation
• Retroperitoneal and Laparoscopic Ligation
• Transvenous Occlusion
• Complicationshydrocele,recurrence,testicular
  atrophy