Testis

1
Testis

• Often difficult to differentiate a serious
  emergent situation from a more benign situation
• Pay attention to history, clinical picture and
  pain expression of patient
• Decide who needs tests and when
• Decide who needs to go to surgery emergent and
  who elective

2
Scrotal Swelling Presentations
HERNIA
Hydrocele
Scrotal abscess
Varicocele
TORSION
Epididymitis
3
Hernia

• Bulge over inguinal canal or scrotum
• Changes size
• Reducible
• Sometimes there, sometimes not
• Open processus vaginalis
• Often not painful
• Diagnosis by exam
• Aggravated by constipation
• Elective surgery unless incarcerated

4
Hydrocele

• Bulge in scrotum or over inguinal canal
• Changes size if communicating
• Translucent
• Diagnosis by exam
• Elective surgery

..but starts screaming during exam
Not painful
5
Torsion

• 1 in 4000 males lt25/year
• Bell clapper deformity
• Lack of fixation
• Testis freely suspended within the tunica vaginal
  
• Extravaginal
• Pre- or neonatal
• Intravaginal
• Older children
• Peak around 13 years
• Left more common
• 2 bilateral
• Trauma as cause is rare
• Only 4-8

Barada et al, J Urol 1989 Seng et al , J Accid
Emerg 2000
6
Torsion

• Sudden onset of extreme pain
• Followed by acute swelling
• Affected side elevated
• Nausea and emesis
• No cremasteric reflex
• Can present as abdominal pain!!!
• If pain gets better by itself
• Not good NECROSIS!!!

• Diagnosis by exam and Doppler - Ultrasound

NO FLOW
Minevich E, emedicine Barada et al, J Urol 1989
7
Torsion - Treatment

• Manuel de-torsion can be attempted
• But extremely painful
• Open book
• Dont delay diagnosis
• Immediate surgery
• Within 6 hours
• Untwist and check for viability
• Remove necrotic testis
• Fixate the other side
• Prevent future torsion

8
Torsion- Prenatal

• Extravaginal torsion
• Presentation at birth
• Non-painful
• Hard
• Attached to scrotal wall
• Dark color shines through scrotum
• Treatment
• Orchiectomy
• Fixate contralateral side

9
Torsion

• Must not miss diagnosis
• Consider diagnosis until proven otherwise
• Doppler Ultrasound
• but perform surgery even if studies are negative
  if clinical suspicion is high

10
Torsion Appendix testis

• Painful
• Swollen in upper part of testis
• Blue dot sign
• Difficult to differentiate from testicular
  torsion
• Diagnosis by exam and ultrasound
• Often found during exploration of testicular
  torsion
• Surgery not necessary if clearly identified on US

11
Scrotal abscess

• Many possibilities
• Bug bite/ Rash
• Orchitis/ Epididimytis
• Trauma
• Exotic infection
• Immune disorder
• Treatment
• Antibiotics
• Drainage
• Debridment
• Evaluate reason

12
Epididymitis/Orchitis

• Very Painful
• Onset gradually
• Swollen and red
• Epididymis more painful than testis
• Diagnosis
• Exam, Lymph nodes, US, UA
• Infection
• UTI (UTI pos)
• Hematogenous (UA neg)
• Reactive (UA neg)
• Consider malformation
• Ectopic ureter
• Treatment
• Antibiotics (E.coli Bactrim)
• Elevation
• Cool

Increased flow to the epididymis
13
Varicocele

• Dilation of the pampiniform venous plexus and the
  internal spermatic vein
• Typically left
• insertion of vein into renal vein
• If right or no decompression on exam US
  recommended to rule out intra abdominal process
• Usually asymptomatic and found on routine exam
• Typical exam- Bag of worms
• Three reasons for OR
• Pain
• Cosmetic
• Testicular dysfunction
• US to verify diagnosis and measure testis

Patient does not want to be here
Redman et al, J Urol 2001, Sheldon et al, J Urol
2001
14
Testicular Tumors

• 2 of all pediatric tumors
• Incidence of 0.05-2 per 100,000 children
• First peak in the first 2 years of life, second
  in young adulthood
• Adult
• mostly germ-cell tumors with malignant potential
  (Seminoma and Embryonal carcinoma)
• Prepubertal
• yolk-sac tumors (malignant)
• Teratoma benign in children
• Seminomas and mixed germ-cell tumors are
  extremely rare
• Gonadoblastoma associated with DSD
• Leukemia
• Paratesticular Rhabdomyosarcoma

15
Testicular Tumors

• Presentation
• Painless scrotal swelling (85)
• Trauma, Hydrocele, Torsion 
• Diagnosis
• Exam
• Ultrasound
• aFT (yolk-sac), bHCG (Gonadoblastoma),
  Testosteron (Leydig- cell tumor)
• Excellent survival rates

Cooper CS, Urol Oncol 2005
16
Testicular Tumors
Surgery with radical orchiectomy in 24 hours
after diagnosis
17
Cryptorchidism

• Testis should descend from 7 months gestation
  until birth
• About half of UDT will drop during first year
• Can be intraabdominal, in canal or ectopic

18
Cryptorchidism

• Exam can be difficult
• Often strong cremasteric reflex
• Differentiate between retractile and undescended
• Frogleg and try to milk testis into scrotum
• Consider ectopic position
• Let the parents feel the testes

Child comfortableuntil exam
19
Cryptorchidism

• Clinical diagnosis
• Consider testicular atrophy if the other testis
  is large
• Ultrasound, MRI, CT usually not helpful
• If testis is not palpable OR
• If testes is found on imaging OR
• If testes is not found on imaging OR
• Reason for surgery
• Fertility
• Self- examination to detect testis tumor
• Timing of surgery after 6 month gestational age

20
Female Genitalia

• Labial adhesions
• Fusion of labia minora
• Not painful
• No emergency
• Can usually void fine
• Treatment
• Lysis (NO!!)
• Estrogen crème
• Lysis under local or full anesthesia
• Observation

21
Imperforate Hymen

• Normal urethral opening
• Bulging introitus
• Can be opened in clinic
• Not painful
• Should be seen soon

22
Sexual abuse

• Detailed knowledge of the anatomy
• Differentiate normal from abnormal
• Suspicious behavior during examination
• Immediate contact of social services

23
Syndromes

• Multiple syndromes impact the outer genitalia
• Many detected prenatally
• Should be referred for prenatal consultation
• Immediate contact with center
• Postnatal transfer to center
• Inform parents that situation will be discussed
  in detail at the center

24
Syndromes - DSD

• DSD

PAIS (46XY)
CAH
Complete androgen insensitivity (CAIS) Genetic
Male DSD
25
Syndromes - Exstrophy
Bladder Exstrophy
Cloacal Exstrophy
26
Obviously there are many more problems ..