Abnormalities Of The Testis And Scrotum

Ahmed Al-Sayyad

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

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

Cryptorchidism

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

Terminology

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

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

Investigations

Hormones US CT MRI Laparoscopy

Hormonal Therapy

HCG or GnRH can be used The lower the pretreatment position the better the

results 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

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).

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

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

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 episodes

Examination:Swelling,Tenderness,High riding,transverse orientation,Loss of cremasteric reflex

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

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

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

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

Epididymitis

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

Varicocele

Dilated and tortuous veins of the pampiniform plexus

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

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

varicocele

Presentation:asymptomatic,pain,scrotal mass,infertility,atrophy

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

atrophy