Approach to a case of scrotal Swellings.pptx

clinical

1. Approach to a case of scrotal Swellings

2. Anatomy

3. History Age : Ca. of skin of scrotum >50 years Malignancies of testis- Teratoma -20 to 30 year ,Seminoma – 30 to 40 year Torsion of testis – teen aged boys Hydrocele –infants, Primary hydrocele >40 years, secondary -20 to 40 years Tuberculous orchitis –young age Epididymal cyst and Spermatoceles – men >40 years Cysts of epididymis – congenital , can appear in middle aged men

4. Occupation: Except carcinoma other conditions –no definite relation to occupation Carcinoma of scrotum – Skin exposed to these irritants for many years before cancer develops a) contact with soot (chimney sweep’s cancer) b) tar or oil (mule spinner’s cancer) Varicocele – prolonged standing(Bus conductors)

5. History of present illness: Haematocele – history of trauma – maintains size for long time Malignant growth of the testis – may present as lump in epigastric or umbilical regions secondary deposits in lymph nodes Tubercular epididymitis-slight ache or trivial injury

6. Torsion of testis – Exciting cause- straining at stools lifting of heavy weight

7. Acute Epididymo orchitis- ache in groin slight raise of temperature severe pain, redness and swelling of groin

8. Filariasis- Periodic attack of fever Pain swelling of spermatic and scrotum

9. Local Examination Inspection Skin and Subcutaneous tissue : Normal-wrinkled and freely mobile over the testis Red and edematous – Acute epididymo orchitis Hydrocele –tense skin ,loss of normal rugosity, subcutaneous veins prominent Normal rugosity also lost in: a)Tuberculous epididymitis b)Gummatous orchitis, c)teratoma and seminoma of testis

10. Multiple sebaceous cysts: more common on scrotum

11. Carcinomatous ulcer : industrial cancers –cleft b/n scrotum and thigh, small circular with everted edges floor with yellowish grey infected necrotic tissue Gummatous ulcer : anterior aspect of scrotum Tubercular ulcer –posterior aspect of scrotum Multiple sinuses in scrotum – Watering can perineum Edema of scrotal skin- Nephritis, heart failure, cellulites, filariasis Elephantiasis of scrotum –Thickening of skin and subcutaneous tissue Lymph scrotum – Filariasis –skin of scrotum excessive rugosity ,lymphorrhagia

12. Ram’s Horn’ penis – Filariasis Skin and subcutaneous tissue of the penis thickened to produce this typical appearance

13. 2.Swelling: Slight swelling of scrotum –infection of testis and epididymis Hydrocele – small to very big swelling 3.Impulse on coughing : Hydrocele associated with hernia –bubonocele or complete inguinal hernia

14. Palpation: Skin: Carcinomatous ulcer- yellowish grey slough in floor ,hard base ,everted margins, early stages freely mobile Malignant ulcer- tethered to underlying testis Gummatous ulcer- anteriorly placed Tuberculous ulcer- posteriorly placed fixed to epididymis Hernia testis- testis cannot be separated from the protruded necrotic mass Hernia of hydrocele – testis can be easily separated

15. 2. Swelling: a)Fluctuation – Hold upper pole of scrotal swelling b/n thumb and the fingers of one hand to make the swelling tense and steady , while intermittent pressure applied at lower pole thumb and fingers of other hand This pushes fluid inside the tunica vaginalis upwards ,the thumb and the fingers holding the upper pole of the swelling will be pushed apart from each other making the test positive.

16. b)Translucency : Done in darkness Pencil torch is placed laterally Red glow – indicates clear fluid Better visualized with roll of paper placed on other side of scrotum Uncomplicated hydrocele and cyst of the epididymis are translucent Spermatocele not translucent

17. c)Reducibility: Tested by raising scrotum and compressing swelling gently Congenital hydrocele and varicocele are reducible In case of congenital hydrocele always examine abdomen for ascites as it is often associated with TB peritonitis d) Impulse on coughing : Many of times scrotal swelling associated with hernia, varicocele or lymph varix Expansile- hernia or congenital hydrocele Thrill like – varicocele or lymph varix

18. 3.Testis: a) Position- may be normal Anteverted (the epididymis lies anteriorly and the body lie posteriorly) completely inverted ( ie . Upside down – Globus major inferiorly) incompletely inverted- testis lies horizontally Inverted positions predispose to torsion

19. . b) size : Smaller testis-underdeveloped Larger testis- gummatous or the tumor Heavy testis- neoplasm and old Haematocele Testicular sensation - lost in a)gumma , b)malignant tumor of testis Location – Testis absent in scrotum a)undescended b)ectopic c)retractile testis

20. 4. Epididymis: Normally- firm nodular structure structure attached to posterior aspect of testis Tuberculosis – Globus minor is first affected (tail /lower ) Filariasis – enlarge and become firm Acute epididymo orchitis- gonococcal or B.coli infection 5. Spermatic cord: Best palpated b/n thumb and index finger at root of scrotum Thickened and beaded vas- TB epididymitis

21. 6.Lymph nodes: Skin of scrotum drains inguinal group of lymph nodes Testis and epididymis- pre and para aortic nodes-level of transpyloric plane Left supraclavicular- malignancies

22. Systemic examination Lungs : TB epididymo – orchitis to exclude Pulmonary TB Malignancies – to rule out secondaries to lung 2. Rectal examination: Acute prostatitis – precedes epididymo orchitis seminal vesicles – enlarged and tender TB epididymitis 3. Renal: varicocele – may be sequel of adenocarcinoma of kidney TB epididymo orchitis- active TB in renal tract

23. Investigations Blood : Filariasis- eosinophilia , microfilaria in peripheral smear TB Epididymo orchitis- lymphocytosis and increased ESR Syphilitic Orchitis- Positive W.R and Kahn tests 2. Urine: Acute epididymo orchites – E.coli, strepto, staphylo ,proteus infection TB Epididymo orchitis- TB bacilli in the urine

24. 3. Chest X – ray: TB Epididymo orchitis- pulmonary TB Testicular malignancies – Secondaries 4. Intravenous pyelography: Testicular tumours- exact position of kidney , retroperitoneal lymph Mets. 5. Ultrasonography: Position of testis hydrocele, haematocele, secondary hydrocele, torsion of testis 6. Aspiration: cystic swelling- spermatocele , chylocele

25. Differential Diagnosis Hydrocele : Congenital – process vaginalis patent communicates with peritoneal cavity Acquired- primary (idiopathic) and secondary( diseases of testis and epididymis) Infantile hydrocele- tunica and process vaginalis up to deep ring Funicular funicular process closed just above tunica vaginalis Hydrocele of hernial sac- neck of hernial sac closed by adhesions or plugged with omentum Encysted hydrocele of cord

26. 2. Acute epididymo orchitis: Retrograde infection Secondary to infection of urethra ,prostate and seminal vesical Severe pain ,swelling of testis Scrotal wall red and oedematous Gonococcus, E.coli, strepto, staphlo, proteus 3. TB epididymo orchitis : Retrograde infection –seminal vesical via vas Slight aching may be only complaint Normal rugosity of skin of scrotum lost

27. 4. Syphilitic orchitis: Bilateral orchitis- congenital syphilis Intertrial fibrosis-gradual destruction of seminiferous tubules Gumma- most common type Other syphilitic stigmas search should be made 5.Filarial (sub acute epididymo orchitis): Epididymis feels swollen, firmer, slightly tender Affects Globus major Digital fossa b/n testis and epididymis – on lateral aspect is obliterated

28. 6.Torsion of testis : Common between 10 to 15 years Sudden agonising pain in groin and lower abdomen Straining of stools ,lifting of heavy weight – exciting causes Affected testis –hangs higher in scrotum

29. 7. Tumours of testis: Consists of 1% of all malignancies in man 99% testicular tumours are malignant Commonest form of malignant tumours in young varieties- a) Seminoma (40%) b) Teratoma (35%) c) Lymphoma (6%) d) Intestial cell tumour (2%) e)other tumours(2%)

30. 8 .Fournier’s gangrene: Idiopathic Sudden appearance of scrotal inflammation in apparently healthy individual Rapid onset of gangrene Infective gangrene-fulminating inflammation-obliterative arteritis of subcutaneous tissue and hence gangrene Hemolytic streptococci, staphylo , E.coli, Cl.Welchii Sudden pain ,pyrexia, prostration and pallor

31. 9.Sabaceous cyst of scrotum: Puberty till middle age Multiple cyst are quite common of different size

32. 10.Carcinoma of scrotum: Chimney sweepers Mule spinners Tar and shale oil workers Majority are unknown aetiology Painless nodule or ulcer- initial presentation On examination – hard feel of nodule or base of ulcer is of significance Inguinal lymph nodes are almost always enlarged ,discrete and hard

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