Inguinoscrotal swelling

Seminar presentation made by students from Widad University College.

1. INGUINOSCROTAL SWELLING Date of presentation: 27 th Dec 2019

2. ADD A FOOTER 2 OUTLINE INGUINOSCROTAL SWELLING Differential diagnosis Clinical feature History Physical examination Investigation Management Complication Case Scenario

3. DIFFERENTIAL DIAGNOSIS 3

4. INGUINAL SWELLING

5. HESSELBACH’S TRIANGLE Medially: Lateral border of rectus muscle Laterally: Inferior epigastric vessels Inferiorly: Inguinal ligament Contains a depression referred to as the medial inguinal fossa, which direct inguinal hernia protrude through the abdominal wall

6. Surface Anatomy of Inguinal Canal Deep Inguinal ring = Above the midpoint of inguinal ligament Superficial Inguinal ring = Superior the pubic tubercle

7. FEMORAL CANAL Lies in the medial border of femoral sheath. Borders: Anterosuperiorly : Inguinal ligament Posteriorly: Pectineal ligament (anterior to superior pubic ramus) Medially: Lacunar ligament Laterally: Femoral vein The entrance of femoral canal is the femoral ring (About 1.2 cm lateral to pubic tubercle) = Femoral hernia

8. SCROTAL SWELLING

9. Anatomy of Scrotum and Testis

10. Anatomy of Scrotum

11. Layers of Scrotum

12. Processus Vaginalis Processus vaginalis is an embryonic development of outpouching of the peritoneum. Present from around 12 th week of gestation. In males: It precedes the testis in their descent down within the gubernaculum, and closes.

13. Inguinal Lymph Nodes 2 groups: Superficial inguinal lymph nodes Horizontal Along lower border of inguinal ligament Vertical Along great saphenous vein Deep inguinal lymph nodes Along medial to femoral vein under cribriform fascia

14. HERNIA Types of hernia in inguinal region: Indirect inguinal hernia Lateral to inferior epigastric vessels Pass through inguinal canal Direct inguinal hernia Medial to inferior epigastric vessels Bulging from the posterior wall of inguinal canal Femoral hernia Pass through femoral ring

15. HISTORY 23

16. 24 DEMOGRAPHIC DATA Male Post-puberty age Teratoma 20-30y/o, Seminoma 30-40y/o Older men with retroperitoneal disease: RCC HOPI Duration of swelling Onset of swelling (sudden or gradual) Presence of pain Increased intra-abdominal pressure: chronic cough, straining, chronic constipation Fever, chills and malaise Back pain (if para-aortic nodes infiltrated with metastases) Poor hygiene Hx of trauma PAST MEDICAL HX Hx malignancy in contralateral testis Symptoms of UTI or STD Cryptorchidism HIV infection Gonadal Dysgenesis Torsion Orchitis Infertility Klinefelter’s Syndrome Infantile Hernia Testicular Microlithiasis Immunocompromised e.g Diabetics Source of infection: urethral stone / stricture / fistulae/ruptured appendicitis, colonic CA, diverticulitis, peri-rectal abscess PAST SURGICAL HX Inguinal hernia repair Vasectomy Orchidopexy Appendicectomy FAMILY HX Malignancy in family SOCIAL HX Smoking Alcoholics Occupation ( heavylifting ) BMI (obesity)  IN GENERAL EXAMINATION

17. PHYSICAL EXAMINATION 25

18. 26

19. ADD A FOOTER 27 HYDROCELE VARICOCELE EPIDIDYMAL CYST HERNIA TESTICULAR TUMOR EPIDIDYMOORCHITIS SCROTAL ABSCESS FOURNIER GANGRENE Characteristic Soft Smooth Fluctuant Bag of worms Soft Smooth Nodule Fluctuant Soft Smooth Hard Nodular Irregular Erythematous overlying skin Erythematous Fluctuant Warm Blackish discolouration Tenderness No No No No; yes if strangulated No Yes Yes Yes Can get above Can Can Can Cannot Can Can Can Can Relationship to testis Continuous Separate Separate Continuous Continuous Separate Separate Separate Reducible No No No Yes No No No No Cough impulse -ve -ve - ve + ve -ve -ve - ve - ve Transillumination + ve - ve + ve - ve - ve - ve - ve - ve Extra Unilateral or bilateral Compressible Disappear on supine More common on left Often multiple in the head of epididymis Valsava maneuver Febrile Pain relieved on elevation of the testis ( Prehn’s sign) Symptoms of infection Presence of crepitus Symptoms of infection

20. 28 Hydrocele Abnormal collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis enveloping the testis. Can form along the spermatic cord and is a differential for lumps in the groin Asymptomatic fluid collection around the testicles ( processus vaginalis) Varicocele Abnormal dilatation of the pampiniform venous plexus within the spermatic cord. 90% of varicoceles are found on the left side as the spermatic vein drains directly into the left renal vein Dull aching, left scrotal pain Testicular atrophy – compare both sides Decreased fertility Epididymal cysts (spermatoceles) Benign fluid-filled sacs arising from the epididymis. Often multiple in the head of epididymis Epididymo -o rchitis Inflammation of the epididymis & testis Pain may be relieved on elevation of the testis ( Prehn’s sign). Scrotal abscess Scrotal fluctuant & may be palpable Fournier Gangrene Necrotizing fasciitis of the perineum and genital region frequently due to a synergistic polymicrobial infection

21. 29 Inguinal Hernia All inguinal hernia should be assessed for strangulation or obstruction. Indirect Hernia Direct Hernia Via deep inguinal ring along the inguinal canal Via transversalis fascia ( Hesselbach’s triangle) Patent/reopen processus vaginalis Enter scrotum Weak abdominal wall/muscle Does not enter scrotum Narrow neck  more liable to strangulate Broad neck impulse on finger Invagination Test Impulse on pulp cough impulse on index finger Zieman’s Test Cough impulse on middle finger do not bulge out Deep Ring Occlusion Test Bulge out

22. ADD A FOOTER 30 SPECIAL TEST FOR HERNIA Invagination test (supine position) Invert the scrotum with index/little finger Enter inguinal canal along the course of the cord up to spfcl ing . ring Ask pt to cough Impulse palpable: On tip: indirect hernia On pulp: direct hernia Zieman’s test (supine position) Index finger: deep inguinal ring (indirect hernia) Middle finger: superficial inguinal ring (direct hernia) Ring finger: saphenous opening(femoral hernia) Ask pt to cough/do vasalva maneuver Ring occlusion test Ask pt to reduce hernia (in supine) Occlude the deep inguinal ring (mid-inguinal point) with thumb Hold the thumb in position & ask pt to stand Ask pt to cough + ve : no bulging of hernia (indirect hernia) - ve : bulging (direct hernia) Other Percussion: dull( omentum ) resonance(enterocele) Auscultation: bowel sound

23. 31

24. 32 hydrocele varicocele Scrotal abscess epididymoorchitis Testicular tumor

25. 33 Epididymal cyst Fournier gangrene Testicular torsion

26. INVESTIGATION 34

27. BLOOD / URINE IX Full blood count ( leukocytosis , platelet, Hb level) Urine specimen for culture & sensitivity (presence of organism) Nucleic acid amplification testing (NAAT) (from urine specimen or urethral swab; presence of gonococcal / chlamydial) Tumor marker (AFP rise in 50-70% NSGCT, hCG rise in 40-60% NSGCT & 30% seminoma) IMAGING IX Ultrasound – nature of the swelling, testis involvement in hydrocele; dilated veins in varicocoele , epididymal cyst, thickened epididymis in epididymoorchitis Abdominal X-ray (small bowel obstruction in femoral hernia) Chest X-ray (classical cannon ball metastases) CT chest, abdomen & pelvis (to detect metastases & respond to treatment)

28. Hydrocoele - anechoic Well defined anechoic lesion with posterior enhancement Hypoechoic in testicular tumor Varicocoele

29. STAGING FOR TESTICULAR TUMOR Stage I – tumour is confined to the testis and epididymis Stage II – nodal disease is present but is confined to nodes below the diaphragm Stage III – nodes are present above the diaphragm Stage IV – non lymphatic metastatic disease (most typically within the lungs)

30. TREATMENT 39

31. HERNIA INGUINAL HERNIA Herniotomy Open suture repair Open flat mesh repair Open plug / device / complex mesh repair Open preperitoneal repair Laparoscopic inguinal hernia repair Emergency inguinal hernia surgery FEMORAL HERNIA Low approach (Lockwood) The inguinal approach ( Lotheissen ) High approach ( McEVEDY ) Laparoscopic approach

32. HYDROCOELE Congenital – herniotomy 3 main surgical technique : Lord’s Plication (a series of uninterrupted absorbable sutures is used to plicate the redundant tunica vaginalis , the tunica bunches at its attachement to the testis) Eversion (the sac is opened and everted behind the testis, with placement of the testis in a pouch prepared by dissection in the fascial planes of the scrotum)( Jaboulay’s procedure) Excision (unless great care is taken to stop the bleeding after excision of the wall, haemorrhage fro the cut edge is liable to cause a large scrotal haematoma. This approach is not recommended)

33. TREATMENT EPIDIDYMAL CYST Excision (single large cyst; interfere with the transportation of sperm from the testis on that side and young men should be counselled regarding this) Partial or total epididymectomy (recurrent or multilocular cyst) VARICOCOELE Not indicated in asymptomatic varicocoele When discomfort is significant Percutaneous embolisation of the gonadal veins Surgical ligation of the testicular vein Recurrence up to 20%

34. PSOAS ABSCESS Percutaneous CT-guided drainage Antibiotic therapy Primary : antistaphylococcal Secondary : broad spectrum antibiotic

35. EPIDIDYMOORCHITIS All patients should drink plenty of fluid Scrotal support and analgesia Antibiotic (at least 2 weeks in acute, 4-6 weeks in chronic) Oral Doxycycline 100-200 mg OD Drainage (if suppuration occurs) Epididymectomy or orchidectomy (may be considered if no resolution)

36. TESTICULAR TUMOR Scrotal exploration and orchidectomy for suspected testicular tumor By staging & histological diagnosis (after orchidectomy ) Stage I tumor Seminoma : adjuvant radiotherapy for para aortic nodes, platinum-based chemotherapy NSGCT : BEP chemotherapy ( bleomycin , etoposide , cis -platinum) Stage II-IV tumors BEP chemotherapy for both seminoma NSGCT Dissection of retroperitoneal lymph node

37. Complication Of Inguinoscrotal Swelling

38. Complication due to non-infectious cause Hernia Strangulated – blood supply is impaired Obstructed – irreducibility associated with intestinal obstruction Hydrocele Rupture Infertility Calcification Hematocele (usually after aspiration) Epididy mal cyst Rarely cause co mplication, but a twisting of the cyst on its stalk (a torsion) can occur Varicocele Infertility

39. Complication due to infectious cause Psoas abscess Sepsis Lymphadenitis Abscess formation Cellulitis  Fistulas (seen in lymphadenitis that is due to tuberculosis) Sepsis Epididymo-orchitis Scrotal abscess and pyocele Testicular infarction: Cord swelling can limit testicular artery blood flow Fertility problems Testicular atrophy Cutaneous fistulization from rupture of an abscess through the tunica vaginalis (seen especially in tuberculosis) Recurrence, chronic epididymitis, and orchialgia

40. Complication due to malignant cause Testicular tu mor Spreading to other organs : Local spread: tunica vaginalis and along sper matic cord Lymphatic spread: para -aortic nodes, mediastinal and supraclavicular nodes Blood-borne spread: lungs and liver Prognosis: Se minoma Stage I, II, III  95% 5-year survival after orchidecto my , chemo and radiotherapy Stage IV  75% 5-year survival Teratoma Stage I, II  85% 5-year survival Stage III, IV  60% 5-year survival

41. Case scenario

42. A 22 year old man presents with right scrotal mass for 2 months duration. He noticed that enlarged scrotum because of being able to feel the heaviness. What are the positive points in this case? Right scrotal swelling 2 months duration Feeling heaviness What are the possible differential diagnosis? Right testicular tumor Hydrocele Hematocele Epididymo-orchitis Epididymal cyst Sarcoidosis What further question to ask? Onset of scrotal swelling: Sudden onset occur in trauma and inflammatory cases meanwhile gradual onset occur in tumor Associated symptoms: Pain: indicates inflammatory conditions like epididymitis Fever: for UTI and paraneoplastic syndrome Dysuria: can occur in patient with epididymo-orchitis Heaviness: usually seen in patient with hydrocele or tumor History of trauma to scrotum: hematoma and hematocele

43. On further questioning, he denied any pain, no history of trauma to the scrotum, no urinary symptoms such as frequency and hematuria, no other palpable swelling on any part of the body. However, he had history of undescended testis (cryptorchidism) when he was a baby. What is the likely diagnosis and give reason? The likely diagnosis is right testicular tumor. This is because patient with history of cryptorchidism has 10 times risk of developing testicular tumor.

44. Give proper explanation on how to do local examination of the scrotum of this patient? Before starting the examination: Approach the patient professionally. Explanation is necessary as the patient needs to be undressed for proper exposure. Give reassurance that the procedure won’t cause discomfort and get verbal consent for examination. Scrotal examination can be done in both standing and supine position. Examination should be started from normal side first. Inspection: Examine all sides of the scrotum during inspection Note the enlarged scrotum of affected site Scrotal skin may appear normal in tumor cases Palpation Lift the scrotum and properly inspect the posterior side. Gentleness is required throughout examination and avoid excessive pressure that could cause deep aching sensation. Rolling the scrotal skin softly between fingers of one or both hands. Individually examine each testicle between the fingers of the one hand for nodules, masses or tenderness. Gently palpate the epididymis, spermatic cord and vas deferens between the thumb and index finger close to the base of penis. This is termed as “can get above swelling”. The tumor is usually inseparable from the testis. Hard, irregular, nodular lesion with absence of testicular sensation. Take note that any swelling within the scrotum should be transilluminated for further evaluation. Testicular tumor usually has negative transillumination test.

45. List the appropriate investigations along with the expected findings? Scrotal ultrasound majority of the lesions appear as an interstitial hypoechoic lesion with heterogenous density and irregular in shape CT thorax, abdomen, pelvis To look for distant metastases CT brain Required in advanced stage lesion Chest X-ray Cannon ball metastases can be seen as pulmonary deposits Tumor markers Not sensitive enough to confirm the diagnosis but can be used to monitor for treatment response in follow up period. Examples include: βHCG: 30% of pure seminomas βHCG and αFP: 90% of non-seminomas

46. How to treat this patient? Surgery High inguinal orchidectomy If patient has enlarged retroperitoneal nodes, proceed with retroperitoneal lymph node dissection Post orchidectomy chemotherapy and radiotherapy (depending on histological type) Psychology Discussion regarding testicular prosthesis Counselling and screening for male siblings in family

47. 56 Manipal Manual Of Surgery, 2th edition, K. Rajagopal Shenoy Doctrina Perpetua, Guides on Clinical Surgery 2 nd edition, 2018 Excellence In Clinical Case Presentation In Surgery And Paediatrics 1st Edition 2012 REFERENCES

48. THANK YOU! 57