scrotal swelling common causes of scrotal

Common causes of scrotal swellings

1. SCROTAL SWELLING

2. CONTENTS ANATOMY CAUSES TORSION OF TESTIS EPIDIDYMO-ORCHITIS HYDROCELE EPIDIDYMAL CYST VARICOCELE

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4. Blood supply

5. Innervation

6. Lymphatic drainage Lymph from the skin, fasciae and tunica vaginalis of scrotum drains into the Superficial inguinal lymph nodes .

7. Coverings of the testis

8. Structure of the testis

9. causes Acute Painful Torsion testis Torsion of testicular appendages Acute epididymo-orchitis

10. causes Chronic Painless Hydrocele Epididymal cyst Spermatocele Varicocele Chronic epididymo-orchitis Testicular tumor

11. Torsion testis Testicle twist in a way that its blood supply becomes compromised Twisting of testis along with spermatic cord StrangulationNecrosis Uncommon (normal testis is anchored and cannot rotate) Predisposing factors Inversion of the testis; the testis is rotated so that it lies transversely or upside down High investment of the tunica vaginalis causes the testis to hang within the tunica like a clapper in the bell Separation of the epididymis from the body of the testis permits torsion of the testis on the pedicle that connects the testis with the epididymis

12. types

13. Clinical features Most common between 10-25 years of age Sudden severe pain in hemiscrotum or both sides Nausea & vomiting Scrotal skin edematous and erythematous Testis exquisitively tender Cremastric reflex absent in affected side

14. Differential diagnosis

15. Investigations Doppler USG ; Used to evaluate blood flow and detect vascular conditions like thrombosis and aneurysm Treatment Ipsilateral side  through a scrotal incision, Exploration, detorsion and fixation orchiopexy Contralateral side Exploration and fixation orchiopexy

16. Torsion of Testicular Appendages Hydatid of testis & epididymis Remnant of obliterated Mullerian ducts Sudden Swelling and redness of hemiscrotum Tender Testis ‘Bluedot sign’ positive Cremastric reflex intact

17. Torsion of Testicular Appendages - Treatment Explore & Excise torsed appendages in early cases In delayed cases >48 hrs, conservative treatment with antibiotics & anti inflammatory drugs

18. Epididymo-Orchitis Inflammation of epididymis & testis due to infection or trauma Commonly associated with UTI or trauma Young  arises secondary to a sexually transmitted genital infection ( Chlamydia trachomatis, Neisseria gonorrhea) Older  secondary to urinary infection Clinical features Scrotal pain, swelling, and erythema Fever Thickened & tender epididymis

19. treatment Can be treated conservatively with antibiotics (Doxycycline/quinolones) and anti-inflammatory drugs Investigations Doppler USG ; Excessive blood flow to Epididymis Normal testicular parenchymal blood flow

20. HYDROCELE Hydrocele is an abnormal collection of serous fluid in a part of the processus vaginalis, usually the tunica vaginalis A hydrocele can be caused by four different ways; By excessive production of fluids within the sac e.g. in secondary hydrocele By defective absorption of fluids i.e. primary hydrocele By interference with lymphatic drainage of scrotal structures By connection with the peritoneal cavity via a patent processus vaginalis (congenital)

21. Clinical features Colour—Straw or amber coloured. Composition—Water, fibrinogen, inorganic salts, albumin and cholesterol crystals Hydrocele fluid normally won’t clot if it is drained into a container but will clot immediately even if it comes into contact with a drop of blood Swelling which is usually painless

22. Primary Hydrocele Defective absorption of fluid Examples; Vaginal & infantile hydroceles Moderate to big size swelling Cough impulse negative Attain moderate to big size Difficult to palpate testis Transillumination positive Consistency  tensely cystic Treatment: Jaboulay’s & Lord’s operations Complications Infection Pyocele Haematocele Atrophy of testis Infertility Hernia of hydrocele sac (rare) Rupture & calcifications

23. Secondary Hydrocele Excessive production of fluid Ex: Filariasis, tumor, trauma & epididymo-orchitis Attain small size Testis easily palpable Transillumination negative Consistency  Lax cystic Treatment: Treat underlying causes

24. Primary Hydrocele -examples 1. Congenital hydrocele 2. Funicular hydrocele 3. Infantile hydrocele 4. Encysted hydrocele of the cord 5. Vaginal hydrocele- commonest type 6. Bilocular hydrocele/-en-bisac 7. Hydrocele of the hernial sac

25. Treatment Congenital hydrocele- Inguinal herniotomy Adult vaginal hydrocele Small size; Lord’s plication / Jaboulay’s operation Large size; Incision and eversion of sac

26. Haematocele usually results from vessel damage during needle drainage of a hydrocele. Prompt refilling of the sac, pain, tender ness and reduced transillumination confirm the diagnosis. Acute haemorrhage into the tunica vaginalis sometimes results from testicular trauma with or without testicular rupture. If the haematocele is not drained, a clotted haematocele usually results Spermatocele This is a unilocular retention cyst derived from some portion of the sperm-conducting mechanism of the epididymis. Clinical features; A spermatocele typically lies in the epididymal head above and behind the upper pole of the testis. It is usually softer and laxer than other cystic lesions in the scrotum but, like them, it transilluminates . The fluid contains spermatozoa and resembles barley water in appearance. Spermatoceles are usually small and unobtrusive. Treatment; Small spermatoceles can be ignored. Larger ones should be aspirated or excised through a scrotal incision.

27. VARICOCELE Is the dilatation of the veins that drain the testis Testis and the epididymis drain into the pampiniform plexus which join the form the testicular veins; right testicular vein drain into the inferior vena cava and the left testicular vein drain into the left renal vein There is drainage into the cremasteric vein which drain into the inferior epigastric vein Most dilated veins are of cremasteric veins is the commonest in the left Obstruction of the left testicular is by either a renal tumor or after a nephrectomy

28. Clinical features Scrotum of the affected hangs lower than the normal Edema od the scrotum There is also a cough impulse In long standing cases the affected testis is smaller and softer Oligospermia is associated with varicocele because it interferes with normal temperature control of the scrotum which keeps the testis at some 2.5⁰C below rectal temperatures The swelling disappears on lying down position and reappears on standing and walking

29. Continuation……. O/E: A mass of dilated vein feeling like a bag of worms is palpable on the left side of the scrotum along the left spermatic cord extending from the upper pole of the testis up to the superficial inguinal ring

30. Investigations Venous Doppler of scrotum and groin Semen analysis Treatment Laparoscopic ligation of the testicular vein above the inguinal ligament where the pampiniform plexus forms the one or wo veins Embolization of the testicular vein under radiographic control Reoccurrence is common after all types of varicocele surgery because of the presence of many collaterals veins Ligation of testicular vein Suprainguinal (Palomo’s) Inguinal (Ivanissevich) Sub inguinal (Marc- Goldstein)* Scrotal

31. Varicocele - Coil Embolization Non-surgical procedure. Steel coil or silicone balloon catheter is introduced into a vein below the groin through a nick in the skin. Passed under X-ray guidance. Tiny metal coils or other embolizing agents introduced through the catheter. No stitches needed. Patient can go back in 24hrs. Lower rates of complications. Less effective, higher recurrence(5-11%), danger that the coil could migrate to the heart and cause death

32. Surgery- Complication Haemorrhage and scrotal haematoma Infection  P yocele Injury to testicular artery Injury to ilioinguinal nerve Recurrence—5-10%

33. D/D for Scrotal Swellings Scrotal Swellings Ex & Px Hx Sx Dx Tx 1. Hydrocele Primary-Idiopathic Secondary- under lying pathology Painless big swelling; not reducible No cough impulse Get above swelling+ Transilluminant + Clinical In doubt- USG of scrotum Lord’s operation Jaboulay’s operation 2. Epididymal cyst & Spermatocele Degeneration of epididymis, occlusion of pathway Swelling in scrotum resembles 3 rd testis Testis palpable separately; Chinese lantern appearance Clinical USG of scrotum Conservative Excision 3. Varicocele Idiopathic Absence of valves in testicular vein Worm like in upper scrotum; infertility Disappears on lying down; Bag of worms appearance Clinical USG color doppler Varicocelectomy Inguinal or Retroperitoneal 4. Testicular torsion & Epididymo - orchitis Abnormal fixation and lie of testis UTI & trauma Severe pain& swelling scrotum Nausea & vomiting Tender hemi scrotum; cremasteric reflex absent Clinical USG color doppler Explore,detorse , orchiopexy or orchidectomy Conservative 5. Testicular carcinoma UDT, Kieinfelter’s Germ cell- Seminoma & Non seminoma Non germ cell tumor Painless heavy swelling Not reducible Hard in consistency Testis felt separately Clinical; No FNAC USG OF scrotum High orcidectomy with or without RPLND+ RT+CT

34. INGUINAL HERNIA 75% of all hernias are inguinal. An inguinal hernia is a protrusion of abdominal cavity contents thru the inguinal canal. Anatomy Boundaries of the inguinal canal Anterior wall: External oblique aponeurosis and a few fibers of internal oblique muscle laterally. Superior : Transversus abdominis muscle. Inferior: Inguinal and lacunar ligament on the medial side. Posterior: Fascia transversalis & conjoined tendon medially.

35. Fruchaud’s myopectineal orifice; it’s a tunnel through which groin hernias occur Classification of inguinal hernias Indirect hernias; these comes out through internal ring along with the cord. Direct hernias; occur through the posterior wall of the inguinal canal through the Hasselbach’s triangle, here the sac is medial to the inferior epigastric artery.

36. Hassel Bach's triangle It’s bounded Medially by lateral border of Rectus Abdominis Muscle. Laterally by inferior Epigastric artery Inferiorly by Inguinal Ligament Indirect inguinal hernia : It comes out through internal ring along with the cord. It is lateral to the inferior epigastric artery Most common type of hernia: 65% Most common in younger age group Its bilateral in 30% of cases Sac is thin & neck is narrow

37. Direct inguinal hernia It occurs through posterior wall of inguinal canal through “Hasselbach’s triangle ” 50% of direct hernias occur bilaterally 35% Inguinal hernias are direct Uncommon in females & children It’s always acquired due to weakening of posterior wall of inguinal canal. Sac is thick with wide neck Occurs through Hasselbach’s triangle

38. Inguinal canal boundaries

39. Anatomy

40. Investigations Abdominal/ pelvic ultrasound scan; To rule out BPH, ascites Plain AXR; To rule out bowel obstruction or perforation and foreign bodies or calcification CXR; To rule out chronic bronchitis Treatment Herniotomy: Excision of the sac alone is done in children. Hernia occurs due to preformed sac. Hence no repair is necessary. Herniorrhaphy; It involves a surgeon making a long incision directly over the hernia then using surgical instruments access the sac. Tissues or a displaced organ are the returned to their original location and the hernia sac is removed.

41. Hernioplasty : It is the type of hernia repair surgery where a mesh patch is sewn over the weakened region of tissue. This is a tension free repair therefore recurrence rates are low Differentials of an Inguinal hernia Hydrocele Undescended testis Femoral hernia Lipoma of the cord Hydrocele of the canal of Nuck Inguinal lymphnode enlargement Groin abscess

42. Treatment Lockwood low operation infrainguinal approach Mc’Evedy -High Operation Lotheissen’s trans inguinal operation in which the inguinal ligament is appoximated to cooper’s ligament

43. COMPLICATIONS Strangulation of hernia ( blood supply is cut off) Obstruction of hernia such as if contents are bowel Heamorrhage / heamatoma formation Post operative pain syndrome Hernia recurrence Foreign body reaction Post operative Infection of the wound (SSI) Ischeamia Necrosis

44. TUMOURS OF THE TESTES The lymphatic drainage of the testes is to the para-aortic lymph nodes near the origin of the gonadal vessel. Lymphatics from the medial side of the testis may run with the artery to the vas and drain into a node at the bifurcation of the common iliac artery. The contralateral para-aortic lymph nodes are sometimes involved by tumor spread, but the inguinal lymph nodes are affected only if the scrotal skin is involved. Most testicular neoplasms are malignant; testicular neoplasm is one of the most common forms of cancer in young men. Maldescent undoubtedly predisposes to malignancy. Even when the testis is located in the scrotum, tumors often escape detection until they have metastasized. Campaigns for regular testicular self-examination help raise awareness of the condition and may lead to earlier diagnosis

45. Tumors of the testis are classified according to their predominant cellular type: • seminoma (40%); • teratoma (32 %); combined seminoma and teratoma (14 %); • interstitial tumors (1.5 %); • lymphoma (7 %); • other tumors (5.5 % Teratomas tend to occur in younger men, with the peak incidence being between 20 and 35 years, whereas the peak incidence of seminoma is between 35 and 45 years. Seminoma is rare before puberty.

46. Seminoma A seminoma compresses neighboring testicular tissue . The enlarged testis is smooth and firm. The cut surface is homogeneous and pinkish cream in color. Occasionally, fibrous septa form lobules. In rapidly growing tumors there may be areas of necrosis. A seminoma consists of oval cells with clear cytoplasm and large, rounded nuclei with prominent acidophilic nucleoli. Sheets of cells resembling spermatocytes are separated by a fine fibrous stroma. Active lymphocytic infiltration of the tumor suggests a good host response and a better prognosis. Seminomas metastasize via the lymphatics and haematogenous spread is uncommon

47. Teratoma A teratoma arises from totipotent cells in the rete testis and often contains a variety of cell types, of which one or more predominate . The tumor may be tiny but can reach the size of a coconut . Even a large tumor is molded by the tunica albuginea so that the overall outline of the testis is maintained although the surface may be distorted. The usual type of teratoma is yellowish in color with cystic spaces containing gelatinous fluid . Nodules of cartilage are often present.

48. Histology Teratoma differentiated (TD) (uncommon): has no histologically recognisable malignant components but it can metastasise. The best known is a dermoid cyst, which may contain cartilage and muscle as well as glandular elements . • Malignant teratoma intermediate, teratocarcinoma (MTI; types A and B) (most common): contains definitely malignant and incompletely differentiated components. There is mature tissue in type A but not in type B . • Malignant teratoma anaplastic (MTA), embryonal carcinoma: contains anaplastic cells of embryonal origin. Cells presumed to be from the yolk sac are often responsible for elevated alpha-fetoprotein levels. MTA is not always radiosensitive. • Malignant teratoma trophoblastic (MTT) (uncommon): contains within other cell types a syncytial cell mass with malignant villous or papillary cytotrophoblasts (choriocarcinoma). It often produces human chorionic gonadotrophin (HCG). Spread by the bloodstream and lymphatics is early. It is one of the most malignant tumours known.

49. Interstitial cell tumours Interstitial cell tumours arise from Leydig or Sertoli cells. A Leydig cell tumour masculinises; a Sertoli cell tumour feminises. Prepubertal interstitial cell tumours excrete androgens, which cause sexual precocity and extreme muscular development . Regression of the symptoms after orchidectomy may be incomplete because of hypertrophy of the contralateral testis. Postpubertal interstitial cell tumours usually arise from Sertoli cells with output of feminising hormones leading to gynecomastia, loss of libido and aspermia . As a rule, the tumour is benign and orchidectomy cures.

50. Staging of testicular tumours The stages are: • stage 1: testis lesion only – no spread; • stage 2: nodes below the diaphragm only; • stage 3: nodes above the diaphragm ; • stage 4: pulmonary or hepatic metastases.

51. Management by staging and histological diagnosis (after orchidectomy) Seminomas are radiosensitive and excellent results have been obtained by irradiating stage 1 and stage 2 tumours. More recently, the tumour has been shown to be highly sensitive to cisplatin, which is already being used for patients with metastatic disease. Experts are divided as to whether patients with stage 1 disease should be treated with adjuvant chemotherapy. Teratomas are less sensitive to radiation. Stage 1 tumours can be managed by monitoring the levels of serum markers and by repeated CT. Teratomas at stages 2–4 are managed by chemo therapy. Cisplatin, methotrexate, bleomycin and vincristine have been used in combination with great success. There are also those who advocate adjuvant chemotherapy for stage 1 teratomas, arguing that effective prophylaxis is less troublesome to the patient than prolonged surveillance . Retroperitoneal lymph node dissection is sometimes needed when retroperitoneal masses remain after chemo therapy (Fig. 75.18). The tissue removed may contain only necrotic tissue, but some patients have foci of mature teratoma or active malignancy. The operation can be formidable if the tumour is large, and retrograde ejaculation is likely unless steps are taken to preserve the sympathetic outflow to the bladder neck

52. Prognosis Prognosis of testicular tumours depends on the histological type and the stage of the growth . Seminoma; If there are no metastases, 95% of patients will be alive 5 years after orchidectomy and radiotherapy or chemotherapy. If there are metastases, the survival rate drops to 75 %. Teratoma; A 5-year survival rate of more than 85% is achievable in patients with stage 1 or 2 teratoma. Among patients with stage 3 and 4 disease, the 5-year survival rate is about 60% and getting better with improvements in chemotherapy

53. TUMOURS OF THE EPIDIDYMIS; These may be benign mesothelioma or malignant sarcoma or secondary carcinoma. They are extremely rare but should not be for gotten when the patient presents with a non-cystic lump in the epididymis Carcinoma of the scrotum Known in the nineteenth century as an occupational hazard for chimney sweeps (described by Pott) and mule spinners, the majority of modern cases of squamous carcinoma of the scrotum arise with no obvious aetiological factor. Unlike carcinoma of the penis, carcinoma of the scrotum is almost unknown in India and Asiatic countries. Clinical features The growth starts as a wart or ulcer and as it grows it may involve the testis. Treatment The growth is excised with a margin of healthy skin. If associated enlargement of the inguinal nodes does not subside with antibiotics , a bilateral block dissection should be carried out up to the external nodes

54. Treatment of testicular tumors Staging is an essential step in planning treatment : • Blood is collected to enable the levels of tumor markers (HCG, alpha-fetoprotein and lactate dehydrogenase) to be measured. Tumor marker levels can be used to monitor the response to treatment. • A chest radiograph shows whether there are pulmonary deposits. • Orchidectomy is essential to remove the primary tumor and to obtain histology. • Computerized tomography (CT) and magnetic resonance imaging (MRI) are the most useful means of detecting secondaries and for monitoring the response to therapy

55. References; Blandy , J.P. and Kaisary , A.V. (2007) Lecture Notes: Urology, 6th edn . Blackwell, Oxford Weiss, G., Weiss, R.M. and O’Reilly, P.H. ( eds ) (2001) Comprehensive Urology. Elsevier Science, Amsterdam Bailey and Love’s short practice of surgery(pdf)…testis and scrotum