Scrotal swellings
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130 slides
Jan 05, 2019
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About This Presentation
In this playlist you can watch everything about Scrotal swellings. I have discussed introduction, hydrocele, torsion testis, epididymal cyst, varicocele and testicular tumors. If you watch all these videos together you will become cofident in dealing with the problem of Scrotal Swellings.
Slide Content
Surgical Teaching Video Cast
Introduction
PROBLEM ORIENTED CASE BASED LEARNING
Dr.B.SelvarajMS;Mch;FICS
Professor of Surgery
Melaka ManipalMedical college
Melaka Malaysia 75150
Introduction
PROBLEM ORIENTED CASE BASED LEARNING
Dr.B.SelvarajMS;Mch;FICS
Professor of Surgery
Melaka ManipalMedical college
Melaka Malaysia 75150
Must to know core clinical problems
1
.Acute RLQ pain
2.
Acute RUQ pain
3.
Acute epigastric pain
4.
Acute LLQ pain
5.
Dysphagia
6.
Abdominal lumps
7.
Upper GI haemorrhage
8.
Lower GI haemorrhage
9.
Obstructive Jaundice
10.
Breast lumps, mastalgia
& nipple discharge
11.
Neck swellings-Thyroid & non thyroidal
12.
Groin swellings
13.
Scrotal swellings
14.
Limb ischemia-Acute & Chronic
15.
Varicose veins
16.
Renal & ureteric colic
17.
Hematuria
18.
Acute retention of urine
1
.Acute RLQ pain
2.
Acute RUQ pain
3.
Acute epigastric pain
4.
Acute LLQ pain
5.
Dysphagia
6.
Abdominal lumps
7.
Upper GI haemorrhage
8.
Lower GI haemorrhage
9.
Obstructive Jaundice
10.
Breast lumps, mastalgia
& nipple discharge
11.
Neck swellings-Thyroid & non thyroidal
12.
Groin swellings
13.
Scrotal swellings
14.
Limb ischemia-Acute & Chronic
15.
Varicose veins
16.
Renal & ureteric colic
17.
Hematuria
18.
Acute retention of urine
Scheme for Problem oriented
Case based Teaching
Scrotal Swellings
Testicular
Carcinoma
Varicocele
Hydrocele
Testicular
Torsion
Epididymal
Cyst
Case based Teaching
Scrotal Swellings
Testicular
Carcinoma
Varicocele
Hydrocele
Testicular
Torsion
Epididymal
Cyst
Scrotal Swellings-
Introduction
•
Various causes( Differential diagnosis) of scrotal swellings
•
Applied Anatomy & Physiology
•
Algorithm
to clinch the correct diagnosis
•
Unique teaching video cast consisting
powerful teaching tools
Classical
clinical vignette
with probable diagnosis
The diagnosis in detail-only one pathology in each episode
Mind map
of the diagnosis
Tabular column
of differential diagnosis depicting their
characteristic features to differentiate them from your
diagnosis
Introduction
•
Various causes( Differential diagnosis) of scrotal swellings
•
Applied Anatomy & Physiology
•
Algorithm
to clinch the correct diagnosis
•
Unique teaching video cast consisting
powerful teaching tools
Classical
clinical vignette
with probable diagnosis
The diagnosis in detail-only one pathology in each episode
Mind map
of the diagnosis
Tabular column
of differential diagnosis depicting their
characteristic features to differentiate them from your
diagnosis
Causes of Scrotal Swellings
ACUTE PAINFUL
•Torsion testis
•
Acute epididymo-orchitis
•
Torsion of testicular
appendages
CHRONIC PAINLESS
•
Hydrocele
•
Epididymalcyst
•
Spermatocele
•
Chronic epididymo-
orchitis
•
Testicular tumor
•
Varicocele
ACUTE PAINFUL
•Torsion testis
•
Acute epididymo-orchitis
•
Torsion of testicular
appendages
CHRONIC PAINLESS
•
Hydrocele
•
Epididymalcyst
•
Spermatocele
•
Chronic epididymo-
orchitis
•
Testicular tumor
•
Varicocele
Causes of Scrotal Swellings
Scrotal contents
•
Purse like arrangement for lodgement of Testis on either sides
with a midline septum separating.
•Contents are:
Testis, Epididymis, Vas Deferens, Testicular artery,
Pampiniformplexus of veins, Artery to the Vas, Lymphatics,
Areolar tissue, & coverings.
•Coverings of Testis:
Skin, Dartos, External Spermatic fascia,
Cremastericfascia, Internal Spermatic fascia, Tunica Vaginalis
Testis –2 layers
•
Purse like arrangement for lodgement of Testis on either sides
with a midline septum separating.
•Contents are:
Testis, Epididymis, Vas Deferens, Testicular artery,
Pampiniformplexus of veins, Artery to the Vas, Lymphatics,
Areolar tissue, & coverings.
•Coverings of Testis:
Skin, Dartos, External Spermatic fascia,
Cremastericfascia, Internal Spermatic fascia, Tunica Vaginalis
Testis –2 layers
Scrotum-Anatomy
Testis -Anatomy
Scrotal Swellings-Algorithm
Thank You
To watch the video version go to
Channel
“ Surgical Educator” in You
Tube
https://www.youtube.com/watch?v=UAn0pL8qUvs
To watch the video version go to
Channel
“ Surgical Educator” in You
Tube
https://www.youtube.com/watch?v=UAn0pL8qUvs
SCROTALSWELLINGS
Case No:1
PROBLEM ORIENTED CASE BASED LEARNING
Dr.B.SelvarajMS;Mch;FICS
Professor of Surgery
Melaka ManipalMedical college
Melaka Malaysia 75150
Case No:1
PROBLEM ORIENTED CASE BASED LEARNING
Dr.B.SelvarajMS;Mch;FICS
Professor of Surgery
Melaka ManipalMedical college
Melaka Malaysia 75150
OVERVIEW
•
Various causes( Differential diagnosis) of scrotal swellings
•
Classical clinical vignette with probable diagnosis
•
The diagnosis in detail-only one pathology in each episode
•
Mindmapof the diagnosis
•
Tabular column of differential diagnosis depicting their
characteristic features to differentiate them from your
diagnosis
•
References and feedback
•
Various causes( Differential diagnosis) of scrotal swellings
•
Classical clinical vignette with probable diagnosis
•
The diagnosis in detail-only one pathology in each episode
•
Mindmapof the diagnosis
•
Tabular column of differential diagnosis depicting their
characteristic features to differentiate them from your
diagnosis
•
References and feedback
Causes of Scrotal Swellings
ACUTE PAINFUL
•Torsion testis
•
Acute epididymo-orchitis
•
Torsion of testicular
appendages
CHRONIC PAINLESS
•
Hydrocele
•
Epididymalcyst
•
Spermatocele
•
Chronic epididymo-
orchitis
•
Testicular tumor
•
Varicocele
ACUTE PAINFUL
•Torsion testis
•
Acute epididymo-orchitis
•
Torsion of testicular
appendages
CHRONIC PAINLESS
•
Hydrocele
•
Epididymalcyst
•
Spermatocele
•
Chronic epididymo-
orchitis
•
Testicular tumor
•
Varicocele
Classical Clinical Vignette
Vaginal Hydrocele
•
A 35-year-old male patient presents with right sided scrota l swelling of two years duration
. It is a
progressively increasing painless swelling
.
•
O/E: the right side of the scrotum shows a
swelling of 15 ×10 cm size
which is confined to the scrotum (
canget above the swelling
). The
surface of the swelling is smooth and borders are well-defined. There is
no local rise of temperature. The swelling is
fluctuant
and
transilluminant
. It is
not reducible
.Thereis
no cough impulse
. The
right
testis is not felt separately
. On
percussion it is dull
.
•
The
spermatic cord is felt above the swelling
and is tender.
•
The contralateral testis and genitalia are normal. There is no evidence
of any mass or lymph nodes in the abdomen
Vaginal Hydrocele
•
A 35-year-old male patient presents with right sided scrota l swelling of two years duration
. It is a
progressively increasing painless swelling
.
•
O/E: the right side of the scrotum shows a
swelling of 15 ×10 cm size
which is confined to the scrotum (
canget above the swelling
). The
surface of the swelling is smooth and borders are well-defined. There is
no local rise of temperature. The swelling is
fluctuant
and
transilluminant
. It is
not reducible
.Thereis
no cough impulse
. The
right
testis is not felt separately
. On
percussion it is dull
.
•
The
spermatic cord is felt above the swelling
and is tender.
•
The contralateral testis and genitalia are normal. There is no evidence
of any mass or lymph nodes in the abdomen
Hydrocele-Etiopathogenesis
•
A hydrocele is an abnormal collection of serous flu id in a part of
the processusvaginalis, usually the tunica vaginalis.
•
A hydrocele can be produced in four different ways
•1
. By excessive production of fluid within the sac in secondary
hydrocele •2
. By defective absorption of fluid in primary hydrocele
•3
. By interference with lymphatic drainage of scrota l structures
in filariasis •4
. By connection with the peritoneal cavity via a pa tent processus
vaginalisincongenitalhydrocele
•
A hydrocele is an abnormal collection of serous flu id in a part of
the processusvaginalis, usually the tunica vaginalis.
•
A hydrocele can be produced in four different ways
•1
. By excessive production of fluid within the sac in secondary
hydrocele •2
. By defective absorption of fluid in primary hydrocele
•3
. By interference with lymphatic drainage of scrota l structures
in filariasis •4
. By connection with the peritoneal cavity via a pa tent processus
vaginalisincongenitalhydrocele
Primary Vs Secondary Hydrocele
Primary Hydrocele
•
Defective absorption of fluid
•
Ex: Vaginal & infantile
hydroceles
•
Attain moderate to big size
•
Difficult to palpate testis
•
Transilluminationpositive
•
Consistencytensely cystic
•
Tx: Jaboulay’s& Lord’s
operations
Secondary Hydrocele
•
Excessive production of fluid
•
Ex: Filariasis, tumor, trauma &
epididymo-orchitis
•
Attain small size
•
Testis easily palpable
•
Transilluminationnegative
•
ConsistencyLax cystic
•
Tx: Treat underlying causes
Primary Hydrocele
•
Defective absorption of fluid
•
Ex: Vaginal & infantile
hydroceles
•
Attain moderate to big size
•
Difficult to palpate testis
•
Transilluminationpositive
•
Consistencytensely cystic
•
Tx: Jaboulay’s& Lord’s
operations
Secondary Hydrocele
•
Excessive production of fluid
•
Ex: Filariasis, tumor, trauma &
epididymo-orchitis
•
Attain small size
•
Testis easily palpable
•
Transilluminationnegative
•
ConsistencyLax cystic
•
Tx: Treat underlying causes
Composition of Hydrocele Fluid
•
Color—Straw or amber colored.
•
Composition—Water, fibrinogen, inorganic salts, albumin
and cholesterol crystals
•
Hydrocele fluid normally won’t clot if it is draine d into a
container but will clot immediately even if it come s into
contact with a drop of blood
•
Following swellings contain cholesterol crystals vi z.
hydrocele, branchial cyst, and dental and dentigerouscyst
•
Color—Straw or amber colored.
•
Composition—Water, fibrinogen, inorganic salts, albumin
and cholesterol crystals
•
Hydrocele fluid normally won’t clot if it is draine d into a
container but will clot immediately even if it come s into
contact with a drop of blood
•
Following swellings contain cholesterol crystals vi z.
hydrocele, branchial cyst, and dental and dentigerouscyst
Primary Hydrocele-Types
•
1.Congenital hydrocele
•
2. Funicular hydrocele
•
3. Infantile hydrocele
•
4. Encysted hydrocele of the
cord
•
5. Vaginal hydrocele-
commonest type
•
6. Bilocularhydrocele
•
7. Hydrocele of the hernialsac
•
1.Congenital hydrocele
•
2. Funicular hydrocele
•
3. Infantile hydrocele
•
4. Encysted hydrocele of the
cord
•
5. Vaginal hydrocele-
commonest type
•
6. Bilocularhydrocele
•
7. Hydrocele of the hernialsac
Primary Hydrocele-Clinical features
•
Moderate to big size swelling
•
Cough impulse negative
•
Get above the swelling positive
•
Not reducible
•
Consistencytensely cystic
•
Transilluminationpositive
•
Testis not felt separately
•
Congenital hydroceleDiurnal
variation +
•
BilocularhydroceleCross
fluctuation +
•
Encysted hydroceleTraction test+
•
Get above the swelling negative in
Infantile and Bilocularhydroceles
•
Transilluminationnegative in
Hematocele, Pyocele, Chyloceleand
thick sac
•
Moderate to big size swelling
•
Cough impulse negative
•
Get above the swelling positive
•
Not reducible
•
Consistencytensely cystic
•
Transilluminationpositive
•
Testis not felt separately
•
Congenital hydroceleDiurnal
variation +
•
BilocularhydroceleCross
fluctuation +
•
Encysted hydroceleTraction test+
•
Get above the swelling negative in
Infantile and Bilocularhydroceles
•
Transilluminationnegative in
Hematocele, Pyocele, Chyloceleand
thick sac
Hydrocele of Canal of Nuck
•
Hydrocele of the canal of Nuck
is a condition in females.
•
The cyst lies in relation to the
round ligament and is always
at least partially within the
inguinal canal
.
•
Hydrocele of the canal of Nuck
is a condition in females.
•
The cyst lies in relation to the
round ligament and is always
at least partially within the
inguinal canal
.
Primary Hydrocele-Clinical Pictures
Primary Hydrocele-Complications
•
Infection
•
Pyocele
•
Hematocele
•
Atrophy of testis
•
Infertility
•
Hernia of hydrocele sac (rare)
•
Rupture & calcifications
•
Infection
•
Pyocele
•
Hematocele
•
Atrophy of testis
•
Infertility
•
Hernia of hydrocele sac (rare)
•
Rupture & calcifications
Primary Hydrocele-Treatment
•
Congenital hydrocele-
Inguinal herniotomy
•
Adult vaginal hydrocele
Small size
Lord’splication
Large size
Jaboulay’soperation
Incision and eversion of sac
After evacuation, the sac with the testis is placed in a newly
created pocket between the fascial layers of the sc rotum
Sharma and Jhawer’stechnique
.
•
Encysted hydroceleInguinalherniotomy+ incision and
drainage of the encysted hydrocele
•
Congenital hydrocele-
Inguinal herniotomy
•
Adult vaginal hydrocele
Small size
Lord’splication
Large size
Jaboulay’soperation
Incision and eversion of sac
After evacuation, the sac with the testis is placed in a newly
created pocket between the fascial layers of the sc rotum
Sharma and Jhawer’stechnique
.
•
Encysted hydroceleInguinalherniotomy+ incision and
drainage of the encysted hydrocele
Primary Hydrocele-Treatment
Complications of surgery
•
Reactionary haemorrhageHematocele
•
Infection
•
Pyocele
•
Sinus formation
•
Recurrent hydrocele
•
Reactionary haemorrhageHematocele
•
Infection
•
Pyocele
•
Sinus formation
•
Recurrent hydrocele
Hydrocele-Mindmap
Scrotal Swellings-Algorithm
Scrotal Swellings Ex & Px Hx Sx Dx Tx 1. HydrocelePrimary-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
Degenaration 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. VaricoceleIdiopathic
Absence of valves in
testicular veins
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
D/D for Scrotal Swellings (Compare & Contrast)
(Vertical Reading)
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
Degenaration 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. VaricoceleIdiopathic
Absence of valves in
testicular veins
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
D/D for Scrotal Swellings (Compare & Contrast)
(Vertical Reading)
References
•
Hunt& Marshall’s clinical problems
in surgery 2
nd
edition
•
Clinical surgery made easy-a
companion to PBL by Mohan De
silva1
st
edition
•
100 cases in surgery 2
nd
edition
•
Case files surgery 4
th
edition
•
Clinical scenarios in surgery-
decision making 1
st
edition
•
Surgery-a case based clinical
review 1
st
edition
•
Surgery Review by Carlos Pestana
•
Clinical surgery pearls by DrDayananda Babu2
nd
edition
•
NMS casebook surgery 2
nd
edition
•
General Surgery-Correlations &
clinical scenarios 1
st
edition
•
Surgery review by Makary3
rd
edition
•
Surgery-Clinical cases uncovered by
Harold Ellis 1
st
edition
•
Self-Life Surgery 1
st
edition
•
Hunt& Marshall’s clinical problems
in surgery 2
nd
edition
•
Clinical surgery made easy-a
companion to PBL by Mohan De
silva1
st
edition
•
100 cases in surgery 2
nd
edition
•
Case files surgery 4
th
edition
•
Clinical scenarios in surgery-
decision making 1
st
edition
•
Surgery-a case based clinical
review 1
st
edition
•
Surgery Review by Carlos Pestana
•
Clinical surgery pearls by DrDayananda Babu2
nd
edition
•
NMS casebook surgery 2
nd
edition
•
General Surgery-Correlations &
clinical scenarios 1
st
edition
•
Surgery review by Makary3
rd
edition
•
Surgery-Clinical cases uncovered by
Harold Ellis 1
st
edition
•
Self-Life Surgery 1
st
edition
Feedback & Suggestions
Thank You
Subscribeto get notified
regarding my new uploads
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Subscribeto get notified
regarding my new uploads
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SCROTALSWELLINGS
Case No:2
PROBLEM ORIENTED CASE BASED LEARNING
Dr.B.SelvarajMS;Mch;FICS
Professor of Surgery
Melaka ManipalMedical college
Melaka Malaysia 75150
Case No:2
PROBLEM ORIENTED CASE BASED LEARNING
Dr.B.SelvarajMS;Mch;FICS
Professor of Surgery
Melaka ManipalMedical college
Melaka Malaysia 75150
OVERVIEW
•
Various causes
(Differential diagnosis)
of scrotal swellings
•
Classical clinical vignette
with probable diagnosis
•
The diagnosis in detail-only one pathology in each episode
•
Mind map
of the diagnosis
•
Tabular column
of differential diagnosis depicting their
characteristic features to differentiate them from your
diagnosis
•
References
and feedback
•
Various causes
(Differential diagnosis)
of scrotal swellings
•
Classical clinical vignette
with probable diagnosis
•
The diagnosis in detail-only one pathology in each episode
•
Mind map
of the diagnosis
•
Tabular column
of differential diagnosis depicting their
characteristic features to differentiate them from your
diagnosis
•
References
and feedback
Causes of Scrotal Swellings
ACUTE PAINFUL
•Torsion testis
•
Acute epididymo-orchitis
•
Torsion of testicular
appendages
CHRONIC PAINLESS
•
Hydrocele
•
Epididymalcyst
•
Spermatocele
•
Chronic epididymo-
orchitis
•
Testicular tumor
•
Varicocele
ACUTE PAINFUL
•Torsion testis
•
Acute epididymo-orchitis
•
Torsion of testicular
appendages
CHRONIC PAINLESS
•
Hydrocele
•
Epididymalcyst
•
Spermatocele
•
Chronic epididymo-
orchitis
•
Testicular tumor
•
Varicocele
Classical Clinical vignette
Torsion Testis
•
A 14-year-old boy presents with acute onset of
right scrotal and
RLQ pain
for the past
4 hours
. He additionally reports
nausea and
one episode of
vomiting.
He denies any similar past pain and
reports
no history of trauma
.
•
O/E: the
skin overlying
the
right
side of the
scrotum
appears to be
slightly
erythematous and edematous
. The
right testicle
appears to
be
lying
significantly
higher in the scrotum
as compared to the left
testicle.
•
The entire
right testicle is exquisitely tender to palpation
, whereas
the left one is nontender
•
He has an
absent cremastericreflex on the right.
Torsion Testis
•
A 14-year-old boy presents with acute onset of
right scrotal and
RLQ pain
for the past
4 hours
. He additionally reports
nausea and
one episode of
vomiting.
He denies any similar past pain and
reports
no history of trauma
.
•
O/E: the
skin overlying
the
right
side of the
scrotum
appears to be
slightly
erythematous and edematous
. The
right testicle
appears to
be
lying
significantly
higher in the scrotum
as compared to the left
testicle.
•
The entire
right testicle is exquisitely tender to palpation
, whereas
the left one is nontender
•
He has an
absent cremastericreflex on the right.
Torsion Testis-Etiopathogenesis
•
Twisting of testis along with spermatic cordStrangulationNecrosis
•
Common in neonates and in puberty
•
Inversion of testis
•
Strong muscular exertion or blunt trauma can trigger it
•
Undescended testis undergo torsion frequently
•
High insertion of tunica vaginalis-bell clapper def ormity-predisposes
•
There are 3 types of torsion-Extravaginal, intravaginal and mesorchial
•
Extravaginalin neonates, intravaginal in adolescents
•
Twisting of testis along with spermatic cordStrangulationNecrosis
•
Common in neonates and in puberty
•
Inversion of testis
•
Strong muscular exertion or blunt trauma can trigger it
•
Undescended testis undergo torsion frequently
•
High insertion of tunica vaginalis-bell clapper def ormity-predisposes
•
There are 3 types of torsion-Extravaginal, intravaginal and mesorchial
•
Extravaginalin neonates, intravaginal in adolescents
Torsion Testis-Types
In Neonates In Adolescents
Bell clapper
deformity
In Neonates In Adolescents
Bell clapper
deformity
Torsion Testis-Clinical Features
•
Sudden severe pain in hemiscrotumor both sides
•
Nausea & vomiting
•
Scrotal skin edematous and erythematous
•
Testis exquisitivelytender
•
Affected testis at higher level because of twisting
Deming’s sign
•
Normal testis lying horizontally
Angel’s sign
•
Pain not relieved on elevation of scrotum
Prehn’ssign
•
Cremastricreflex absent in affected side
•
Sudden severe pain in hemiscrotumor both sides
•
Nausea & vomiting
•
Scrotal skin edematous and erythematous
•
Testis exquisitivelytender
•
Affected testis at higher level because of twisting
Deming’s sign
•
Normal testis lying horizontally
Angel’s sign
•
Pain not relieved on elevation of scrotum
Prehn’ssign
•
Cremastricreflex absent in affected side
Torsion Testis-Clinical Features
Torsion Testis-Clinical Features
Torsion Testis-Clinical Features
Torsion Testis-Differential Diagnosis
Torsion Testis-Doppler USG
Torsion Testis-Doppler USG
Central testicular blood flowNormal
Testis
No Central testicular blood flow but
excessive peripheral blood flow
Central testicular blood flowNormal
Testis
No Central testicular blood flow but
excessive peripheral blood flow
•
Ipsilateral side
Exploration, detorsionand fixation orchiopexy
Detorsionis away from median raphaeof scrotum like opening a
book
•
Contralateral side
Exploration and fixation orchiopexy
•
In doubtful cases
and nonavailabilityof Doppler USGBetter to
explore rather than unduly delay the treatment
•
Testicular salvage rate is 100% if surgery is done within 6 hrs
and it is 20% if surgery is delayed > 24 hrs
Torsion Testis-Treatment
Ipsilateral side
Exploration, detorsionand fixation orchiopexy
Detorsionis away from median raphaeof scrotum like opening a
book
•
Contralateral side
Exploration and fixation orchiopexy
•
In doubtful cases
and nonavailabilityof Doppler USGBetter to
explore rather than unduly delay the treatment
•
Testicular salvage rate is 100% if surgery is done within 6 hrs
and it is 20% if surgery is delayed > 24 hrs
Torsion Testis-Treatment
•
Hydatid of testis & epididymisRemnant of obliterated
Mullerianducts
•
Sudden Swelling and redness of hemiscrotum
•
Tender Testis
•
‘Bluedotsign’ +ve
•
Cremastricreflex intact
Torsion of Testicular appendages
Hydatid of testis & epididymisRemnant of obliterated
Mullerianducts
•
Sudden Swelling and redness of hemiscrotum
•
Tender Testis
•
‘Bluedotsign’ +ve
•
Cremastricreflex intact
Torsion of Testicular appendages
Torsion of Testicular appendages
“Blue dot sign”
“Blue dot sign”
•
Explore & Excise torsedappendages in early cases
•
In delayed cases >48 hrs conservative treatment with
antibiotics & anti inflammatory drugs
Torsion of Testicular appendages
Treatment
Explore & Excise torsedappendages in early cases
•
In delayed cases >48 hrs conservative treatment with
antibiotics & anti inflammatory drugs
Torsion of Testicular appendages
Treatment
•
Inflammation of epididymis & Testis due to infection or
trauma
•
Sudden onset of pain in a hemiscrotum
•
Commonly associated with UTI or trauma
•
Thickened & Tender epididymis
•
Pain relief by elevation of hemiscrotum
Prehn’ssign
•
Can be treated conservatively with antibiotics and
antiinflammatorydrugs
Acute epididymo-orchitis
Inflammation of epididymis & Testis due to infection or
trauma
•
Sudden onset of pain in a hemiscrotum
•
Commonly associated with UTI or trauma
•
Thickened & Tender epididymis
•
Pain relief by elevation of hemiscrotum
Prehn’ssign
•
Can be treated conservatively with antibiotics and
antiinflammatorydrugs
Acute epididymo-orchitis
Acute Epididymo-orchitis
Doppler USG
USG Scrotum •
Thickened Epididymis
•
Reactive Hydrocele
•
Thick scrotal wall
Doppler USG •
Excessive blood flow to
Epididymis •
Normal testicular parenchymal
blood flow
Doppler USG
USG Scrotum •
Thickened Epididymis
•
Reactive Hydrocele
•
Thick scrotal wall
Doppler USG •
Excessive blood flow to
Epididymis •
Normal testicular parenchymal
blood flow
Testicular Torsion- Mindmap
Scrotal Swellings-Algorithm
Scrotal Swellings Ex & Px Hx Sx Dx Tx 1. HydrocelePrimary-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
Degenaration 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. VaricoceleIdiopathic
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
D/D for Scrotal Swellings (Compare & Contrast)
(Vertical Reading)
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
Degenaration 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. VaricoceleIdiopathic
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
D/D for Scrotal Swellings (Compare & Contrast)
(Vertical Reading)
References
•
Hunt& Marshall’s clinical problems
in surgery 2
nd
edition
•
Clinical surgery made easy-a
companion to PBL by Mohan De
silva1
st
edition
•
100 cases in surgery 2
nd
edition
•
Case files surgery 4
th
edition
•
Clinical scenarios in surgery-
decision making 1
st
edition
•
Surgery-a case based clinical
review 1
st
edition
•
Surgery Review by Carlos Pestana
•
Clinical surgery pearls by DrDayananda Babu2
nd
edition
•
NMS casebook surgery 2
nd
edition
•
General Surgery-Correlations &
clinical scenarios 1
st
edition
•
Surgery review by Makary3
rd
edition
•
Short practice of surgery by Bailey
and Love 26
th
edition
•
Shelf life surgery 1
st
edition
•
Hunt& Marshall’s clinical problems
in surgery 2
nd
edition
•
Clinical surgery made easy-a
companion to PBL by Mohan De
silva1
st
edition
•
100 cases in surgery 2
nd
edition
•
Case files surgery 4
th
edition
•
Clinical scenarios in surgery-
decision making 1
st
edition
•
Surgery-a case based clinical
review 1
st
edition
•
Surgery Review by Carlos Pestana
•
Clinical surgery pearls by DrDayananda Babu2
nd
edition
•
NMS casebook surgery 2
nd
edition
•
General Surgery-Correlations &
clinical scenarios 1
st
edition
•
Surgery review by Makary3
rd
edition
•
Short practice of surgery by Bailey
and Love 26
th
edition
•
Shelf life surgery 1
st
edition
Feedback & Suggestions
Thank You
To watch the video version go to
Channel
Surgical Educator in You Tube
https://www.youtube.com/watch?v=HqHEf0krIng
To watch the video version go to
Channel
Surgical Educator in You Tube
https://www.youtube.com/watch?v=HqHEf0krIng
SCROTALSWELLINGS
Case No:3
PROBLEM ORIENTED CASE BASED LEARNING
Dr.B.SelvarajMS;Mch;FICS
Professor of Surgery
Melaka ManipalMedical college
Melaka Malaysia 75150
Case No:3
PROBLEM ORIENTED CASE BASED LEARNING
Dr.B.SelvarajMS;Mch;FICS
Professor of Surgery
Melaka ManipalMedical college
Melaka Malaysia 75150
OVERVIEW
•
Various causes
(Differential diagnosis)
of scrotal swellings
•
Classical clinical vignette
with probable diagnosis
•
The diagnosis in detail-only one pathology in each episode
•
Mind map
of the diagnosis
•
Tabular column
of differential diagnosis depicting their
characteristic features to differentiate them from your
diagnosis
•
References
and feedback
•
Various causes
(Differential diagnosis)
of scrotal swellings
•
Classical clinical vignette
with probable diagnosis
•
The diagnosis in detail-only one pathology in each episode
•
Mind map
of the diagnosis
•
Tabular column
of differential diagnosis depicting their
characteristic features to differentiate them from your
diagnosis
•
References
and feedback
Causes of Scrotal Swellings
ACUTE PAINFUL
•Torsion testis
•
Acute epididymo-orchitis
•
Torsion of testicular
appendages
CHRONIC PAINLESS
•
Hydrocele
•
Epididymalcyst
•
Spermatocele
•
Chronic epididymo-
orchitis
•
Testicular tumor
•
Varicocele
ACUTE PAINFUL
•Torsion testis
•
Acute epididymo-orchitis
•
Torsion of testicular
appendages
CHRONIC PAINLESS
•
Hydrocele
•
Epididymalcyst
•
Spermatocele
•
Chronic epididymo-
orchitis
•
Testicular tumor
•
Varicocele
Classical Clinical vignette
EpididymalCyst
•
A45 years old male patient presented with a
swelling in right side
of the
scrotum
for last 3 years which is
increasing very slowly
in
size. There is
no pain
over the swelling.
•
O/E: There is a
soft cystic swelling
in relation to the
head of the
right epididymis
. The swelling has a
lobulated surface
and feels
like a bunch of grapes
.
•
Testis
can be
felt separately
from the swelling
•
The swelling is
brilliantly transilluminantand has Chinese
lantern pattern appearance
EpididymalCyst
•
A45 years old male patient presented with a
swelling in right side
of the
scrotum
for last 3 years which is
increasing very slowly
in
size. There is
no pain
over the swelling.
•
O/E: There is a
soft cystic swelling
in relation to the
head of the
right epididymis
. The swelling has a
lobulated surface
and feels
like a bunch of grapes
.
•
Testis
can be
felt separately
from the swelling
•
The swelling is
brilliantly transilluminantand has Chinese
lantern pattern appearance
EpididymalCyst-Etiopathogenesis
•
These are cysts in connection with the epididymis divided into the
following types:
•
1.
Degeneration cysts
occur due to cystic degeneration of the
epididymisEpididymalcyst
•
2.
Retention cysts
due to obstruction of the sperm conducting
mechanismSpermatoceleEx: after vasectomy
•
These are cysts in connection with the epididymis divided into the
following types:
•
1.
Degeneration cysts
occur due to cystic degeneration of the
epididymisEpididymalcyst
•
2.
Retention cysts
due to obstruction of the sperm conducting
mechanismSpermatoceleEx: after vasectomy
EpididymalCyst-Clinical Features
•
Most epididymalcysts occur in males over the age of 40 years
•
An epididymalcyst usually contains clear fluid
•
The variety that contains slightly grey, opaque, ‘b arleywater’-like fluid
and few spermatozoa is sometimes termed a Spermatocele
•
They are often multiple or multilocularand are frequently bilateral
and feels like bunch of grapes
•
Brilliantly transilluminant“Chinese lantern pattern”
•
Testis palpable separately
•
Cysts are connected to the head of the epididymis, so lie above the
testis3rd testis
•
Most epididymalcysts occur in males over the age of 40 years
•
An epididymalcyst usually contains clear fluid
•
The variety that contains slightly grey, opaque, ‘b arleywater’-like fluid
and few spermatozoa is sometimes termed a Spermatocele
•
They are often multiple or multilocularand are frequently bilateral
and feels like bunch of grapes
•
Brilliantly transilluminant“Chinese lantern pattern”
•
Testis palpable separately
•
Cysts are connected to the head of the epididymis, so lie above the
testis3rd testis
EpididymalCyst-Clinical Features
EpididymalCyst-Clinical Features
EpididymalCyst Vs Spermatocele
EpididymalCyst -Treatment
•
Single large cyst Excision of cyst
•
Recurrent or multilocularcystExcision + partial or total
epididymectomy •
No role for aspiration because cysts are multilocul ar
•
Spermatoceleif big aspiration or excision; If small no
intervention
•
Single large cyst Excision of cyst
•
Recurrent or multilocularcystExcision + partial or total
epididymectomy •
No role for aspiration because cysts are multilocul ar
•
Spermatoceleif big aspiration or excision; If small no
intervention
EpididymalCyst -Mindmap
Scrotal Swellings-Algorithm
Scrotal Swellings Ex & Px Hx Sx Dx Tx 1. HydrocelePrimary-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
Degenaration 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. VaricoceleIdiopathic
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
D/D for Scrotal Swellings (Compare & Contrast)
(Vertical Reading)
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
Degenaration 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. VaricoceleIdiopathic
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
D/D for Scrotal Swellings (Compare & Contrast)
(Vertical Reading)
References
•
Hunt& Marshall’s clinical problems
in surgery 2
nd
edition
•
Clinical surgery made easy-a
companion to PBL by Mohan De
silva1
st
edition
•
100 cases in surgery 2
nd
edition
•
Case files surgery 4
th
edition
•
Clinical scenarios in surgery-
decision making 1
st
edition
•
Surgery-a case based clinical
review 1
st
edition
•
Surgery Review by Carlos Pestana
•
Clinical surgery pearls by DrDayananda Babu2
nd
edition
•
NMS casebook surgery 2
nd
edition
•
General Surgery-Correlations &
clinical scenarios 1
st
edition
•
Surgery review by Makary3
rd
edition
•
Surgery-Clinical cases uncovered by
Harold Ellis 1st edition •
Shelf life surgery 1
st
edition
•
Hunt& Marshall’s clinical problems
in surgery 2
nd
edition
•
Clinical surgery made easy-a
companion to PBL by Mohan De
silva1
st
edition
•
100 cases in surgery 2
nd
edition
•
Case files surgery 4
th
edition
•
Clinical scenarios in surgery-
decision making 1
st
edition
•
Surgery-a case based clinical
review 1
st
edition
•
Surgery Review by Carlos Pestana
•
Clinical surgery pearls by DrDayananda Babu2
nd
edition
•
NMS casebook surgery 2
nd
edition
•
General Surgery-Correlations &
clinical scenarios 1
st
edition
•
Surgery review by Makary3
rd
edition
•
Surgery-Clinical cases uncovered by
Harold Ellis 1st edition •
Shelf life surgery 1
st
edition
Feedback & Suggestions
Thank You
https://www.youtube.com/watch?v=hZovqzif3ck
https://www.youtube.com/watch?v=hZovqzif3ck
SCROTALSWELLINGS
Case No:4
PROBLEM ORIENTED CASE BASED LEARNING
Dr.B.SelvarajMS;Mch;FICS
Professor of Surgery
Melaka ManipalMedical college
Melaka Malaysia 75150
Case No:4
PROBLEM ORIENTED CASE BASED LEARNING
Dr.B.SelvarajMS;Mch;FICS
Professor of Surgery
Melaka ManipalMedical college
Melaka Malaysia 75150
OVERVIEW
•
Various causes
(Differential diagnosis)
of scrotal swellings
•
Classical clinical vignette
with probable diagnosis
•
The diagnosis in detail-only one pathology in each episode
•
Mind map
of the diagnosis
•
Tabular column
of differential diagnosis depicting their
characteristic features to differentiate them from your
diagnosis
•
References
and feedback
•
Various causes
(Differential diagnosis)
of scrotal swellings
•
Classical clinical vignette
with probable diagnosis
•
The diagnosis in detail-only one pathology in each episode
•
Mind map
of the diagnosis
•
Tabular column
of differential diagnosis depicting their
characteristic features to differentiate them from your
diagnosis
•
References
and feedback
Causes of Scrotal Swellings
ACUTE PAINFUL
•Torsion testis
•
Acute epididymo-orchitis
•
Torsion of testicular
appendages
CHRONIC PAINLESS
•
Hydrocele
•
Epididymalcyst
•
Spermatocele
•
Chronic epididymo-
orchitis
•
Testicular tumor
•
Varicocele
ACUTE PAINFUL
•Torsion testis
•
Acute epididymo-orchitis
•
Torsion of testicular
appendages
CHRONIC PAINLESS
•
Hydrocele
•
Epididymalcyst
•
Spermatocele
•
Chronic epididymo-
orchitis
•
Testicular tumor
•
Varicocele
Classical Clinical Vignette
•
30 years male patient presented with a
swelling in the left side
of
the scrotum for last 4years. The swelling
started in the lower part
of the scrotum
and subsequently the swelling is
slowly increasing
in size and grown up to the root of the scrotum . The swelling
disappears on lying down
position and
reappears on standing
and
walking
•
Patient complains of
dull aching pain
in the left side of the scrotum
for last 6 months, the pain is
more towards the evening
when the
swelling enlarges in size
•
There is
no pain abdomen, no urinary complaints
•
30 years male patient presented with a
swelling in the left side
of
the scrotum for last 4years. The swelling
started in the lower part
of the scrotum
and subsequently the swelling is
slowly increasing
in size and grown up to the root of the scrotum . The swelling
disappears on lying down
position and
reappears on standing
and
walking
•
Patient complains of
dull aching pain
in the left side of the scrotum
for last 6 months, the pain is
more towards the evening
when the
swelling enlarges in size
•
There is
no pain abdomen, no urinary complaints
Classical Clinical Vignette
Varicocele
•
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 sper matic cord
extending from the upper pole of the testis up to t he superficial
inguinal ring
•
No expansileimpulse on cough
is palpable,
instead a thrill is
palpable.On lying down
and on elevation of the scrotum the
swelling disappears
•
On asking the patient to
stand up the dilated veins reappeared
.
The
left testicular volume is smaller
than the right one. Abdominal
examination is normal
Varicocele
•
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 sper matic cord
extending from the upper pole of the testis up to t he superficial
inguinal ring
•
No expansileimpulse on cough
is palpable,
instead a thrill is
palpable.On lying down
and on elevation of the scrotum the
swelling disappears
•
On asking the patient to
stand up the dilated veins reappeared
.
The
left testicular volume is smaller
than the right one. Abdominal
examination is normal
Varicocele-Anatomy
•
Surgical Anatomy:
Pampiniformplexus of veins (15 –20) draining the
testis and epididymis makes the major bulk of the spermatic cord. As
they ascend, the number is reduced to 12 and on reaching the
superficial inguinal ring they unite to form 4 vein s. At the level of deep
ring they are 2 in number and in retroperitoneum, it forms single
testicular vein.
•
Left testicular vein drains into left renal vein an d right testicular vein
into inferior vena cava
•
Surgical Anatomy:
Pampiniformplexus of veins (15 –20) draining the
testis and epididymis makes the major bulk of the spermatic cord. As
they ascend, the number is reduced to 12 and on reaching the
superficial inguinal ring they unite to form 4 vein s. At the level of deep
ring they are 2 in number and in retroperitoneum, it forms single
testicular vein.
•
Left testicular vein drains into left renal vein an d right testicular vein
into inferior vena cava
Varicocele-Anatomy
Varicocele
•
Dilatation and tortuosity of the pampiniformplexus of veins
•
Seen commonly in men aged 15-30yrs and rarely after 40yrs.
•
Occur in 15-20% of all males and 40% of all inferti le males.
•
Normal vein diameter of vessels of plexus-0.5-1.5mm. Diameter
greater than 2mm-Varicocele.
•
Dilatation and tortuosity of the pampiniformplexus of veins
•
Seen commonly in men aged 15-30yrs and rarely after 40yrs.
•
Occur in 15-20% of all males and 40% of all inferti le males.
•
Normal vein diameter of vessels of plexus-0.5-1.5mm. Diameter
greater than 2mm-Varicocele.
Varicocele
•
It is common on the left side5 reasons.
Left testicular vein is longer than right testicula r vein
Left testicular vein enters at right angle to the l eft renal vein
Left testicular artery is arching over left testicu lar vein
Aloaded sigmoid colon compressing left testicular vein
Left renal vein is compressed b/w the Aorta and SMA
•
It is common on the left side5 reasons.
Left testicular vein is longer than right testicula r vein
Left testicular vein enters at right angle to the l eft renal vein
Left testicular artery is arching over left testicu lar vein
Aloaded sigmoid colon compressing left testicular vein
Left renal vein is compressed b/w the Aorta and SMA
Varicocele-Etiology
•
1.Idiopathic/Primary
–due to incompetency of valves. 98% occur on
the left side
•
2.Secondary
Pelvic or abdominal mass.
Lt renal cell carcinoma with tumorthrombus in left renal vein.
Nutcracker syndrome-SMA compressing left renal vein. Other
conditions- Retroperitoneal fibrosis or adhesions
•
1.Idiopathic/Primary
–due to incompetency of valves. 98% occur on
the left side
•
2.Secondary
Pelvic or abdominal mass.
Lt renal cell carcinoma with tumorthrombus in left renal vein.
Nutcracker syndrome-SMA compressing left renal vein. Other
conditions- Retroperitoneal fibrosis or adhesions
Varicocele-Bag of Worms Appearance
Varicocele-Clinical Features
•
The patient may have aching or dragging pain particularly after
prolonged standing.
•
It can be differentiated from an omentoceleby the peculiar
feel of the
bag of worms
.
•
Many varicoceles are asymptomatic and found incidentally
•
It is more common on the left side for reasons stat ed above
•
Infertility:
Varicocele is often associated with infertility. Th e scrotal
temperature is usually higher in the presence of varicocele and this
may impair spermatogenesis
•
The patient may have aching or dragging pain particularly after
prolonged standing.
•
It can be differentiated from an omentoceleby the peculiar
feel of the
bag of worms
.
•
Many varicoceles are asymptomatic and found incidentally
•
It is more common on the left side for reasons stat ed above
•
Infertility:
Varicocele is often associated with infertility. Th e scrotal
temperature is usually higher in the presence of varicocele and this
may impair spermatogenesis
Varicocele-Clinical Features
•
Bow sign-
hold varicocele b/w thumb and fingers, patient is a sked to
bow-reduced in size
•
On lying down it gets reduced; On standing up it reappears
•
Long standing cases-affected side testis is reduced in size and softer.
Testis size can be measured by Praderorchidometer
•
No expansilecough impulse present, but thrill present while coughing
•
Bow sign-
hold varicocele b/w thumb and fingers, patient is a sked to
bow-reduced in size
•
On lying down it gets reduced; On standing up it reappears
•
Long standing cases-affected side testis is reduced in size and softer.
Testis size can be measured by Praderorchidometer
•
No expansilecough impulse present, but thrill present while coughing
Varicocele-Grading
•
Grade I:
Small varicocele which is palpable only when patient performs
Valsalva maneuver(expiration against a closed glottis).
•
Grade II:
Moderate sized. Easily palpable varicocele without Valsalva’s
maneuver
•
Grade III:
Large varicocele visible through the scrotal skin.
•
Grade IV :
Very much dilated and tortuous veins
•
Grade I:
Small varicocele which is palpable only when patient performs
Valsalva maneuver(expiration against a closed glottis).
•
Grade II:
Moderate sized. Easily palpable varicocele without Valsalva’s
maneuver
•
Grade III:
Large varicocele visible through the scrotal skin.
•
Grade IV :
Very much dilated and tortuous veins
Varicocele-Investigations
•
Venous colordoppler
of the scrotum and groin-
-standing/ valsalva’smanoeuvre
•
USG abdomen
to look for kidney tumours.
•
Seminal analysis
Oligospermiaor azospermia
•
Venous colordoppler
of the scrotum and groin-
-standing/ valsalva’smanoeuvre
•
USG abdomen
to look for kidney tumours.
•
Seminal analysis
Oligospermiaor azospermia
Varicocele-Investigations
Varicocele-Indications for Surgery
•
American Urological Society recommends that varicocele treatment
should be offered to the male partner of a couple attempting to c onceive
when all of the following are present.
•
A varicocele is palpable.
•
The couple has documented infertility.
•
The female has normal fertility or potentially correctable inf ertility
•
The male partner has one or more abnormal semen parameters or sperm
function test results.
•
The indications in adolescents-presence of significant testic ular
asymmetry (>20%) demonstrated on serial examinations, testicular pain,
and abnormal semen analysis results.
•
American Urological Society recommends that varicocele treatment
should be offered to the male partner of a couple attempting to c onceive
when all of the following are present.
•
A varicocele is palpable.
•
The couple has documented infertility.
•
The female has normal fertility or potentially correctable inf ertility
•
The male partner has one or more abnormal semen parameters or sperm
function test results.
•
The indications in adolescents-presence of significant testic ular
asymmetry (>20%) demonstrated on serial examinations, testicular pain,
and abnormal semen analysis results.
Varicocele-Treatment
•
Asymptomatic varicocele—No treatment is required, only scrotal support
and reassurance •
Symptomatic varicocele—Excision of the pampiniformplexus in the
inguinal canal after ligating them. Testis still has v enous drainage via the
cremastericveins
•
VARICOCELECTOMY
- The most common approaches are
•
Inguinal(groin)-easier and safer.
•
Retroperitoneal(abdominal)
•
Suprainguinalextraperitonial( Palomo’soperation)Open & Laparoscopic
•
Scrotal approach-For Gr 4
•
Asymptomatic varicocele—No treatment is required, only scrotal support
and reassurance •
Symptomatic varicocele—Excision of the pampiniformplexus in the
inguinal canal after ligating them. Testis still has v enous drainage via the
cremastericveins
•
VARICOCELECTOMY
- The most common approaches are
•
Inguinal(groin)-easier and safer.
•
Retroperitoneal(abdominal)
•
Suprainguinalextraperitonial( Palomo’soperation)Open & Laparoscopic
•
Scrotal approach-For Gr 4
Varicocele-Treatment
Varicocele-
•
Non-surgical procedure.
•
Steel coil or silicone balloon catheter is introduc ed into a vein below
the groin through a nick in the skin.
•
Passed under X-ray guidance.
•
Tiny metal coils or other embolizingagents introduced through the
catheter.
•
No stitches needed.
•
Patient can go back in 24hrs.
•
Lower rates of complications. Less effective, highe r recurrence(5-11%),
danger that the coil could migrate to the heart and cause death
Coil Embolization
,
•
Non-surgical procedure.
•
Steel coil or silicone balloon catheter is introduc ed into a vein below
the groin through a nick in the skin.
•
Passed under X-ray guidance.
•
Tiny metal coils or other embolizingagents introduced through the
catheter.
•
No stitches needed.
•
Patient can go back in 24hrs.
•
Lower rates of complications. Less effective, highe r recurrence(5-11%),
danger that the coil could migrate to the heart and cause death
Coil Embolization
,
Varicocele-Coil Embolization
,
,
Varicocele-Complications
•
Haemorrhage and scrotal haematoma
•
InfectionPyocele
•
Injury to testicular artery
•
Injury to ilioinguinalnerve and pain
•
Recurrence—5-10%
•
Haemorrhage and scrotal haematoma
•
InfectionPyocele
•
Injury to testicular artery
•
Injury to ilioinguinalnerve and pain
•
Recurrence—5-10%
Varicocele -Mindmap
Scrotal Swellings-Algorithm
Scrotal Swellings Ex & Px Hx Sx Dx Tx 1. HydrocelePrimary-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
Degenaration 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. VaricoceleIdiopathic
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
D/D for Scrotal Swellings (Compare & Contrast)
(Vertical Reading)
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
Degenaration 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. VaricoceleIdiopathic
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
D/D for Scrotal Swellings (Compare & Contrast)
(Vertical Reading)
References
•
Hunt& Marshall’s clinical problems
in surgery 2
nd
edition
•
Clinical surgery made easy-a
companion to PBL by Mohan De
silva1
st
edition
•
100 cases in surgery 2
nd
edition
•
Case files surgery 4
th
edition
•
Clinical scenarios in surgery-
decision making 1
st
edition
•
Surgery-a case based clinical
review 1
st
edition
•
Surgery Review by Carlos Pestana
•
Clinical surgery pearls by DrDayananda Babu2
nd
edition
•
NMS casebook surgery 2
nd
edition
•
General Surgery-Correlations &
clinical scenarios 1
st
edition
•
Surgery review by Makary3
rd
edition
•
Surgery-Clinical cases uncovered by
Harold Ellis 1st edition •
Shelf life surgery 1
st
edition
•
Hunt& Marshall’s clinical problems
in surgery 2
nd
edition
•
Clinical surgery made easy-a
companion to PBL by Mohan De
silva1
st
edition
•
100 cases in surgery 2
nd
edition
•
Case files surgery 4
th
edition
•
Clinical scenarios in surgery-
decision making 1
st
edition
•
Surgery-a case based clinical
review 1
st
edition
•
Surgery Review by Carlos Pestana
•
Clinical surgery pearls by DrDayananda Babu2
nd
edition
•
NMS casebook surgery 2
nd
edition
•
General Surgery-Correlations &
clinical scenarios 1
st
edition
•
Surgery review by Makary3
rd
edition
•
Surgery-Clinical cases uncovered by
Harold Ellis 1st edition •
Shelf life surgery 1
st
edition
Feedback & Suggestions
Thank You
https://www.youtube.com/watch?v=jFqZimnOWd0
https://www.youtube.com/watch?v=jFqZimnOWd0
SCROTALSWELLINGS
Case No:5
PROBLEM ORIENTED CASE BASED LEARNING
Dr.B.SelvarajMS;Mch;FICS
Professor of Surgery
Melaka ManipalMedical college
Melaka Malaysia 75150
Case No:5
PROBLEM ORIENTED CASE BASED LEARNING
Dr.B.SelvarajMS;Mch;FICS
Professor of Surgery
Melaka ManipalMedical college
Melaka Malaysia 75150
OVERVIEW
•
Various causes
(Differential diagnosis)
of scrotal swellings
•
Classical clinical vignette
with probable diagnosis
•
The diagnosis in detail-only one pathology in each episode
•
Mind map
of the diagnosis
•
Tabular column
of differential diagnosis depicting their
characteristic features to differentiate them from your
diagnosis
•
References
and feedback
•
Various causes
(Differential diagnosis)
of scrotal swellings
•
Classical clinical vignette
with probable diagnosis
•
The diagnosis in detail-only one pathology in each episode
•
Mind map
of the diagnosis
•
Tabular column
of differential diagnosis depicting their
characteristic features to differentiate them from your
diagnosis
•
References
and feedback
Causes of Scrotal Swellings
ACUTE PAINFUL
•Torsion testis
•
Acute epididymo-orchitis
•
Torsion of testicular
appendages
CHRONIC PAINLESS
•
Hydrocele
•
Epididymalcyst
•
Spermatocele
•
Chronic epididymo-
orchitis
•
Testicular tumor
•
Varicocele
ACUTE PAINFUL
•Torsion testis
•
Acute epididymo-orchitis
•
Torsion of testicular
appendages
CHRONIC PAINLESS
•
Hydrocele
•
Epididymalcyst
•
Spermatocele
•
Chronic epididymo-
orchitis
•
Testicular tumor
•
Varicocele
Classical Clinical Vignette
•
A
22-year-old male
presents with a
left scrotal mass
. He notes that he
was playing soccer about 5 weeks ago and sustained mild trauma to
the left hemi scrotum at that time. The
trauma prompted him to
palpate his testicle
, at which time he noted the mass. The patient
states that he had mild pain initially that resolve d on its own and
denies any hematoma.
•
He denies any pain at this time. He states that the
mass
does
not
seem
to be
increasing in size
and that it is approximately the size of a large
almond. The
mass,
he notes, seems to be “
in the middle
”
of his left
testis
.
•
A
22-year-old male
presents with a
left scrotal mass
. He notes that he
was playing soccer about 5 weeks ago and sustained mild trauma to
the left hemi scrotum at that time. The
trauma prompted him to
palpate his testicle
, at which time he noted the mass. The patient
states that he had mild pain initially that resolve d on its own and
denies any hematoma.
•
He denies any pain at this time. He states that the
mass
does
not
seem
to be
increasing in size
and that it is approximately the size of a large
almond. The
mass,
he notes, seems to be “
in the middle
”
of his left
testis
.
Classical Clinical Vignette
Testicular Carcinoma
•
On review of symptoms
he denies
subjective
fevers, chills, dysuria,
gross hematuria, or urethral discharge
•
O/E:Physicalexamination reveals a
firm 2 cm mass within the left
testis.
There is
no pain to palpation
. There are no epididymal
masses bilaterally, and the right testis is normal to examination.
Abdominal exam reveals no masses and no hepatomegaly.
•
There are
no supraclavicular nodes and no gynecomastia
•
Laboratory analysis reveals a
normal urinalysis and complete
blood count
.
Testicular Carcinoma
•
On review of symptoms
he denies
subjective
fevers, chills, dysuria,
gross hematuria, or urethral discharge
•
O/E:Physicalexamination reveals a
firm 2 cm mass within the left
testis.
There is
no pain to palpation
. There are no epididymal
masses bilaterally, and the right testis is normal to examination.
Abdominal exam reveals no masses and no hepatomegaly.
•
There are
no supraclavicular nodes and no gynecomastia
•
Laboratory analysis reveals a
normal urinalysis and complete
blood count
.
Testicular Carcinoma-Epidemiology
•
The most common malignancy to affect young men.
•
There is a peak frequency in early childhood, and a larger peak
incidence between 20 and 35 years of age. Uncommon after age 40.
•
Occurs in whites more than African-Americans.
•
It is a curable cancer
•
The most common malignancy to affect young men.
•
There is a peak frequency in early childhood, and a larger peak
incidence between 20 and 35 years of age. Uncommon after age 40.
•
Occurs in whites more than African-Americans.
•
It is a curable cancer
Testicular Carcinoma-Risk Factors
•
Men with cryptorchid(undescended) testes (intra-abdominal testes
with the highest risk). It is important to note tha t both testicles are at
risk.
•
Surgical placement of the testis into the scrotum d oes not decrease
malignant risk, but facilitates surveillance.
•
Testicular cancer in the contralateral testis
•
Family H/O Testicular Cancer
•
Klinefelter’ssyndrome
•
Men with cryptorchid(undescended) testes (intra-abdominal testes
with the highest risk). It is important to note tha t both testicles are at
risk.
•
Surgical placement of the testis into the scrotum d oes not decrease
malignant risk, but facilitates surveillance.
•
Testicular cancer in the contralateral testis
•
Family H/O Testicular Cancer
•
Klinefelter’ssyndrome
Testicular Carcinoma
Clinical features
•
Painless enlargement of the testicle
•
Firmness of the testicle; Lax Secondary hydrocele
•
Back or abdominal pain secondary to retroperitoneal (inter-aortocaval)
lymphadenopathy.
•
Weight loss. Lt supraclavicular LN +
•
Enlarged retro peritoneal LN; Hepatomegaly;
•
Dyspneasecondary to pulmonary metastasis.
•
Gynecomastia secondary to hormonal secretions
Clinical features
•
Painless enlargement of the testicle
•
Firmness of the testicle; Lax Secondary hydrocele
•
Back or abdominal pain secondary to retroperitoneal (inter-aortocaval)
lymphadenopathy.
•
Weight loss. Lt supraclavicular LN +
•
Enlarged retro peritoneal LN; Hepatomegaly;
•
Dyspneasecondary to pulmonary metastasis.
•
Gynecomastia secondary to hormonal secretions
Testicular Carcinoma
Clinical features
Clinical features
Testicular Carcinoma-Classification
Testicular Carcinoma-Classification
Testicular Carcinoma-Histology
Testicular Carcinoma
Seminoma vs Nonseminoma
Seminoma vs Nonseminoma
Testicular Carcinoma-Workup
•
Testicular self-examination(TSE)
or by a clinician
•
USG of Scrotum
•
CT scan
/magnetic resonance imaging
(MRI)
of abdomen and pelvis to
assess for metastasis and lymphadenopathy
•
Tumormarkers
—α-fetoprotein
(AFP),
human chorionic gonadotropin
(HCG),
and lactic dehydrogenase
(LDH).
•
Tissue diagnosis-
high inguinal orchidectomy(diagnostic &
therapeutic) –
Chevassumaneuver
•
Trans-scrotal biopsy –contraindicated
•
Testicular self-examination(TSE)
or by a clinician
•
USG of Scrotum
•
CT scan
/magnetic resonance imaging
(MRI)
of abdomen and pelvis to
assess for metastasis and lymphadenopathy
•
Tumormarkers
—α-fetoprotein
(AFP),
human chorionic gonadotropin
(HCG),
and lactic dehydrogenase
(LDH).
•
Tissue diagnosis-
high inguinal orchidectomy(diagnostic &
therapeutic) –
Chevassumaneuver
•
Trans-scrotal biopsy –contraindicated
Testicular Carcinoma-USG Scrotum
Testicular Carcinoma-Tumor
Markers
•
AFP
: Normal value < 16 ngm/ml; Half life 5 to 7 days; Raised in
Pure embryonal Ca
TeratoCa
Yolk sac tumor
Mixed tumor
REMEMBER: AFP Not raised is Pure Choriocarcinomaor Pure
Seminoma
Markers
•
AFP
: Normal value < 16 ngm/ml; Half life 5 to 7 days; Raised in
Pure embryonal Ca
TeratoCa
Yolk sac tumor
Mixed tumor
REMEMBER: AFP Not raised is Pure Choriocarcinomaor Pure
Seminoma
Testicular Carcinoma-Tumor
Markers
•
HCG:
Normal value < 5 IU/ml; Half life 24 to 36 hrs; Ra ised in
Choriocarcinoma 100%
Embryonal carcinoma 60%
Teratocarcinoma 55%
Yolk sac tumor25%
Seminomas 7%
•
LDH:
Normal value 105 to 333 IU/ L; Half life 1 day
-Not diagnostic
-prognostic marker
-correlates tumor
burden
Markers
•
HCG:
Normal value < 5 IU/ml; Half life 24 to 36 hrs; Ra ised in
Choriocarcinoma 100%
Embryonal carcinoma 60%
Teratocarcinoma 55%
Yolk sac tumor25%
Seminomas 7%
•
LDH:
Normal value 105 to 333 IU/ L; Half life 1 day
-Not diagnostic
-prognostic marker
-correlates tumor
burden
Testicular Carcinoma-Staging
Testicular Carcinoma
-
Treatment
Goals
•
Treatment should be aimed at one level higher then the clinical stage
•
Seminomas-radiosensitive
•
Non seminomas-radio-resisitanthence best treated with surgery
•
Advanced disease or mets-chemotherapy
•
Radical inguinal orchidectomyis the standard first line therapy
•
Lymphatic spread first to the RETRO-PERITONEAL NODES
•
Early hematogenousspread rare
•
Bulky tumorsor metastatic tumorsinitially down staged with
Neoadjuvant chemotherapy
-
Treatment
Goals
•
Treatment should be aimed at one level higher then the clinical stage
•
Seminomas-radiosensitive
•
Non seminomas-radio-resisitanthence best treated with surgery
•
Advanced disease or mets-chemotherapy
•
Radical inguinal orchidectomyis the standard first line therapy
•
Lymphatic spread first to the RETRO-PERITONEAL NODES
•
Early hematogenousspread rare
•
Bulky tumorsor metastatic tumorsinitially down staged with
Neoadjuvant chemotherapy
Testicular Carcinoma-Treatment
•
Surgical approach: High radical inguinal orchiectomy
•
Trans-scrotal biopsy of the testis or a trans-scrot al orchiectomy
should not be performed •
Early seminoma: Orchiectomy + retroperitoneal x-ray therapy (XRT).
•
Advanced seminoma: Orchiectomy, and combination chemotherapy
followed by restaging •
Stage I nonseminoma: Orchiectomy + retroperitoneal lymph node
dissection (RPLND) or surveillance
•
Surgical approach: High radical inguinal orchiectomy
•
Trans-scrotal biopsy of the testis or a trans-scrot al orchiectomy
should not be performed •
Early seminoma: Orchiectomy + retroperitoneal x-ray therapy (XRT).
•
Advanced seminoma: Orchiectomy, and combination chemotherapy
followed by restaging •
Stage I nonseminoma: Orchiectomy + retroperitoneal lymph node
dissection (RPLND) or surveillance
Testicular Carcinoma-Treatment
•
Stage II Nonseminoma: The optimal management of this group of
patients is controversial. RPLND can be curative but have a high
relapse rate. If relapse occurs, chemotherapy can b e given as
adjunctive therapy. Alternatively, chemotherapy can be given prior to
RPLND
•
Advanced stage Nonseminoma: Orchiectomy + chemotherapy ±tumor
reductive surgery. •
The most commonly used chemotherapeutic regimen: EBP (etoposide,
bleomycin, cisplatin).The prognosis of seminomas is excellent due
to its exquisite sensitivity to radiation!
•
Stage II Nonseminoma: The optimal management of this group of
patients is controversial. RPLND can be curative but have a high
relapse rate. If relapse occurs, chemotherapy can b e given as
adjunctive therapy. Alternatively, chemotherapy can be given prior to
RPLND
•
Advanced stage Nonseminoma: Orchiectomy + chemotherapy ±tumor
reductive surgery. •
The most commonly used chemotherapeutic regimen: EBP (etoposide,
bleomycin, cisplatin).The prognosis of seminomas is excellent due
to its exquisite sensitivity to radiation!
Testicular Carcinoma-Treatment
Testicular Carcinoma -Mindma
p
p
Scrotal Swellings-Diagnostic Algorithm
Testicular Carcinoma-Treatment Algorithm
Scrotal Swellings Ex & Px Hx Sx Dx Tx 1. HydrocelePrimary-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
Degenaration 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. VaricoceleIdiopathic
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
D/D for Scrotal Swellings (Compare & Contrast)
(Vertical Reading)
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
Degenaration 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. VaricoceleIdiopathic
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
D/D for Scrotal Swellings (Compare & Contrast)
(Vertical Reading)
References
•
Hunt& Marshall’s clinical problems
in surgery 2
nd
edition
•
Clinical surgery made easy-a
companion to PBL by Mohan De
silva1
st
edition
•
100 cases in surgery 2
nd
edition
•
Case files surgery 4
th
edition
•
Clinical scenarios in surgery-
decision making 1
st
edition
•
Surgery-a case based clinical
review 1
st
edition
•
Surgery Review by Carlos Pestana
•
Clinical surgery pearls by DrDayananda Babu2
nd
edition
•
NMS casebook surgery 2
nd
edition
•
General Surgery-Correlations &
clinical scenarios 1
st
edition
•
Surgery review by Makary3
rd
edition
•
Surgery-Clinical cases uncovered by
Harold Ellis 1st edition •
Shelf life surgery 1
st
edition
•
Hunt& Marshall’s clinical problems
in surgery 2
nd
edition
•
Clinical surgery made easy-a
companion to PBL by Mohan De
silva1
st
edition
•
100 cases in surgery 2
nd
edition
•
Case files surgery 4
th
edition
•
Clinical scenarios in surgery-
decision making 1
st
edition
•
Surgery-a case based clinical
review 1
st
edition
•
Surgery Review by Carlos Pestana
•
Clinical surgery pearls by DrDayananda Babu2
nd
edition
•
NMS casebook surgery 2
nd
edition
•
General Surgery-Correlations &
clinical scenarios 1
st
edition
•
Surgery review by Makary3
rd
edition
•
Surgery-Clinical cases uncovered by
Harold Ellis 1st edition •
Shelf life surgery 1
st
edition
Feedback & Suggestions
Thank You
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https://www.youtube.com/watch?v=xz0ZbzgR0RM
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