scrotalswelling-220904185347-ef20b1de.pptx

Scrotal Swellings

1. PRESENTED BY Mr VICTOR SIMWINGA INGUINAL SCROTAL SWELLINGS

2. EXAMPLES OF INGUINAL AND SCORTAL SWELLINGS Hernias Hydrocele Varicocele Spermatocele Orchitis Orchitisepididymitis Testicular torsion Fournier's gangrene

3. Orchiepididymitis What is it? • Epididymitis is the inflammation of the epididymis. • If the inflammation spreads to the testicle spreads to the scrotum it is called Orchiepididymitis. INCIDENCE  The mean age of these patients was 40.2 ± 17.3 years.  Young adults are predominantly affected, with a frequency peak between 20 and 40 years of age. Structural urologic abnormalities are common in children and in men older than 40 years with acute epididymitis.

4. RISK FACTORS • Sexual intercourse with more than one partner and not using condoms •Being uncircumcised •Recent surgery or a history of structural problems in the urinary tract •Regular use of a urethral catheter CAUSE •Among sexually active men aged <35yrs e.g Transmission Chlamydia trachomatis or Neisseria gonorrhoea •Men who are the insertive partner during anal intercourse: e.g Escherichia coli and Pseudomonas aeruginosa •Men aged >35 years –Sexually transmitted epididymitis is uncommon –Bacteriuria secondary to obstructive urinary disease is more common.

5. SYMPTOMS •Heavy sensation in the testicle area •Painful scrotal swelling •Fever •Chills •Testicle pain gets worse with pressure •Lump in the testicle •Blood in the semen •Discharge from the urethra •Pain or burning during urination or ejaculation •Discomfort in the lower abdomen or pelvis CLINICAL PRESENTATIONS Tenderness and induration occurring first in the epididymal tail and then spreading • Elevation of the affected hemiscrotum • Normal cremasteric reflex • Erythema and mild scrotal cellulitis • Reactive hydrocele (in patients with advanced epididymo-orchitis) • Bacterial prostatitis or seminal vesiculitis (in postpubertal individuals) • With tuberculosis, focal epididymitis and a draining sinus

6. LABORATORY INVESTIGATIONS • Urinalysis: Pyuria or bacteriuria (50%); urine culture indicated for prepubertal and elderly patients • Complete blood count: Leukocytosis • Gram stain of urethral discharge, if present • Urethral culture, nucleic acid hybridization, and nucleic acid amplification tests to facilitate detection of Neisseria gonorrhoea and Chlamydia trachomatis • Performance of (or referral for) syphilis and HIV testing in patients with a sexually transmitted etiology • The use of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to differentiate epididymitis from other causes of acute scrotum is under investigation IMAGING STUDIES Voiding cystourethrogram (VCUG) •Retrograde urethrography •Abdominal/pelvic ultrasonography •Radionuclide scanning and scintigraphy •In tuberculosis epididymitis, chest radiography, computed tomography, or excretory urography.

7. TREATMENT • Empiric treatment is indicated before laboratory results are available • Goals of treatment of acute epididymitis caused by C. trachomatis or N. gonorrhoea: –Microbiological cure of infection –Improvement of signs & symptoms –Prevent transmission to others –Reduce potential complications • Recommended Regimens: –Ceftriaxone 250mg IM in a single dose PLUS –Doxycycline 100mg PO BID x 10 days For epididymitis most likely caused by enteric organisms: –Levofloxacin 500mg PO once daily x 10 days OR – Ofloxacin 300mg PO BID X 10 days. PROPHYLAXIS • Practicing safe sex • Treating sexual partners as a contact to epididymitis. •Repeat screening for STI ~ 2 months after initial testing for re-infection. •Abstain from sex until the individual & sex partners have completed treatment.

8. HYDROCELE  Hydrocele is a collection of fluid around one or both testicles and cause swelling of scrotum or groin area. INCEDENCE It commonly occurs in men older than 40 years 1 in 10 male infants has a hydrocele at birth, but most hydrocele disappear without treatment within the first year of life.

9. TYPES OF HYDROCELE Non communicating Communicating Non communicating A non communicating hydrocele occurs when the sac closes, but your body doesn’t absorb the fluid. The remaining fluid is typically absorbed into the body within a year Communicating A communicating hydrocele occurs when the sac surrounding your testicle doesn’t close all the way. This allows fluid to flow in and out.

10. ETIOLOGIES Idiopathic  Inflammation of infection of the epididymis or testicles.  In rare cases, may be caused by cancer of testicle or left kidney.  Men over the age of 40 Clinical manifestation Swelling of scrotum Pain sometime Redness of scrotum Feeling of pressure at base of penis present. Testicular torsion Infertility

11. DIAGNOSTIC EVALUATION History taking Physical examination Transillumination : It is a test used to identify abnormalities in an organ or body cavity. The test is performed in a dark room, with a bright light shined at a specific body part to see the structures beneath the skin. Ultrasound of scrotum done to rule out presence of fluid Blood test done to rule out infection

12. TREATMENT Surgery : If your new infant has a hydrocele, it will probably go away on its own in about a year. If your child’s hydrocele doesn’t go away on its own or becomes very large, he might need surgery by a urologist  Needle aspiration done.  Sclerotherapy done to reduce re accumulation.  In adults, hydroceles typically go away within six months

13. VARICOCELE Dilatation and tortuosity of the pampiniform plexus and so also of the testicular veins. Incidence  Seen commonly in men aged 15-30yrs and rarely after 40yrs.  Occur in 15-20% of all males and 40% of all infertile males.  Normal small vessels of plexus- 0.5-1.5mm. Diameter greater than 2mm- Varicocele Seen commonly on the left side – For 5 reasons. longer enters at right angle to the renal vein left testicular artery arching over it a loaded sigmoid colon. compressed b/w the aorta and SMA

14. CAUSES 1.IDIOPATHIC/PRIMARY – due to incompetency of valves, 98% occur on the left side. 2.SECONDARY pelvic or abdominal mass. renal cell carcinoma with tumor thrombus in left vein. Nutcracker syndrome- SMA compressing left vein. Common conditions RCC Retroperitoneal fibrosis or adhesions

15. CLINICAL MANIFESTATION Swelling Dragging /aching pain in the groin and scrotum “ bag of worms” feeling Scrotum on the affected side hangs down. On lying down , it gets reduced. Bow sign- hold varicocele between thumb and fingers , patient is asked to bow-reduced in size Cough impulse present Long standing cases- affected side testis is reduced in size and softer. Fertility problems

16. INVSTGATIONS Venous doppler of the scrotum and groin- Standing/ valsalva’s manouevre . U/S abdomen to look for kidney tumours. Semen analysis

17. TREATMENT 3 SURGICAL AND 1 NON SURGICAL PROCEDURE.  VARICOCELECTOMY- The most common approaches are  inguinal (groin)-easier and safer.  retroperitoneal (abdominal)  infrainguinal / subinguinal (below the groin),  suprainguinal extraperitonial ( Palomo’s operation),  Scrotal approach- grade 4.  Done in spinal.  2-3 inch incision.  Ligate the offending veins.  Avoid strenuous exercise for several days after surgery.  Apply scrotal support

18. Complications  20% chance of recurrence.  5% chance of hydrocele  Damage to testicular artery.  Infection.  hematoma

19. Spermatocoele Benign cystic accumulation of sperm Arises from the head (caput)of the epididymis-on superior aspect. Lesions are benign – retention cysts Usually uniclocular Contain barley water like fluid spermatozoa

20. CAUSES  remains undefined  In a mouse model - occluded by agglutinated germ cells.  Physical trauma, inflammation Epidydimal scarring obstruction spermatocoele  In utero exposure to diethylstilbestrol (DES)

21. Clinical features Symptoms Typically asymptomatic Incidental findings examination Usually a painless mobile swelling postero superiorly Associated symptoms scrotal heaviness and dull discomfort Signs Smooth and spherical Fluctuant Transillumination on examination

22. Investigation Uncomplicated asymptomatic spermatocele no investigation needed scrotal pain , urine analysis to rule out epididymitis. FNAC-dead sperm Ultrasonography Cystic lesions that arise from the epididymal Head Less commonly- intratesticular lesion attached to the mediastinum testis. Hypoechoic with posterior acoustic enhancement and cannot be differentiated from an epididymal cyst . Occasionally, may have internal echoes within the cyst. Scrotal USS - spermatocele visible to the left of a normal testis Color Doppler -"falling snow" appearence (internal echoes moving away from the transducer) Histologic Findings -fibromuscular wall that is lined by cuboidal epithelium

23. Medical Therapy No specific medical therapy . Oral analgesics i.e ibuprofen  If an underlying epididymitis - give antibiotics i.e ceftriaxone  Observation is usually used for simple, small asymptomatic Spermatoceles Surgical Therapy Spermatocelectomy The primary operative intervention is Via a transscrotal approach Relative contraindications - Systemic anticoagulation -family incomplete Performed on an outpatient basis With either regional or general anesthesia

24. Complications chemical epididymitis epididymal damage infertility Bleeding infection spermatocele recurrence scrotal wall thickness.

25. TESTICULAR TORSION Testicular torsion refers to the torsion of the spermatic cord structures and subsequent loss of the blood supply to the ipsilateral testicle Normal anatomy • The tunica vaginalis does not completely surround the testis and epididymis, which are attached to the posterior scrotal wall

26. PATHOPHYSIOLOGY Torsion occurs as the testicle rotates between 90° and 180°, compromising blood flow to and from the testicle. • Complete torsion usually occurs when the testicle twists 360° or more; incomplete or partial torsion occurs with lesser degrees of rotation. The degree of torsion may extend to 720°. • The twisting of the testicle causes venous occlusion and engorgement as well as arterial ischemia and infarction of the testicle. • The degree of torsion the testicle endures may play a role in the viability of the testicle over time. • In addition to the extent of torsion, the duration of torsion prominently influences the rates of both immediate salvage and late testicular atrophy. Testicular salvage is most likely if the duration of torsion is less than 6-8 hours. • If 24 hours or more elapse, testicular necrosis develops in most patients.

27. TYPES OF TESTICULAR TORSION Intravaginal torsion Is the more common type, occurring most frequently at puberty. It results from anomalous suspension of the testis by a long stalk of spermatic cord, resulting in complete investment of the testis and epididymis by the tunica vaginalis. • This anomaly has been likened to a bell-clapper Extravaginal torsion • Most often occurs in newborns without the “bell clapper” deformity. • It is thought to result from a poor or absent attachment of the testis to the scrotal wall, allowing rotation of the testis, epididymis, and tunica vaginalis as a unit and causing torsion of the cord at the level of the external ring.

28. HISTORY Severe unilateral scrotal pain • Previous episodes, spontaneous resolution • Related to activity, trauma, during sleep • Nausea, vomiting, abdominal pain, fever PHYSICAL EXAMINATION Prenatal torsion, firm, hard, scrotal mass, which does not transilluminate in an otherwise asymptomatic newborn male. The scrotal skin characteristically fixes to the necrotic gonad. • Older patient, swollen, tender, highriding testis with abnormal transverse lie and loss of the cremasteric reflex

29. DIAGNOSIS CLINICAL SUSPICION • Nuclear scintigraphy – Radiation, limited availability • Ultrasound – Altered echotexture (B-mode) – Vascular flow (Color / Spectral / Power Doppler) • Infrared scrotal Spectroscopy ULTRASOUND FOR TESTICULAR TORSION Sensitivity 86%, specificity 100% experienced provider using color / power doppler1 • Gray -scale findings on ultrasound depend on how much time has passed since the torsion occurred. • The gray-scale findings of acute and subacute torsion are not specific and may be seen in testicular infarction caused by epididymitis, epididymo-orchitis, and traumatic testicular rupture or infarction.

30. ULTRASOUND FOR TESTICULAR TORSION CON’T Early stages, scrotal contents may have a normal sonographic appearance. • After 4 to 6 hours, the testis becomes swollen and hypoechoic , • After 24 hours, the testis becomes heterogeneous as a result of hemorrhage , infarction, necrosis, and vascular congestion • The epididymal head appears enlarged and may have decreased echogenicity or may become heterogeneous. • The spermatic cord immediately cranial to the testis and epididymis is twisted, causing a characteristic torsion knot or “whirlpool pattern” of concentric layers Large, echogenic or complex extratesticular masses caused by hemorrhage in the tunica vaginalis or epididymis may be seen in patients with undiagnosed torsion

31. TREATMENT Definitive treatment: surgical detorsion and orchioplexy • Manual detorsion : medial to lateral; “opening a book” – May need to rotate 2-3 times for complete detorsion Roberts

32. THANK YOU