Anatomy

ACUTE vs. CHRONIC scrotal swelling

Acute Chronic
Torsion of spermatic cord/testis
Torsion of appendix, epididymis
Acute epididymitis/orchitis
Mumps orchitis
Henoch-Schnlein purpura (painless)
Trauma
Insect bite
Thrombosis of spermatic vein
Fat necrosis
Hernia
Folliculitis
Dermatitis, acute

Hydrocele (painless)
Hernia (painless)
Varicocele
Spermatocele
Sebaceous cyst
Tumor (painless)

Acute
Characteristic
Pain
Swelling
Erythema
Sudden onset
Always an EMERGENCY!!!
Why EMERGENCY?
Potential for testicular loss and infertility
Legal action can be taken
Accurate diagnosis limited by similarity of
presentation and physical findings of different
causes
Radiological techniques is helpful, but may
delay treatment
Operation may be needed for Dx and Tx
purposes

Chronic
Long standing
Slow growing (>6 weeks)
Pain/painless
Incidental finding

Testicular torsion
Torsion of the testis (spermatic cord) strangulation of gonadal blood
supply testicular necrosis and atrophy.
Window of opportunity to salvage - within 6 hours!
Acute scrotal swelling in children indicates torsion of the testis until
proven otherwise

_________________________________________________________

Acute-onset agonising pain over hemiscrotum, groin, lower abdomen
Nausea and vomiting
Scrotal swelling with erythema
High lie of testis, palpable thickening tender cord
May occur at rest or may relate to sports or physical activities (sometimes
upon straining at stool, coitus, during sleep)
May describe similar previous episodes, which may suggest intermittent
testicular torsion (spontaneous detorsion)
No voiding problems or painful urination
Difficulty in ambulation
Predisposing causes
1. Inversion of testis
transverse lie/upside down
2. High investment of tunica vaginalis
3. Separation of epididymis from body (long mesorchium)
torsion without involving cord, confined to pedicle that connect testis
with epididymis

2 types of torsion:
Extravaginal (5%)
- testis rotates freely prior to fixation of testis
- more common in neonates
Intravaginal (16%) : Bell Clapper deformity
- lack of fixation (testis freely suspended within tunica vaginalis)
- peak incidence at adolescence age 13

Incidence
Most common between 10-25yo (1:4000)

Pathophysiology :
Violent contraction of abdominal muscles contraction of cremaster
favors rotation around vertical axis


Torsion of 3-4 turns : irreversible changes (necrosis)
within 2 hours
Torsion of 1 turn (360:) : well tolerated for 12 hours (20% viability)
necrosis after 24 hours
Torsion of 90: : well tolerated for 7 days
L P SONDA, J LAPIDES in Surgical Forum (1961)

O/E
Extremely tender, enlarged
High riding testis
Reactive hydrocele
Scrotal wall erythema
Ecchymosis
Cremasteric reflex
if present, no torsion
if absent 66% rule in torsion

Ix
UFEME : TRO UTI/epididymorchitis, leucocytes in 30% patients
FBC : TWC in 60% patients
US Doppler scrotum/testis
Contrast MRI : evidence of torsion knot or whirlpool patterns
Nuclear testicular scan/scintigraphy
to ddx torsion from acute epididymitis by demonstrating cold spot and ring
signs.

* Radiologic techniques are helpful but may delay treatment*
US Doppler scrotum/testis
Sensitivity 80 - 90%
Specificity 100%






The case on the left shows a testicular torsion of the left testis.
Complete absence of intratesticular blood flow and normal
extratesticular blood flow on color Doppler images is diagnostic, if
the flow is normal in the contralateral testis.





Nuclear testicular scan/scintigraphy
- Technetium-99 (
99m
Tc-pertechnetate) to trace testicular blood flow
- Requires 1-2 hours
- 86-100% accuracy



Management
1. Alleviation of symptoms
Analgesic : IV/IM pethidine
Antiemetic : IV stemetil 10mg, IV maxolon
Anxiolytic : IV valium

2. Manual Detorsion
Rotate testicle in medial to lateral direction open the book
usually 1-2 complete turns
relief of pain
return of blood supply to testicle (confirmed with US)
additional time before OR
patient may not tolerate.

3. Surgical exploration
Bilateral orchidopexy to prevent future torsion
Orchidectomy + contralateral orchidopexy

4. Placement of testicular prosthesis after 6 months of orchidectomy via
inguinal incision

Prognosis
< 6 hours, 90% salvage
> 6 hours, 20% viability likelihood for orchidectomy
> 24 hours, 100% loss and atrophy

Complications
Testicular atrophy : may occur days-to-months after
the torsion has been corrected.
Severe infection of the testicle and scrotum is also
possible if the blood flow is restricted for a prolonged
period.
Epididym-/orchitis
Most common cause of acute
scrotum(75-80%)
Acute : < 6 weeks (CDC, STD treatment guidelines)
Young men hx of STD exposure
(Chlamydia trachomatis, Ureoplasma urealyticum,
Neisseria gonorrhea)
Children : UTI, urinary tract structural
anomalies (E. coli, Streptococci, Staphylococci, Proteus)
Older men : BPH, post vasectomy, post urological operative
procedure/instrumentation, indwelling catheter, infectious
prostatitis, TB
Orchitis : Syphillis, leprosy
Viral cause : Mumps (18% males), usually a/w parotid swelling


Chronic tuberculous epididymo-orchitis usually
insidious onset a/w cold abscess discharge
Syphillis
usually affects body of testis
1. Bilateral orchitis : congenital syphillis
2. Interstitial fibrosis painless destruction of testis
3. Gumma : unilat. painless slow growing swelling
Leprous orchitis : testicular strophy in 25%
male lepers.

S/Sx
Acute progressive onset of scrotal/ groin pain
(>24hr)
Gradual swelling, erythematous, shiny scrotum
Febrile fever
Dysuria
Difficulty in ambulation
Urethral discharge
Hx of recent instrumentation/indwelling CBD
O/E
Scrotal swelling (secondary hydrocele), enlarged,
erythematous and indurated
Indistinguishable testis (in later stage)
Cremasteric reflex is usually present
Prehn sign positive : elevation of the scrotum may
provide relief of pain.
Pyuria

Ix :
UFEME : leucocytes > 10 visual field
MSU C&S/pus C&S : bacterial growth
Venereal disease screening : for sexually active men
Immunofluorescent antibody test, if suspected mumps
US scrotum/testis
Flex CU : to detect structural anomalies
Scrotal exploration or aspiration (rare)
If torsion cannot be ruled out
Complications eg. abscess, pyocele, testicular infarction
Failed conservative treatment in 48-72 hours


US scrotum/testis (sensitivity 82-100%, specificity 100%)





The case on the left shows the typical features of
epididymitis.
Swollen, heterogeneous, hyperemic
Hydrocele
Scrotal wall thickening.
With color doppler there is increased flow.

A normal epididymis has only limited colorflow.
Diagnostic Criteria for Epididymitis
Gradual onset of pain
Dysuria, discharge, or recent instrumentation/CBD
History of genitourinary abnormality
(UTI, neurogenic bladder, hypospadias, etc.)
Fever > 38:C
Tenderness and induration at epididymis
Abnormal UFEME (>10 leucocytes visual fields/RBC)

3 or more findings present - definite Epididymitis
2 findings present - probable Epididymitis
1 finding present - possible Epididymitis
Management
1. Antibiotic therapy : if UFEME/MSU C&S positive
for infection
Suspect STD : IV rocephine + T. doxycycline x 10/7
Suspect UTI : IV/T. ciprobay x 10/7
Others : Azithromycin, Bactrim, Gentamicin,
2. Bed rest/scrotal elevation : if UFEME/MSU C&S
negative sterile chemical epididymo-orchitis
(structural anomalies)
3. Supportive therapy : ice packs, cool Sitz bath
4. Analgesia : opioids, NSAIDs
5. Orchidectomy : if complications developed
Complications
Abscess
Pyocele
Testicular infarction
Testicular atrophy
Infertility

Prognosis
Resolution of sx in 2-4 weeks if properly treated
Chronic epididymoorchitis may have frequent mild
attacks, may have lumps in scrotum due to
fibroplasia
May have threat of infertility

Torsion of testicular/epididymal appendage
Remnant of Wolffian(epididymis)/Mullerian(testis) duct
Can be twisted torsion
o/e : testis palpable with normal lie, edematous, torsed
appendage palpable over upper pole of testis, blue-dot sign
if ecchymotic
US Doppler : normal testicular perfusion with hyperemia over
appendage
Self limiting (infarct atrophy)

Testicular trauma
Damage occurs when the testis is forcefully
compressed against the pubic bones
Traumatic epididymitis : noninfectious
inflammatory condition occurs within a few days
after a blow to the testis. Treatment is same like
nontraumatic epididymitis.
Scrotal trauma can also result in intratesticular
hematoma, hematocele or laceration of the
tunica albuginea (testicular rupture).
US Doppler : imaging technique of choice.


Degree of testicular trauma
1. Blunt (85%) : direct external force to testicle
2. Penetrating (15%) : sharp objects, high velocity missiles
3. Degloving : Scrotal skin sheared off

Genital self-mutilation : if testis vital, reimplantation is
possible

Pathophysiology : rupture intratesticular hemorrhage
in tunica vaginalis HEMATOCELE! extends up to
epididymis bleeding SCROTAL HEMATOMA!
O/E
Swelling
Tenderness
Ecchymosis
Scrotal wall thickening
Palpable testis : unlikely rupture
Difficulty in palpation : US urgent to determine
degree of testis injury

Management
1. Bed rest
2. Scrotal support
3. Pain relief
4. Testicular debridement
5. Closure of tunica albuginea

Penetrating trauma : urgent exploration to assess
degree of injury and control intratesticular hemorrhage

Degloving injury : often need debridement, skin closure
may not be possible

Indications for scrotal exploration include the
following:
Uncertainty in diagnosis after appropriate clinical and
radiographic evaluations
Clinical findings consistent with testicular injury
Disruption of the tunica albuginea
Absence of blood flow on US Doppler studies

Complications
Testicular infection
Testicular atrophy
Testicular necrosis
Infertility
Disruption of male hormonal functions
Incarcerated inguinal hernia
Irreducible inguinal hernia a/w pain
A surgical emergency
Scrotal swelling, groin
pain/swelling, abdominal pain, constipation,
fever, nausea/vomiting
Ix : FBC, US scrotum, CT
Mx : surgical exploration,
herniotomy/hernioplasty

Hydrocele
A collection of serous fluid in the tunica vaginalis
Congenital : occurs in infants due to patent processus
vaginalis peritoneal fluid can enter the scrotum


Primary. (idiopathic)
Develop slowly
Large
Hard & tense
No defined cause
Over 40s


Secondary
Develop rapidly
Small
Lax
Underlying cause
younger age group(20-40)

Congenital hydrocele: processus vaginalis is patent &
connects to the peritoneal cavity. In children <3yrs
Infantile hydrocele: the tunica and processus
vaginalis are distended to the superficial inguinal
ring. There is no connection. Occurs in all ages
Hydrocele of the cord: swelling near the spermatic
cord. Ddx hernia, lipoma of the cord

O/E
often bilateral
Can get above it
Testes cannot be felt separately
Transluminates
Fluctuant
Fluid thrill
Not compressible or pulsatile
Cant be reduced
Normal skin color & temp
Not tender if primary (may be tender if secondary)
Size can be reach up to 10-20cm in diameter
Surface smooth



Ix : US scrotum to ddx from other causes





Management :
If congenital hydrocele persists beyond the age of 1year, surgical treatment
is indicated. This involves the division and ligation of the processus.
In an adult with primary hydrocele
Surgery
Opening the tunica vaginalis longitudinally
Emptying hydrocele
Everting the sac
Suturing it behind the cord thus obliterating the potential space
Aspiration recurance
I n elderly patient who are not fit for surgery

Secondary hydrocele treat the underlying cause

Testicular tumor
Rare 11.5% of male cancers.
mainly affects younger men of 30 40yo
90 - 95% arise from germ cells and are either
seminomas (45%) or nonseminomas(50%).
(Nonseminoma : choriocarcinoma, embryonal carcinoma, teratoma,
and yolk sac tumors)
5% are lymphomas, sertoli cell tumours or
leyding cell tumours.
Prognosis is good particularly if there was no
lymph node involvement


Incidence and frequency
Seminomas in 30-40y.
Teratomas in 20-30y.
Imperfectly descended testes have a 20-30 times
increased incidence of malignancy.

Recommended pathologic classification (EUA, 2011)

Germ cell tumours
Intratubular germ cell neoplasia, unclassified type
Seminoma (including cases with syncytiotrophoblastic cells)
Spermatocytic seminoma (mention if there is a sarcomatous component)
Embryonal carcinoma
Yolk sac tumour
Choriocarcinoma
Teratoma (mature, immature, with malignant component)
Tumours with more than one histologic type (specify percentage of individual components)

Sex cord/gonadal stromal tumours
Leydig cell tumour
Malignant Leydig cell tumour
Sertoli cell tumour (lipid-rich variant, sclerosing, large cell calcifying)
Malignant Sertoli cell tumour
Granulosa (adult and juvenile)
Thecoma/fibroma group of tumours
Other sex cord/gonadal stromal tumours (incompletely differentiated, mixed)
Tumours containing germ cell and sex cord/gonadal stromal (gonadoblastoma)

Miscellaneous nonspecific stromal tumours
Ovarian epithelial tumours
Tumours of the collecting ducts and rete testis
Tumours (benign and malignant) of nonspecific stroma

Classification
1. Germ cell tumors (90%)
- Seminoma 90%
- Embryonal carcinoma 20%
- Choriocarcinoma <1%
- Teratoma 5%
- Teratocarcinoma 40%
(teratoma + embryonal carcinoma)

2. Gonadal stromal tumor (5%)
- Leydig cell tumor
- Sertoli cell tumor

3. Secondary tumor (5%)
Lymphoma
Leukemia
Risk factors for testicular cancer

Epidemiologic risk factors
History of cryptorchidism
Klinefelter syndrome
Testicular cancer in first-grade relatives
Contralateral tumour
Testicular intraepithelial neoplasia or infertility

Pathologic prognostic risk factors for occult metastatic disease (stage I)
1. Seminoma
Tumour size (4 cm)
Invasion of the rete testis
2. Nonseminoma
Vascular/lymphatic invasion or peritumoural invasion
Proliferation rate (MIB-1) >70%
Percentage embryonal carcinoma >50%

Clinical risk factors (metastatic disease)
Primary location
Elevation of tumour marker levels (AFP, B-HCG)
Nonpulmonary visceral metastasis*
Dx is made based on
1. Clinical examination of the testis
2. General examination to exclude enlarged
nodes or abdominal masses
3. US to confirm testicular mass.
Signs
can get above it
Testes cannot be felt separately
Harder than normal testis
Dull to percussion hydrocele
No pain
Irregular, different sizes
Surface usually smooth (sometime irregular or
nodular)

Symptoms
Painless swelling of the testis
Heaviness in the scrotum
Maybe history of trauma delays diagnosis
Tiredness, LOW ,LOA
Abdominal pain if lymph nodes are enlarged
Swelling of legs caused by lymphatic or
venous obstruction
Infertility
Secondary hydrocele

O/E
Painless unilateral mass in the scrotum or the
casual finding of an intrascrotal mass.
Gynaecomastia (common in nonseminomatous
tumor)
Back and flank pain (rarely)

Ix :
US testis
CXR to see cannon ball lesion if metastasized
Tumour markers: AFP, HCG, LDH
CT TAP
CT brain
CT spine
Bone scan
US liver

Serum tumour markers : prognostic factors used in diagnosis
and staging (LDH).
The lack of an increase does not exclude
testicular cancer
LDH levels are elevated in 80% of patients with advanced
testicular cancer, therefore should always be measured in
advanced cancer
Tumour markers must be reevaluated after orchidectomyto
determine half-life kinetics.
The persistence of elevated serum tumour markers 3 wk after
orchidectomy may indicate the presence of disease, whereas
its normalisation does not indicate absence of tumour.
Tumourmarkers should be assessed until they are normal, as
long as they follow their half-life kinetics and no metastases
During chemotherapy, the markers should decline;
persistence has an adverse prognostic value.
Management
Inguinal exploration and orchidectomy
If the diagnosis is unclear, a testicular biopsy
(enucleation of the intraparenchymal tumour) should
be taken for HPE
If metastasized : delay orchidectomy
1. If seminoma: Start radiotherapy plus
chemotherapy.
2. If teratoma: combination chemotherpay 3
drugs(etoposide, vinblastine, methotrexate,
bleomycin, cisplastin)

Organ-preserving surgery
Synchronous bilateral testicular tumours,
metachronous contralateral tumours, or in a
tumour in a solitary testis with normal
preoperative testosterone levels, provided
tumour volume is <30% of testicular volume
Radiotherapy may be delayed in fertile
patients who wish to father children
must be carefully discussed with the patient