TESTIS

SUMMARY OF

INDEX
TESTICULAR NEOPLASM
TESTICULAR CYSTS
EPIDIDYMO-ORCHITIS
TORSION TESTIS
UNDESCENDED TESTIS
VARICOCELE

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99% of testicular tumors are malig. / Bilat. in 3-5%

Etiology
GERM CELL TUMORS INTERSTITIAL TUMORS
2RY TUMORS
1) Incomp. descended tetsis (85%) (1.5%)
esp. intra-abdominal.
1) Leydig Cell tumor.
2) Klinefelter's $. 1) Seminoma. 40% · Lymphoma. 7%
2) Sertoli cell tumor:
3) Iso-chromosome 12p. 2) Teratoma. (Non- seminoma) 32% · Leukimic infilt.
· After puberty.
(80% of testicular tumors) 3) Combined. 14% · Metastatic.
· Bening - feminize.

SEMINOMA (40%) TERATOMA (32%)

AGE 35 – 45 ys. 20 – 35 ys.
CELL OF ORIGIN Spermatocytes in the Seminiferous tubules. Embryonic (Totipotent) cells in the rete testis.
MAC. · Size ® Moderate to large. · Size ® Variable (small as a peanut large as coconut)
· Surface ® Smooth – lobulated. · Surface ® Smooth.
· C/S ® homog. & pink creamy in color. · C/S ® heterog. & Yellow containing gelat. mat. & cartilage.
MIC. 1) Sheets of Rounded or oval cells resemble Spermatocytes: 1) Dermoid cyst. (Malig. Teratoma Differentiated)
· Rounded or oval cells. 2) Terato-Carcinoma (M/C). (Malig. Teratoma Intermediate)
· Vacuolated cytoplasm. 3) Emberyonal carcinoma. (Malig. Teratoma Anaplastica)
2) Lymphocytic infiltration. 4) Choriocarcinoma. (M/D) (Malig. Teratoma Trophoblastica)
LDH: 5) Endodermal Sinus Tumor. “EST”
SPREAD (MAINLY) · Leukemia.
Lymphatics to the para-aortic & iliac LNs. Blood mainly to lungs.
· Lymphoma.
TUMOR MARKERS 1) b-HCG in 10%. · Seminoma. 1) b-HCG in 100% of Chorio-carcinoma.
(SEE INVEST.) 2) LDH. · Pulm. Embolism
2) a -FP in 75%.
TTT. & STAGING · high Retro-grade inguinal Orchiectomy in both! · Postop. Chemotherapy. (highly radio-resistant)
1
· Post-op. Radioth. for LNs & Cisplatin for dx. metastasis. · Retro-peritoneal Lymphadenectomy after chemo th.

Symptoms
Typical
MAIN = PAINLESS TETSIS ++
1) Sense of heaviness.
2) Loss of testicular sens. (early)
3) hx. of trauma.
4) Para-aortic LN ++.
CL./P STAGING
Signs · STAGE I: Testis ONLY.
· STAGE II: LNs below diaph.
1) TESTIS ® see path. (Mac) · STAGE III: LNs above diaph.
Atypical 2) EPIDIDYMIS ® oblit. of its sulcus · STAGE IV: Dx. metastasis to
(3 X 2) & infiltrated with the tumor. lung & liver.
3) LAX 2RY HYDROCELE in 10%.
· 2 ACUTE:
ACUTE vag. hydrocele.
ACUTE EpididymoOrchitis.
· 2 H ® Hormonal. (Sertoli ® feminization.
Leydig ® precocious puberty & Infantile hurcles) INVEST.
Huricane. (if highl malig.)
· 2 OCCULT: Teratoma ® lung metastasis.
Seminoma ® Virchow's LN.
1ry Tumor 2ry Tumor
1) FROZEN SECTOIN BIOPSY (inguinal
approach & never scortal to avoid local 1) CXR & CT chest.
implantation + involvement of ing. LN) 2) CT abd. for para-aortic LNs.
2) SCROTAL US. 3) IVP for retro-perit. metastasis.
3) TUMOR MARKERS. (C B4) 2
 EPIDIDYMAL CYSTS
ETIO. Degenerative cysts of the
vestigial embryonal remnants.
(remnant of mesonephric tubules)
C/P Painless scrotal swelling.
SITE · Just above & behind ! testis.
· Multilocular + crystal clear fluid
SP. · Brilliant translucent with
CCC. numerous septa & tessellated
® Chinese lantern app.
CONSIST · Tense cystic. (not lax)
TTT. 1) No TTT. is required.
2) Excision if discomfort but the
pt. should be warned that it
would interfere with the
transport of sperms from testis.
DD 1) Spermtocele / Epidermal Cyst.
2) Encysted hydrocele of SC.
3) Vaginal hydrocele.
SPERMATOCELE HYDROCELE
ENCYSTED HYDROCELE CONG. HYDROCELE
OF THE SC OF THE TV
1RY VAGINAL HYDROCELE
Unknown but:
Retention cysts from the Persistent intermediate Persistence of the whole · Repeated sub-clinical infection.
tubules of Vasa efferentia part of process vaginalis process vaginalis
· Or repeated trauma.
Painless scrotal swelling Mother complains that her Painless scrotal swelling.
Painless scrotal swelling
but sometimes v. large ® infant has scrotal swelling 1) Infection ® pyocele. Calcification – Rupture.
at the spermatic cord 2) Hge ® hematocele.
mistaken for 3rd testis. with Diurnal variation. Herniation through ! dartos ms.
· Just above! testis. · Above the Sp. cord · Abd. exam. ® ± TB · Scrotal neck test = purly scrotal swelling.
· Unilocular – smooth. separated by Gap. st
peritonitis is the 1 manifest · Scrotal US if testis is impalpable.
Dimly Translucent · Translucent, moves · Fills gradually on standing · Moves from side to side
(Barley water in app. from side to side not & empties on lying down not along the cord.
dt sperms) along the cord. & elevating the scrotum.
· Tense cystic. · Cystic. · Cystic Translucent with
· +ve Traction. (fixed) bi-polar fluctuation test & dull percussion.
1) Small ® ignore. Excision through an Upper part ® Excision. Surgical & NEVER Aspiration dt:
inguinal incision. a) Recurrence. / inf. / hge.
2) Large ® Excision Lower part ® Eversion.
but the pt. should be b) If testicular tumor ® implantation.
warned. 1) EVERSION OF TV. (any fluid formed will be
drained by the scrotal lymphatic)
2) SUB-TOTAL EXCISION OF TV ® if large,
thick walled or calcified.
3) LORDS’ ® incision & plication of TV.
hydrocele of ! hernial sac. Infantile hydrocele 2ry Vaginal hydrocele
3


ACUTE EPIDIDYMO-ORCHITIS CHRONIC EPIDIDYMO-ORCHITIS

ETIOLOGY: TB B FILARIASIS
· CA ® E. Coli – Staph. & Strept – Proteus – ROI Worms reach pampiniform plexus via 2 Through lymphatics
1) Blood borne. (rare)
Chlamydia. routes:
2) Lymph. spread form the · Vesico-prostatic plexus of veins.
· SOI ® UTI along the vas – peri-vasal lymph. – bl. urinary tract via Vas. · SM through Anastomosis bet.
stream.
mesenteric & spermatic vs.!
CL./P: SITE (M/C) · lymph. borne ® tail then ! rest. Perivascular affection: All of the cord
· Dysuria + FAHM. (390) · Grandular type. becomes thick &
· Blood borne ® head then ! rest!
· Acute painful scrotal swelling · Nodular type. matted.
¯ by elevating the scrotum. THE CORD Vas only is affected. (thickened & · Intact Vas. Vas. (matted)
· 2ry hydrocele. beaded in lymph. born) · Beading of veins. can’t be identified.
Nodular & swollen. testis is Fine nodules & non-tender Swollen & tender
DD = TORSION TESTIS. TESTIS & EPIDYD
rarely affected
INVEST.: 2RY HYDROCELE Small lax hydrocele moderate Large hydrocele
1) Urine analysis – C&S.
2) Duplex to exclude Torsion. DRE TB nodules in the seminal vesicle &
prostate. Urine & semen analysis Chronic fibrotic prostatita free
COMPLICATIONS: for TB by ZN & LJ medium.
1) Testicular abscess. TTT. 1) Anti-TB drugs. 1) Anti-bilhrzial drugs. Only medical:
2) Testicular atrophy. ABS & hetrazan.
2) If failed > 2ms. ® Excision 2) Surgical excision ® Settle the
3) Chronicity. ACUTE FILARIAL FUNICULO EO of Vas deferens & epididymis diagnosis & relieve the dragging
3 diff. · Endemic areas. pain.
TTT. · Acute. (sup. – gang. - fulminating)
1) R AAA. (Quinolones) · Matting of the cord.
2) If abscess ® Drainage
Invest= Eosinophilia + m filarial bl. film.
3) Lead sub-acetate.
TTT. = Anti-filarial. 4
 PATHOLOGY
· Rt. Testis rotates clockwise!
· Lt Testis ® Anti-clockwise!
· Sperm. Cord ® vs. Thrombosis
ETIOLOGY CL./P · Scrotal skin ® RHTS.
· Gangrene in 4-6 hrs.

PDF PPT. factors Symptoms Signs

1) Inversion of the testis: · Sudden straining. SUDDEN SEVERE

(sup. – ant. – lat. – loop) AGONIZING PAIN
· Lifting heavy objects. TOSION OF TESTIS APPENDIX
2) Arrested & ectopic testis. in the groin & lower abd. · TESTIS = RHTS +
· Minor trauma. (HYDATID OF MORGAGANI)
¯ No impulse on cough.
3) Incomplete descended testis. · Embryonic remnant of para-
4) Long Mesorchium. Reflex NV & Abd. · TACHYCARDIA ± SHOCK! mesonephric duct.
distention dt p. ileus. · LOSS OF CREMASTERIC
5) High investment of TV. · Trans-ilumm. ® blue dot sign.
reflex in the affected side.
· TTT. = Immediate ligation &
excision of the twisted appendix.
DD = STRANGULATED HERNIA:
(IRREDUCIBLE – NO IMPULSE ON COUGH – TENSE & TENDER)
Invest. Scrotal Duplex & US is diagnostic. TORSION ACUTE EPIDIDYMO-
ORCHITIS
Eversion of TV to prevent AGE Adult & Child Adult or elderly
Viable hydrocele + Orchipexy to ORCHIPEXY OF ! HX. Mild trauma UTI symptoms
Urgent Inguino- prevent recurrence OTHER TESITS
TTT. scrotal incision
(AS ITS BILATERAL)
TEMP. Slight ­ ­­
® untwist the testis Non- Orchiectomy SCROTAL ELEV. ­ Partially ¯pain
viable above the twist U. ANALYSIS Free Pus cells
5
DUPLEX Obst. vs. Patent vs.
 PATH. ETIOLOGY CL./P

INCIDENCE:
1) Rt. testis = 50%
2) Lt. testis = 30%.
3) Bilateral = 20%.
SITE OF ARREST (acc. to freq.):
1) External ring.
2) Scrotal neck.
3) Inguinal canal.
4) Abdominal.
Bilateral cases Unilateral cases
dt hormonal defect
& ass. with hypo-
dt Anatomical barrier
gonadism & slipped 1) Short testicualr a. ü
upper epiphysis
2) Ass. hernial sac.
3) Inadeq. inguinal canal.
4) Rtetro-perit. adhesiins.
5) Rupture gubernaculum.
Symptoms & Signs
Empty scrotal compart. +
Not well developed + Testis is
1) Palpated if arrested at ext.
ring or neck of scrotum.
2) Impalpable if intrta-abd.
3) diif. to plapate in ing. canal.
4) Cong. hernia in 80-90%
Complications = 4T
1) Tumor.
2) Trauma. (abnorm. site)
3) Tortion.
4) aTrophy ® loss of
Spermatogensis sparing
intrstitial cells ® (N) 2ry
sex ccc. & erection.

Ain Shams Classif. of

INVEST. Abd. Undescended Testis

· Type I: No testis is visualized.

for Implapable Tetsis only
1) Laparoscopy. (Diag.)
2) Abd. US & CT scan.
3) MRI if failed to localize.
· Type II: at Int. ring + Vas & vs. looping to
the internal ring
· Type III: at int. ring + Vas & vs. going
directly to testis. (no looping)
6
· Type IV: Abd. testis not related to int. ring.
 TREATMENT

Inguinal Abdominal

DD OF EMPTY SCROTAL COMPARTMENT

1. Arrested testis.
UNILATERAL OR 2 Stage Lap.
BILATERAL 2. Mal descended testis.
FAILED MEDICAL Orchipexy
3. Retractile testis.
4. Surgically removed testis.
b-HCG single course ORCHIPEXY AT 1.5 YRS
1ST STAGE = lap. clipping of
to avoid precosious to preserve the hormonl f.
the test. a so testis depends
RETRACTILE TESTIS:
puberty but doesn't ¯ malig. · Common in childhood dt active cremasteric ms.
on ! artrey of vas.
ORCHEICTOMY ONLY AFTER puberty · Chair test or Squatting pos. test.
2ND STAGE = LAO after 6 ms.
· No ttt. is required.

Mobilize Retain Ectopic inguinal Inguinal arrested

1) Free from the surrounding. 1) Scrotal Stich. Sites: Site of Arrest:
2) Excise ass. hernial sac. 2) Ext. dartos pouch. 1) Superf. Inguinal pouch. ü 1) External ring.
3) Divide Inf. epigastric a. to 2) Peritoneum. 2) Scrotal neck.
abolish the ang. of vas around it.
3) Root of penis. 3) Inguinal canal.
IF ORCHIPEXY FAILED ® 3 OPTIONS
4) Femoral triangle. 4) Intra-abd.if bilat.
Etiology: traction by side way ® Cryptochidism.
2 Stage Fowler-Stephens tech. m vascular tech. gubernaculum. (Look wood th.)

after max. mobilization, · Division of the Testicular a. Straining ®Testis more apparent Less apparent
Testsis anchored with (but the A. of vas should be intact) Division & Reanast. Testis can be pushed medially The reverse.
prolene suture & 2nd · Known by clamping the test. a. for of test. a. with Inf.
stage is done after 6 several mins. ® if the testis didn't epigastric a. Open Orchipexy as the testicular See above
ms. become ischemic ® Artery is divide. vs. & vas are of optimal length. 7

ETIOLOGY
PDF
1) Age: Puberty till 35 ys.
2) Cong. mesench. weakness
® ass. with hernia, VV & piles.
It is varicosity (Dilatation, Elongation & torsiousity)
of pampiniform & cremasteric plexus of veins
1RY
CL./P
PPT. Symptoms
­ Venous pr. 1) Asypmtomatic. (M/C)
· Standing. (prolonged) 2) Dragging pain dt ms.
· Starining as cosntip. relaxation ® ­on standing.
· Cong. dt unreleievd
sexual excitement.
COMPLICATIONS
1) Neurosis. (most. Imp.)
2) Sub-fertility (20%): dt warmth
+ Toxic Adrenal metabolites.
3) 2ry hydrocele dt ch. Cong.
4) Recurrent Thrombophelbitis.
2RY
M/C CAUSE = hypernephroma
· > 40 ys.
· Both sides equally.
· Rapid onset & prog.
Signs
· Doesn't disapp. on lying
down or scrotal elev.
· TTT = of the cause.
Tall - Thin - Visceroptosis
· ‫ ® ﺑﺺ‬lt. is lower > rt. side.
· ‫ ® اﻣﺴﻚ‬bag full of worms.
· ‫ ® ﻛﺢ‬thrill dt turbulence.
· ‫ ¯ ® ﻧﺎم‬swelling.
8

Invest. Treatment

1) Semen Analysis ® Stress Triad.

2) Scroal Duplex.
3) Scrotal US for GRADING.
4) Abd. US to exclude 2ry cause as RCC.
GRADING
· 0 = detected by Duplex only.
· 1 = detected by straining.
· 2 = detected by palpation.
· 3 = detected by inspection.
Conservative Surgery
1) Reassure. 1) If Sub-firtility after exclusion of
2) Pain ® Scrotal support. all causes of infertility.
3) Freq. cold baths. 2) Large painful varicocele.
4) Avoid sexual cong. &
prolonged standing.
RECENTLY = LAPAROSCOPIC VARICOCELECTOMY
5) Venotonics
OTHER OPERATIONS APPROACH

WHY LT. VARICOCELE > RT. SIDE?

RETRO-PERITONEAL INGUINAL SCROTAL
1) LT. TESTICULAR V.
(PALOMO’S OP.) (NOT DONE)
a) Opens at Rt. angle in the lt. RV.
b) Compressed by the sigmoid colon. IDEA Ligation & division of the Ligation of pampiniform plexus in Ligation of pampiniform
c) Opens close to the adrenal veins so its testicular v retro-perit. ing. canal + Excision of ! v. to plexus high in the scrotum
exposed to the action of its metabolites. avoid recanalization
d) Longer than the rt. testicular v. ADV. No post-op. hydrocele. No recurrence
e) Lack of anti-reflux valves at the as ! cremasteric v. is ligated.
junction bet. the testicular vein & RV.
DISADV. Recurrence as the Post-op. hydrocele Injury of the sympath. NFs.
2) LT. RV passes ant. to the Aorta & post. Cremastric v. is not ligated ® Eversion of TV is routinely. around the pampiniform
to the SMA. (Nut cracker) 9
plexus ® Testicular Atrophy!