Abnormalities Of The Testis And Scrotum

Ahmed Al-Sayyad

Embryology

Testicular differentiation is initiated in the 7th

week of gestation by the SRY gene
At 4 to 6 weeks gestation, the genital ridges
organize. This is followed by migration of
primordial germ cells
At 7 to 8 weeks both sertoli and leydig cells have
developed

Embryology

During the 8th week, the fetal testis begins to secrete

testosterone and MIS independent of pituitary hormonal
regulation
MIS is secreted by the Sertoli cells and causes
degeneration of the mllerian structures after the 8th week
of gestation
The gubernaculum appears at the 7th week of embryologic
development where its cranial aspect envelops the cauda
epididymis and lower pole of the testis and extends
caudally into the inguinal canal, where it maintains a firm
attachment

Cryptorchidism

3% of full-term male newborns and 30.3% incidence in

premature infants
More prevalent among preterm, small-for-gestational-age,
low-birth-weight, and twin neonates
Approximately 70% to 77% of cryptorchid testes will
spontaneously descend by 3 months of age
By 1 year of age, the incidence of cryptorchidism declines
to about 1% and remains constant throughout adulthood

Descent Factors

Hormonal: androgens,MIS,estrogen,descendin
Gubernaculum
GFN and CGRP
Epididymis
Intra-abdominal pressure

Terminology

Undescended
Ascended
Gliding
Retractile
Ectopic

Nonpalpable testis

Intra-abdominal
Vanishing
Atrophic
Missed on examination
Bilateral nonpalpable work-up

Consequences of Cryptorchidism

Infertility
Neoplasia
Hernia
Torsion
Trauma
Cosmetic

Work-UP

Maternal history including the use of gestational

steroids, Perinatal history, including
documentation of a scrotal examination at
birth,PMH,PSH,FH
Examine in a warm room,supine,squatting etc
Look for genital abnormalities,scrotal
size,contralateral hypertrophy

Investigations

Hormones
US
CT
MRI
Laparoscopy

Hormonal Therapy

HCG or GnRH can be used

The lower the pretreatment position the better the
results
Self limiting side effects
Overall success rate < 20%
Limited indications if any

Surgical Intervention

When
Inguinal orchiopexy
Laparoscopic orchiopexy
Fowler-Stephens orchiopexy
Staged orchiopexy
Microvascular autotransplantation

Hydrocele

Normally, the processus vaginalis is obliterated

from the internal inguinal ring to the upper
scrotum, leaving a small potential space in the
scrotum that partially surrounds the testis
Embryologic misadventures may occur and results
in (hydrocele, hydrocele of the cord, and
communicating hydrocele).

Simple Hydrocele

Simple (scrotal) hydrocele is an accumulation of fluid

within the tunica vaginalis
Results from persistence of or delayed closure of the
processus vaginalis
Commonly seen at birth, frequently bilateral, may be quite
large. They transilluminate and may seem quite tense but
not painful
Most resolve during the first 2 years of life
If surgical repair is elected, an inguinal approach should be
used

Communicating Hydrocele

Persistence of the processus vaginalis which

allows peritoneal fluid to communicate with the
scrotum
The classic description is that of a hydrocele that
changes in size
It can be compressible during examination
All should be fixed using an inguinal approach
Do it bilateral if patient got VP shunt or on
peritoneal dialysis

Hydrocele of the cord

Segmental closure of the processus, which leaves

a loculated hydrocele of the cord
Presents as a painless groin mass which is mobile
and transilluminates
Inguinal exploration and high ligation is curative

Acute Scrotum

Differential Diagnosis

Torsion testis
Torsion appendix testis
Torsion appendix epididymis
Epididymo-orchitis
Hernia
Trauma
Vasculitis
Dermatological

Testicular Torsion

True surgical emergency of the highest order

Irreversible ischemic injury may begin as soon as
4 hours after occlusion of the cord
Intravaginal torsion, result from lack of normal
fixation of the testis and epididymis to the fascial
and muscular coverings that surround the cord
This creates an abnormally mobile testis that
hangs freely within the tunical space (a "bellclapper deformity")

Testicular Torsion

Happens in any age but most commonly in

prepubertal males
Presentation: Pain,N\V,Poor appetite,previous
episodes
Examination:Swelling,Tenderness,High
riding,transverse orientation,Loss of cremasteric
reflex

Testicular Torsion

Doppler US may help in the diagnosis

Manual detorsion may be attempted in ER
Scrotal exploration is mandatory
Detorte the affected testis and pex the other side
while waiting for the testis to pink up
If the testis is still alive pex it , if not do an
orchiectomy

Intermittent Torsion

Recurrent episodes of acute, self-limited scrotal

pain
Normal physical examination will be found inbetween
If the suspicion is strong , elective scrotal
exploration and bilateral orchiopexy should be
performed

Prenatal testicular torsion

Extravaginal torsion
Presents at birth as a hard,nontender testis fixed to
the scrotal skin which is usually discolored
Doppler US may help in the diagnosis
Management is controversial: observation Vs
exploration

Torsion Appendix Testis

presentation is extremely variable, from an

insidious onset of scrotal discomfort to an acute
presentation identical to torsion testis
Exam:Tenderness or mass in the upper pole,Blue
dot sign,cremasteric reflex usually present
Doppler US may help in diagnosis
Management:conservative,pain meds,limit activity

Epididymitis

Rare in pediatrics
Presentation:pain,swelling,erethyma,LUTS,fever,
urethral discharge,STDs
Investigations:pyuria, bacteriuria, positive urine
culture, increased flow on doppler
IV Abx given if systematically ill then oral for
total of 10-14 days
Screening US usually indicated
? VCUG

Varicocele

Dilated and tortuous veins of the pampiniform

plexus
Found in approximately 15% of male adolescents,
with a marked left-sided predominance
Etiology:increased venous pressure in the left
renal vein, incompetent valves of the internal
spermatic vein

varicocele

Unilateral varicocele may affect testicular function

bilaterally
Toxic effect of varicocele may manifest as testicular
growth failure, semen abnormalities, Leydig cell
dysfunction, and histologic changes
Possible mechanisms:reflux of adrenal metabolites,
hyperthermia, hypoxia, local testicular hormonal
imbalance, and intratesticular hyperperfusion injury

varicocele

Presentation:asymptomatic,pain,scrotal
mass,infertility,atrophy
Grading on physical examination
Obtain scrotal US
Treat if there is loss of volume (> 2 mls or > 20%)

Treatment Alternatives

Inguinal Ligation and Subinguinal Ligation

Retroperitoneal and Laparoscopic Ligation
Transvenous Occlusion
Complications:hydrocele,recurrence,testicular
atrophy