Transcript Scrotal Problems

Scrotal Problems
Yewande Ogunyemi
Introduction
The scrotum is a protuberance of skin and
muscle containing the testicle.
 Function is to regulate the temp of the
testicles through the cremaster muscle
and the dartos fascia in the scrotum.
 Ideal temp is about 34.4, > 36.7 may
damage sperm count.
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Incidence of common causes of acute scrotal problems in infants and children.
Davenport, M. BMJ 1996;312:435-437
Copyright ©1996 BMJ Publishing Group Ltd.
Rarer causes in children
Henoch – Schonlein purpura
 Leukaemia
 Scrotal hyperpigmentation – congenital
adrenal hyperplasia
 Epididymo-orchitis
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Acute scrotal pain
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Causes;
Acutely painful scrotum is torsion of testis until proven
otherwise.
Strangulated inguino-scrotal hernia is tender, painful,
irreducible groin lump.
Torsion of the hydatid of Morgagni
Acute epididymitis
Haematocoele - trauma or scrotal surgery
Fournier’s gangrene-necrotising fasciitis
Appendicitis - referred pain (same visceral afferent nerve
supply as testis - T10)
Chronic scrotal pain
Causes;
 Inflammation
 Chronic bacterial epididymitis
 Recurrent incomplete testicular torsion
 Chronic scrotal discomfort-in absence of
infection. Often hx of scrotal surgery or
trauma.
 TB
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Testicular torsion in newborn infant
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Twist of the whole spermatic cord due to unfixed nature
of newly descended testis.
Almost all of such torsions present late with overt
testicular necrosis
Pain and tenderness are not prominent.
scrotum usually red and swollen and contains hard
testicular mass
surgery to excise damaged organ and to fix other testis.
Testicular torsion in older boys and
adults
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Many cases yearly of ‘epididymitis‘ treated with antibiotics.
Slight left sided bias, incidence higher in winter months
Major predisposing factor is undescended testis
Symptoms include severe testicular pain which may radiate to the
groin +/- nausea and vomiting.
Examination - gentle. high riding or horizontal testis. No specific path
gnomonic clinical signs to differentiate from epididymitis.
Treatment - successful testicular salvage highly dependent on time
b/w start of symptom and surgery. Detorsion and fixation of viable
testis. contra lateral testis fixed at same time.
Rates of testicular salvage by time from start of symptoms.
Davenport, M. BMJ 1996;312:435-437
Copyright ©1996 BMJ Publishing Group Ltd.
Scrotal swellings
May or may not be confined to scrotum
 The cardinal sign of true scrotal swelling is
that it is possible to get above it.
 Cystic masses transilluminate, solid
masses do not.
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Cystic scrotal swellings
Separate from testis
- Epididymal cysts
- Spermatocoele
 Testis lies within swelling
- Hydrocoele
-Haematocoele - does not transilluminate
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Solid scrotal masses
Separate from testis
-Acute/chronic epididymitis
-Torsion of hydatid of Morgagni
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Within the testis
-Testicular tumour
-Torsion of testis
-Orchitis- bac/viral (mumps,influenza,TB,STD)
-Testicular gumma
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Scrotal mass not confined to
scrotum
Examiner is unable to get above
- Inquino- scrotal hernia
- Varicoecoele of the pampiniform plexus
- Encysted hydrocoele of the spermatic cord
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Hydrocoele
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Result of excessive fluid in tunica vaginalis
Congenital/acquired
Primary - occur in absence of disease in testis. Tends to be large
and tense. Common in young boys.
Secondary - represent a rxn to testicular pathology - tumour,
infection, and torsion
Presentation is usually as a soft non tender and cystic swelling in
scrotum which transilluminates. One can get above lesion. Testis
lies within fluid collection and is not palpable
Conservative mgt. Scrotal support. Refer if symptomatic or children
> 1 yr. needle aspiration, surgery.
Secondary- Rx underlying cause
Varicocoele
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Varicose veins in the pampiniform plexus of the
spermatic cord and scrotum.affects 15 - 20% of males.
rare after 40yrs.
Most are asymptomatic found during investigation for
infertility in 40 % males.
Pelvic mass compressing venous drainage of testicle
Dull ache at the end of the day or following exercise
Dragging or feeling of heaviness
Visible on standing and feels like a ‘bag of worms’. Pos
cough impulse. Disappears when recumbent.
Surgical intervention only if painful, infertile or testicular
atrophy
Testicular tumours
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Most common cancer in men ages 20 – 40
Most growths in scrotum are benign.
However take seriously painless lump in scrotum or in
testicle or unexplained pain in one testis.
Presence of hydrocoele.
Mass is hard and does not transilluminate
Predisposing factor is hx of undescended testis
Urgent referral under 2 wk rule.- tumour markers LDH,
AFP and HCG
NICE GUIDELINES-refer pts with a swelling or mass in
body of testis. Consider urgent USS in men with scrotal
mass that does not transilluminate and when body of
testis cant be distinguished
Epididymitis
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Inflammation of epididymis +/- orchitis
Predisposing factors ;UTI,Urethral instrumentation,
STI; E.coli and Chlamydia with hx of discharge
CF- pain and swelling, inflammation, fever +/- rigors.
Prehn’s sign - scrotal elevation relieves pain
Secondary hydrocoele
Clinically indistinguishable from torsion
Inv –fbc,blood culture,msu,plain abdo xray, IVU/USS
Rx –rest, scrotal elevation, broad spectrum abx,nsaid
and non exertion for 1-3 wks
Other causes
Idiopathic scrotal oedema
 CCF
 Kidney/liver disease
 Contact dermatitis
 Yeast infection
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Epididymitis: swollen, tender, non-transilluminable scrotum in 18 month old child (top)
and the underlying acute epididymitis (bottom).
Davenport, M. BMJ 1996;312:435-437
Copyright ©1996 BMJ Publishing Group Ltd.
Scrotal bruising due to idiopathic haemorrhage in a 3 day old infant.
Davenport, M. BMJ 1996;312:435-437
Copyright ©1996 BMJ Publishing Group Ltd.