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Scrotal and Testicular Swelling.pptx

Benign and malignant causes of scrotal and testicular swelling

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Scrotal and Testicular
Swellings
Moderator- Dr. Abebe
Prepared by-
Michael Sintayehu
Outline
•Anatomy of the scrotum
•Anatomy of the testis
•DDx of scrotal swelling
•Breifing of the DDxs
•Reference
2
Anatomy of the Scrotum
• The scrotum is an anatomic male reproductive structure.
• It’s a dual chambered suspension sack distending from the perineum.
• The sack is made of skin, Skeletal muscle, Fascia and Tunica Vaginalis & Albuginea.
• It contains the testis, epididymis and spermatic cord.
Vas deferens and its artery
Testicular artery and pampniform plexus
Genital branch of genitofemoral nerve
Lymphatic vessels and symp nerve fibers
Fat and connective tissue surrounding the cord
The spermatic cord
is made of
3
4
5
Anatomy of the Testis
• The testes develop in the retroperitoneum below the kidneys.
• About the same time as the wolffian duct becomes the
epididymis and vas deferens, the precursor of the
gubernaculum develops as a fold of peritoneum.
• Approximate average size is 4cm x 3cm x 2.5cm.
• Functional unit is a lobule and there are 250 of them.
• Has cells like germ cells, lydig cells and sertoli cells.
• 5-7 efferent ductules.
6
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Scrotal and Testicular Swelling.pptx

  • 1. Scrotal and Testicular Swellings Moderator- Dr. Abebe Prepared by- Michael Sintayehu
  • 2. Outline •Anatomy of the scrotum •Anatomy of the testis •DDx of scrotal swelling •Breifing of the DDxs •Reference 2
  • 3. Anatomy of the Scrotum • The scrotum is an anatomic male reproductive structure. • It’s a dual chambered suspension sack distending from the perineum. • The sack is made of skin, Skeletal muscle, Fascia and Tunica Vaginalis & Albuginea. • It contains the testis, epididymis and spermatic cord. Vas deferens and its artery Testicular artery and pampniform plexus Genital branch of genitofemoral nerve Lymphatic vessels and symp nerve fibers Fat and connective tissue surrounding the cord The spermatic cord is made of 3
  • 4. 4
  • 5. 5
  • 6. Anatomy of the Testis • The testes develop in the retroperitoneum below the kidneys. • About the same time as the wolffian duct becomes the epididymis and vas deferens, the precursor of the gubernaculum develops as a fold of peritoneum. • Approximate average size is 4cm x 3cm x 2.5cm. • Functional unit is a lobule and there are 250 of them. • Has cells like germ cells, lydig cells and sertoli cells. • 5-7 efferent ductules. 6
  • 7. The Epididymis • The epididymis extends as a fleshy strip on the posterior aspect of the testis and is palpable as a separate structure. • Approximately 6 cm in length. • Has head, body and tail lined by tall columnar cells. • Continue up to make the vas deferens. 7
  • 8. 8
  • 9. 9
  • 10. 10
  • 11. Differential diagnosis of Scrotal Swelling Acute Testicular torsion Torsion of the appendices. Epididymitis or Orchitits Epididymo-orchitis. Trauma. Inflammatory vasculitis (Henoch- Schönlein purpura). Chronic Inguinal hernia Hydrocele Hematocele Pyocele Chylocele Spermatocele Epididymal cyst Varicocele Idiopathic scrotal edema Intra-scrotal tumors Dermatologic lesions Systemic (idiopathic lymphedema, TB…) 11
  • 12. Testicular Torsion • AKA Acute Scrotum • Surgical emergency • The spermatic cord will twist along its vertical axis(commonly inwards) • The twisting might be several times (360O)affecting the blood supply leading to ischemia and gangrene with in 4-6 hrs • Common in teenagers age 10 - 25yrs 12
  • 13. Types • Intravaginal - torsion of the cord within the space of the tunica vaginalis - 90% of adolescent age group. • Extravaginal - torsion of the cord outside the space of the tunica vaginalis - Exclusive to perinatal period - Torsion of the testis, spermatic cord and tunica vaginalis. - It is usually ASYMPTOMATIC 13
  • 14. 14
  • 15. Risk Factors • Bell-clappers deformity • Undescended testis • Added weight of the testis after puberty • Trauma or athletic activity • Sudden contraction of the cremasteric muscle. 15
  • 16. 16
  • 17. Clinical manifestations On Hx • Sudden agonising pain in the scrotum refered to the ipsilateral lower abdomen • Scrotal swelling (An acute hydrocele or massive scrotal edema) • Nausea & vomit On PE • Testis elevated • Testis in transverse position • Abscent cremastric reflex • Prehn’s sign negative 17
  • 18. Diagnosis • Mostly clinical Ixs • Color Doppler Ultrasound - Noninvasive assessment of anatomy and determining the presence . or absence of blood flow. • Sensitivity of 88.9% Specificity of 98.8% • Operator dependent. • Radionuclide imaging - Sensitivity of 90% and specificity of 89% 18
  • 19. FIGURE 1. Color Doppler ultra- sonogram showing acute torsion affecting the left testis in a 14- year-old boy who had acute pain for four hours. Note decreased blood flow in the left testis compared with the right testis 19
  • 20. Treatment • Manual detorsion(Outwards) • Explore the testis • Untwist the testis • If viable, fix to scrotum by anchoring it to scrotal septum and if the other testis is abnormal fix it.(bilateral orchieopexy) • If infracted, remove it 20
  • 21. Torsion of testicular appendages(testicular or epididymal) • Common in the age group 12 – 24yrs • Most common structure to twist is the appendix of the testis (pedunculated hydatid of morgagni ) • Usually a more gradual onset • Pain moderately severe • Testicles not in transverse position • Blue dot sign. • Normal vasculature or even hyperemia on Doppler US with detection of swollen appendix. 21
  • 22. Treatment • Medical (with sure diagnosis) by anti-inflammatory, analgesia, rest. • Surgical exploration - excision of appendix. 22
  • 23. 23
  • 24. Acute Epididymitis Inflammation or infection of the epididymis. Clinically present with- • Scrotal swelling, erythema, and pain. • Symptoms varied from localized epididymal tenderness, to tenderness and swelling of the entire epididymis, to a massively inflamed hemiscrotum. • Dysuria and other bladder symptoms are usually present. • The presence of pyuria, bacteriuria or a positive urine culture. • Increased blood flow on scrotal scintigraphy or Color Doppler study. Treatment: • Rest, Antibiotics, Analgesics. 24
  • 25. Epididymorchitis • Isolated orchitis is a relatively rare condition and is usually viral in origin. Bacterial orchitis. • UTI. • STD. Nonbacterial orchitis. • Viral (mumps). Noninfectious orchitis. • Traumatic. • Autoimmune. 25
  • 26. Epididymorchitis • Most cases of orchitis, particularly bacterial, occur secondary to local spread of an ipsilateral epididymitis and are termed epididymo-orchitis. • UTIs are usually the underlying source caused by urinary pathogens, (ascending infection) 1.E. coli and Pseudomonas. 2.Less commonly, Staphylococcus species or Streptococcus species are responsible. 3.The most common sexually transmitted microorganisms responsible are Neisseria gonorrhoeae, C. trachomatis, and Treponema pallidum. 26
  • 27. Epididymorchitis On Hx: • Testicular pain, often associated with abdominal discomfort, fever, nausea, and vomiting. • Symptoms of UTIs or symptoms of an STD in sexually active men. • Although the process is usually unilateral, it is sometimes bilateral, especially if viral. On PE: • Toxic and febrile patient. • The skin of the involved hemiscrotum is erythematous and edematous, • Testicular tenderness on palpation or can be associated with a transilluminating hydrocele. • For acute noninfectious orchitis, the clinical picture resembles the above description, except that these patients lack the toxic appearance and fever. 27
  • 28. Epididymorchitis Investigation: • CBC. • urinalysis and urine culture. • If STD is suspected, a urethral swab should also be taken for culture. • Ultrasonography. • Doppler imaging to determine testicular blood flow) is especially helpful in differential diagnosis (torsion). Treatment: • Rest. • Antibiotics (UTI, STD). • Analgesia. • Scrotal elevation. • Surgery (abscess formation). 28
  • 29. Scrotal Trauma • Usually due to athletic activities, an assault or a fall. • It may be penetrating or blunt trauma. Penetrating trauma: • In all cases of penetrating trauma a meticulous examination to determine the depth of penetration, cleansing and débridement of the wound, administration of broad-spectrum antibiotics. • Suspect injuries to the urethra and rectum. • The presence of occult blood in the stool or hematuria should prompt further evaluations for coexisting urethral and rectal injuries. Blunt trauma: • Scrotal bruising and/or • Significant testicular discomfort. • Hematocoele. • Testicular rupture. 29
  • 30. Management • Investigation: • Scrotal ultrasound • Pelvic x-ray • Treatment: CONSERVATIVE • Bed rest • Scrotal elevation • Surgical exploration may needed if: - Expanding scrotal hematoma - To evcuate the haematocele and to repair the split in tunica albugenea. - Very sever pain 30
  • 31. Hydorcele • an abnormal collection of serous fluid in a part of the processus vaginalis, usually the tunica. • If it contains pus or blood it is called pyocele or haematocele. 31
  • 32. 32
  • 33. Etiology • by excessive production of fluid within the sac, e.g. secondary hydrocele • by defective absorption of fluid; this appears to be the explanation for most primary hydroceles although the reason why the fluid is not absorbed is obscure • by interference with lymphatic drainage of scrotal structures; • by connection with the peritoneal cavity via a patent processus vaginalis (congenital). 33
  • 34. 34
  • 36. Clinical presentation On Hx • Primary hydroceles are most common in newborns • Secondary hydroceles are more common between 20 to 40 years. • Painless swelling- Because of this it may reach a prodigious size before the patient presents for treatment. • Frequency and dysuria may occur if hydrocele is secondary to epididymo-orchitis • Beware of an acute hydrocele in a young man  there may be a testicular tumour 36
  • 37. 37
  • 38. Clinical picture • On PE • Position- the swelling is usually unilateral but can be bilateral.(Suspect ascites) • If communicating can not feel the cord above the lump.(May mimic inguinal hernia) • Size change- It may change in size (communicating) or may not (noncommunicating) • Tenderness- primary are not tender but secondary may be tender • Composition- fluctuant and have fluid thrill if large enough • Reducibility- can not be reduced(Communicating may be slightly reduced) • Positive fluctuation & Transillumination test 38
  • 39. Transillumination test Negative or reduced transillumination test if- • Sac is very thick • Sac is calcified • Chylocele • Hematocele • Pyocele • Malignancy testis- blood stained effusion 39
  • 40. Complications • Transformation into a hematocele occurs after trauma or if there is spontaneous bleeding into the sac. • The sac may calcify. • Rarely it may rupture. 40
  • 41. Management •Primary (in infants)  Communicating - most neonatal hydrocele resolve in first 2 year of life if persists . repair as herniotomy(inguinal incision ). Indications for surgery before age 2 yrs - very large amount - if can not be differentiated from a hernia - increase intrabdominal pressure Non- communicating(rare) - usually resolves spontaneously 41
  • 42. Management • In adults • If the patient can’t undergo surgery then we can drain the hydrocele until the patient is eligible for surgery. • If and when the patient is elligible two types of procedure can be used. Jaboulay’s procedure and Lord’s procedure • Lord’s procedure is suitable when the sac is reasonably thin-walled. There is minimal dissection and the risk of hematoma is reduced. • Jaboulay’s procedure is for thick walled sacs and involves opening the tunica vaginalis longitudinally (with a scrotal incision), emptying the hydrocele, everting the sac after excising the redundant sac and suturing the sac behind the cord thus obliterating the potential space • Secondary hydrocele needs treatment of the underlying condition 42
  • 43. 43
  • 44. • This is a unilocular retention cyst derived from some portion of the sperm-conducting mechanism of the epididymis. • The cyst contains dead or dying spermatozoas • It may occur anywhere in the epididymis but is more common in the caput region. • The nature of the obstruction may be congenital, traumatic or inflammatory • Identified incidentally in up to 30% of men undergoing ultrasonography. Spermatocele 44
  • 45. 45
  • 46. Clinical features Typically, a young adult presents with • Globular painless cystic swelling situated above the testicle. (3rd testicle) • Discomfort(dragging) or even pain. • A spermatocele typically lies above and behind the upper pole of the testis. It is usually softer and laxer than other cystic lesions in the scrotum but, like them, it transilluminates. • Spermatoceles are usually small and unobtrusive. Treatment • Small spermatoceles can be ignored. Larger ones and ones associated with pain should be aspirated or excised through a scrotal incision. 46
  • 47. Epididymal cyst • This condition is due to cystic degeneration occurring in the paradidymis. • These are filled with a crystal- clear fluid. • They are very common after age 40yrs. • Usually multiple and vary in size at presentation 47
  • 48. Clinical Presentation • Patients are usually asymptomatic • The clusters of tense cysts feel like a tiny bunches of grapes • Transilluminate very well  Epididymal Cyst may closely resemble a spermatocele, but they differ . in that Epididymal Cysts are multiple rather than single. Epididymal Cysts are often bilateral The contained fluid is crystal clear (contains no sperms) U/S is diagnostic Treatment • Surgical excision (not aspiration) 48
  • 49. Varicoceles • A varicocele is a varicose dilatation of the veins draining the testis. • Found in approximately 15% of male adolescents. • The veins draining the testis and the epididymis form the pampiniform plexus. The left testicular vein empties into the left renal vein, the right into the inferior vena cava below the right renal vein. • Most varicoceles present in adolescence or early adulthood, usually on the left. In many cases the dilated vessels are cremasteric veins and not part of the pampiniform plexus. • Obstruction of the left testicular vein by a renal tumour or after nephrectomy and Incompetent valves of the internal spermatic vein are proposed causes of varicocele. 49
  • 50. Varicocele Effect on testicular function: • Varicocele is known to have adverse effect on spermatogenesis may be due to one or a combination of the followings: i. Reflux of adrenal metabolites. ii. Hyperthermia. iii. Hypoxia. • The effect of Varicocele may be manifested as: i. Testicular growth failure. ii. Semen abnormalities. iii. Leydig cell dysfunction iv. Histologic changes (tubular thickening, interstitial fibrosis, decreased spermatogenesis, maturation arrest). 50
  • 51. Clinical presentation On Hx • Usually asymptomatic. • Self-discovered scrotal masses. • Scrotal aching discomfort(esp. if the scrotum isn’t supported) relieved by assuming the supine position. On PE • painless, compressible mass above and in some cases surrounding the testis " bag of worms” • Varicoceles have been graded according to physical characteristics: • grade I - small, palpable only with a Valsalva maneuver • grade II - moderately sized, easily palpable without a Valsalva maneuver • grade III - large, visible through the scrotal skin • Bilateral varicoceles are palpable in less than 2% of males. 51
  • 52. 52
  • 53. 53
  • 54. Investigations: • Semen analysis. • Doppler US. Treatment: 1. Conservatives in grade 1. 2. Sclerptherapy (intravenous occlusion). 3. Surgery “venous legation” ( inguinal, high, laparoscopic). Indications of surgery: • Pain. • Decrease in testicular size. • Abnormal semen analysis. 54
  • 55. Idiopathic scrotal edema • Difficult to distinguish from torsion/tumor • Ages 4 to 12 • Sudden onset, unilateral or bilateral but commonly bilateral . • Minimal tenderness • Normal gonads by U/S • Pathognomic sign is thickness of scrotal wall on U/S • Self limiting process - conservative treatment 55
  • 57. Testicular Tumors • They constitute almost 1-2% of tumors in males and almost all (98- 99%) are malignant • testicular neoplasm is one of the most common forms of cancer in young men. • Even when the testis is located in the scrotum, tumors often escape detection until they have metastasized. 57
  • 58. Testicular tumors Seminoma (40%) Combined Seminoma and Teratoma (14%) Interstitial tumours (1.5%) Teratoma (32%) Lymphoma (7%) Other tumours (5.5%) 58
  • 59. Epidemiology • 12% of all cancer death in patients between the ages of 20 and 35 years. • The most common affected age group is 20-35-45 years, with germ cell tumors. • Seminoma is more common at ages 35-45 years. • Teratomas are more common at ages 20-35. • Rarely, infants and boys below 10 years develop yolk sac tumors and, • 50% men >60 years with Testicular Cancer have lymphoma. • Patient with testis cancer has a greater chance for development of contralateral cancer than normal. 59
  • 60. Etiology Congenital Cryptorchidism. • 7% to 10% of patients with testicular tumors have a prior history of cryptorchidism. • TC occurs 2ry to ultrastructural abnormalities of Spermatogonia and Sertoli's cells due to - abnormal germ cell morphology - elevated temperature - interference with blood supply - endocrine dysfunction - gonadal dysgenesis. • More chance to develop malignancy in the contralateral testis. Klinfeilter syndrome • also predisposes patients to seminoma. 60
  • 61. Etiology Acquired Causes  Trauma • Chemical (zinc-induced or copper-induced ) associated with high incidence of teratomas in animals.  Hormones • Sex hormone (estrogen) fluctuations may contribute to the development of testicular tumors in experimental animals and humans.  Atrophy • Nonspecific or mumps-associated atrophy of the testis has been suggested as a potential causative factor in testicular cancer. 61
  • 62. Seminoma • A seminoma compresses neighboring testicular tissue. The enlarged testis is smooth and firm. The cut surface is homogeneous and pinkish cream in color. Occasionally, fibrous septa form lobules. • In rapidly growing tumors there may be areas of necrosis. • A seminoma consists of oval cells with clear cytoplasm and large, rounded nuclei with prominent acidophilic nucleoli. Sheets of cells resembling spermatocytes are separated by a fine fibrous stroma. • Active lymphocytic infiltration of the tumor suggests a good host response and a better prognosis. • Seminomas metastasize via the lymphatics and hematogenous spread is uncommon. 62
  • 63. Teratoma • teratoma arises from totipotent cells in the rete testis and often contains a variety of cell types, of which one or more predominate. • The tumour may be tiny but can reach the size of a coconut. • Even a large tumour is moulded by the tunica albuginea so that the overall outline of the testis is maintained although the surface may be distorted. • The usual type of teratoma is yellowish in colour with cystic spaces containing gelatinous fluid. • Nodules of cartilage are often present. 63
  • 64. Types of teratoma • Teratoma differentiated (TD) (uncommon): has no histologically recognizable malignant components but it can metastasize. - The best known is a dermoid cyst, which may contain cartilage and muscle as well as glandular elements. • Malignant teratoma intermediate teratocarcinoma (MTI; types A and B) (most common): contains definitely malignant and incompletely differentiated components. There is mature tissue in type A but not in type B. • Malignant teratoma anaplastic (MTA), embryonal carcinoma: contains anaplastic cells of embryonal origin. Cells presumed to be from the yolk sac are often responsible for elevated alpha-fetoprotein levels. MTA is not always radiosensitive. • Malignant teratoma trophoblastic (MTT) (uncommon)- contains within other cell types a syncytial cell mass with malignant villous or papillary cytotrophoblasts (choriocarcinoma). • It often produces human chorionic gonadotrophin (HCG). • Spread by the bloodstream and lymphatics is early. It is one of the most malignant tumors known. 64
  • 65. Diagnosis On Hx: • Asymptomatic scrotal mass. (All mass arising from the testis should be considered as malignant until proved other wise). • Pain in 20% of patients. • Systemic symptoms in 10%. • Gynecomastia in 5%. • Chest smptoms if metastasis On PE: • Testicular mass (painless or painful). • Hydrocele in 10%. • Abdominal mass. 65
  • 66. Tumor Markers AFP (alpha fetoproteins): • Not elevated in pure seminoma or chriocarcinoma. • False positive results in hepatoma, hepatitis, bronchogenic carcinoma. hCG: • Markedly elevated in choriocarcinoma and teratocarcinoma. • Pure seminoma produce slight elevation. LDH: • Elevated in advanced seminoma and non seminoma. PLAP: • Elevated in seminoma. 66
  • 67. Imaging Ultrasonography • Rapid and accurate assessment. • Can determine whether the mass is truly intratesticular. Chest radiographs (posteroanterior and lateral) • To assess metastatic spread in the lungs. • Detect 85–90% of pulmonary metastases. • The role of CT scanning of the chest remains controversial because of its decreased specificity. CT scan of the abdomen and pelvis • To assess metastatic spread in retroperitoneum. • Not very accurate in low volume disease. 67
  • 68. • Tx The primary tumour has not been assessed (no radical orchidectomy) • T0 No evidence of primary tumour • Tis Intratubular germ cell neoplasia (carcinoma in situ) • T1 Tumour limited to testis and epididymis without vascular invasion; may invade tunica albuginea but not tunica vaginalis • T2 Tumour limited to testis and epididymis with vascular/lymphatic invasion, or tumour involving tunica vaginalis • T3 Tumour invades spermatic cord with or without vascular invasion • T4 Tumour invades scrotum with or without vascular invasion • Nx Regional lymph nodes cannot be assessed • N0 No regional lymph node metastasis • N1 Metastasis with a lymph node less than 2cm or multiple lymph nodes, none >2cm • N2 Metastasis with a lymph node size less than 5cm or multiple lymph nodes, collected size not more than 5cm • N3 Metastasis with a lymph node mass >5cm • Mx Distant metastasis cannot be assessed • M0 No distant metastasis • M1a Non-regional lymph node or pulmonary metastasis • M1b Distant metastasis other than to non-regional lymph node or lungs TNM staging of testicular tumors 68
  • 69. Treatment • Radical inguinal orchidectomy even with metastatic tumor. • Trans-scrotal exploration or needle biopsy should be avoided. 69
  • 70. Treatment after orchiectomy For germ cell seminoma (radiosensitive): • Stage A : follow up and ipsilateral retroperitoneal radiotherapy. (relapse 25%). • Stage B1 & B2: ipsilateral retroperitoneal radiotherapy. • Stage B3 & C: combination chemotherapy (either bleomycin, etoposide, and cisplatin or etoposide and cisplatin) my be followed by surgery if there is residual mass or radiotherapy. 70
  • 71. Treatment after orchiectomy For germ cell nonseminoma (radioresistant): • Stage A : RPLND vs. follow up (relapse 25%). • Stage B1 & B2 : RPLND followed by combination chemotherapy (bleomycin, etoposide, cisplatin). • Stage B3 & C : combination chemotherapy followed by surgery if there is residual mass. 71
  • 72. Treatment after orchiectomy For non-germ cell tumor • RPLND is indicated in malignant changes. • The roles of chemotherapy and radiotherapy remain unclear. • Prognosis is excellent in benign disease very poor in malignant variant. 72
  • 73. References • Bailey & Love’s SHORT PRACTICE of SURGERY (25th edition) • Schwartz’s Principles of Surgery (9th edition) • Manipal Manual of Surgery • Grays Anatomy for Students (2nd Edition) • Atlas of Human Anatomy- Netter, 2006 • Wikipedia/urology • Mayomed Picture Archive 73
  • 74. 74

Editor's Notes

  1. Genital branch of genitofemoral supplies the cremastric muscle
  2. external spermatic fascia derived from the aponeurosis of external oblique muscle cremasteric muscle & fascia derived from the internal oblique muscle and fascia internal spermatic fascia derived from the transversalis fascia tunica vaginalis(remnant of Peritoneum )
  3. The processus vaginalis starts as a dimple of peritoneum in about the 10th week of gestation and precedes the testis in its journey through the abdominal wall down to the scrotum. Lydig  testosterone sertoli  estrogen Maternal chorionic gonadotrophin hormone stimulates growth of the testis and may stimulate its migration Covered by tunica albuginea thick fibrous tissue
  4. (head and body are commonly hit by TB leading to a posterior sinus)
  5. The testicular arteries originate high up in the retroperitoneum. From the abdominal aorta on the left and from the renal artery on the right. The venous drainage finds its way to the left renal vein and the inferior vena cava. For much of their course the testicular artery and vein run parallel to the ipsilateral lureter, for which they may be mistaken during retroperitoneal surgery.
  6. Gloden hour  The first 6 hrs
  7. Extravaginal ASYMPTOMATIC because we discover it early before appearance of symptoms
  8. Bell-clappers account for 90% of the cases  Causes intravaginal torsion  normally the testis is attached to the posterior of the inner surface of the scrotum by mesorchium but in bell clappers the mesorchium terminates early leaving the testis freely floating in the tunica vaginallis
  9. -ve prehn’s sign Elevation of scrotum doesn’t provide relife of pain
  10. Hydrocele fluid contains albumin and fibrinogen. If the contents of a hydrocele are allowed to drain into a collecting vessel, the liquid does not clot; however, the fluid coagulates if mixed with even a trace of blood that has been in contact with damaged tissue.
  11. Communicating  it connects with the peritoneal cavity. Non-communicating  it dosen’t connect with the peritoneal cavity. 1O no definite cause or 2O post traumatic, post inflammatory, 2ry to tumor, parasites…
  12. Sac is very thick  Sac is calcified  Chylocele  Hematocele  Pyocele  Malignancy testis- blood stained effusion
  13. NEVER do needle aspiration EVEN in the non-communicating type because it will reaccumulate
  14. Surgical excision carries a risk of infertility.
  15. Secondary varicocele could be a sign of a retroperitoneal mass like Renal Cell Carcinoma, Wilms tumor and phaeochromocytoma