Benign and malignant causes of scrotal and testicular swelling

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

35. Classification
Hydrocele
Congenital
Acquired
2O
1O
Communicating
Non-communicating
35

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

56. Testicular tumors

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