2. Content
1. Anatomy of the inguinal and scrotal region that is of surgical importance
2. Definition of hernia
3. Clinical features of a hernia
4. Distinguish an inguinal hernia from a scrotal and inguinal region swellings
5. Distinguish a femoral hernia from an inguinal hernia
6. Distinguish a direct from an indirect inguinal hernia
7. Pre-disposing factors causing a hernia and a recurrent hernia
8. Surgical management of a hernia
9. Distinguish a scrotal swelling into testicular and extra testicular swelling
10. Clinical features of a solid and cystic testicular swelling
11. Clinical features of inflammatory (acute and chronic) testicular
conditions
12. Clinical features and presentations of malignant testicular swelling
13. Surgical management of scrotal swelling
5. INGUINAL REGION
Surface Markings
● ASIS
● Pubic symphysis
● Pubic tubercle
Inguinal ligament: ASIS to Pubic tubercle
Mid-inguinal point: midpoint between ASIS
to pubic symphysis
6. INGUINAL CANAL
● Above and parallel to medial half of inguinal
ligament
● Directed downward and medially / lying obliquely
● Extending from deep to superficial inguinal ring
● The canal serves as a pathway by which structures
can pass from the abdominal wall to the
external genitalia
● 1.5 - 2 inches / 4-6 cm long
● It is of clinical importance as a potential
weakness in the abdominal wall, and thus a
common site of herniation
7. OPENINGS
The inguinal canal has 2 openings:
1. Deep (internal) inguinal ring
2. Superficial (external) inguinal
ring
8. Deep Inguinal Ring
● Entrance to the inguinal canal
● Oval opening in the transversalis fascia
● Lateral to the inferior epigastric vessels that lies
about
1.5 cm above mid-inguinal point
● From the margin of the ring. “Internal spermatic
fascia”
extends into the spermatic cord
9. Superficial Inguinal Ring
● Triangular opening in the external oblique
aponeurosis
● Above and medial to the pubic tubercle
● From the margin of the ring, external spermatic
fascia extends into the spermatic cord
11. CONTENT OF INGUINAL CANAL
Males
● Spermatic cord (with the genital branch of the
genitofemoral
nerve)
● Ilioinguinal nerve (passes through the superficial ring
but does not completely run through the entire inguinal
canal)
Females
● Round ligament of the uterus
● Genital branch of the genitofemoral nerve
● Ilioinguinal nerve
12. HESSELBACH’S TRIANGLE
It is described as the area where a direct inguinal
hernia will extrude from posterior to anterior
Boundaries
● Medially: lateral border of rectus
abdominis
● Laterally: inferior epigastric vessels
● Inferiorly: Inguinal ligament
Surgical importance:
● Not reinforced by conjoint tendon
● Potentially weak area
● Direct inguinal hernia protrudes through it
13. FEMORAL TRIANGLE
Femoral triangle consists of three borders
● Superior border: inguinal ligament
● Lateral border: medial border of the
sartorius muscle
● Medial border: medial border of
the adductor
longus muscle
Content ( lateral to medial)
● Femoral Nerve (landmark is midpoint
of inguinal ligament)
● Femoral Artery (landmark is at the
mid- inguinal point, inferiorly)
● Femoral Vein
● Femoral canal - contains loose connective
tissue, lymphatic vessels, and lymph nodes
of cloquet
14. FEMORAL CANAL
● It is an anatomical compartment, located in the anterior thigh
● It is the innermost compartment of the three compartments
on the femoral sheath
● Extends from the femoral ring above to the saphenous
opening
● 1.25 cm long, 1.25 cm wide
● Contains fats, lymphatic vessels, and lymph nodes
Clinical significance
The entrance to the femoral canal is the femoral ring, through which
bowel can sometimes enter, causing femoral hernia
15. FEMORAL RING
It is the abdominal opening of the femoral canal
Boundaries
● Anterior: inguinal ligament
● Posterior: Ligament of Astley cooper
● Medial: Lacunar ligament
● Lateral: Femoral vein
In cases of femoral hernia, part of the bowel pushes
into the femoral canal
16. SPERMATIC CORD
● The cord passes through the
inguinal canal, entering the
scrotum via the superficial
inguinal ring
● It continues into the scrotum,
ending
at the posterior border of the testes
● Here, its contents disperse to
supply
the various structures of the
testes and scrotum
17. COVERINGS OF THE SPERMATIC
CORD
There are three layers of fascia derived from the layers of
the anterior abdominal wall.
Each covering is acquired as the processus vaginalis descends
into
the scrotum through the layers of the abdominal wall.
1. External spermatic fascia derived from the external
oblique
aponeurosis
2. Cremasteric fascia derived from the internal oblique
muscle
3. Internal spermatic fascia derived from transversalis fascia
and attached to the margins of the deep inguinal ring
The cremasteric muscle forms the middle layer of the
spermatic cord fascia. It is a discontinuous layer of striated
muscles that is orientated longitudinally
19. SCROTUM
Sacs of skin and fascia
out-pouching of the lower part of the anterior abdominal
wall It contains
● testes,
● epididymis, and
● lower end of spermatic cord
20. SCROTUM
The dartos muscle is supplied by the genital branch of genitofemoral
nerve
Arterial supply ● External pudendal branch of femoral artery
● Internal pudendal artery
Venous drainage ● Veins accompany the corresponding arteries
Lymphatic drainage ● Superficial inguinal nodes (medial group)
Nerve supply ● Ilioinguinal nerve
● Genital branch of genitofemoral nerve
● Perineal nerves
● Posterior cutaneous nerves of thigh
21.
22. TESTES
● Male gonad
● Homologous with ovary of the female
● Suspended in the scrotum by the spermatic cord
● Lies obliquely, so that its upper pole is tilted
forwards
and medially
● The left testes is slightly lower than the right
● Function:-
○ Production of spermatozoa
○ Secretion of testosterone
● Shape: oval/ellipsoid
● Measurements: 4 cm x 3 cm x 2.5 cm
● Weight (adult): 10 -15 g
23. EXTERNAL FEATURES OF THE
TESTES
● Two poles (upper and lower)
● Two surfaces (medial and lateral)
● Two borders (anterior and posterior)
● Epididymis
Coverings of the testes
1. Tunica vaginalis
2. Tunica albuginea
3. Tunica vasculosa
24.
25.
26. TESTES
Lymphatic drainage drains into
the pre aortic and para aortic
groups of lymph nodes at the
level of second lumbar
vertebrae
27. EMBRYOLOGICAL DEVELOPMENT OF THE TESTES
A. 5th week: Testes begins its primary
descent; kidney ascends
B. 8th - 9th week: Kidney reaches
adult position
C. 7th month: Testes at internal inguinal
ring; gubernaculum (in inguinal fold)
thickens and shortens
D. Postnatal life.
29. Definition of Hernia
A hernia is the bulging of part of the contents of the abdominal cavity
through a weakness in the abdominal wall.
CAUSES
● Basic design weakness
● Weakness due to structures entering and leaving the abdomen.
● Developmental failures
● Genetic weakness of collagen
● Sharp and blunt traumas
● Weakness due to ageing and pregnancy
● Primary neurological and muscle diseases
● Excessive intra-abdominal pressure
30.
31. Composition of Hernia
Hernia consists of 3 parts:
The sac The sac is a diverticulum of peritoneum, consisting of mouth,
neck, body, and fundus.
The covering Coverings are derived from the layers of the abdominal wall
through which the sac passes.
The contents ● Omentum = omentocele
● Intestine = enterocele;more commonly small bowel but may
be large intestine or appendix
● A portion of the circumference of the intestine = Richter's
hernia
● A portion of the bladder (or a diverticulum)
● Ovary with or without the corresponding fallopian tube
● A Meckel’s diverticulum = Littre’s hernia
● fluid= as part of ascites
32. Classification of Hernia
Reducible A swelling that appears and disappears
Irreducible A swelling that cannot be replaced in the abdomen, high
risk of complications
Strangulated Painful swelling with vascular compromise, requires
urgent surgery
33. Clinical Features of Hernia
CLINICAL HISTORY
● Self-diagnosis common (patient usually
aware of lump)
● Painless, aching/heavy feeling
● Sharp, intermittent pain (pinching of
tissue)
● Severe pain (strangulation)
● Symptoms of bowel obstruction
● Primary hernia or recurrence
EXAMINATION
Patient examined lying down initially and then
standing, as this will increase hernia size.
● Reducibility
● Cough impulse
● Tenderness
● Overlying skin colour changes
● Multiple defects/contralateral side
● Signs of previous repair
● Scrotal content for groin hernia
35. Groin Swelling
4 questions:
1. Can you get above the swelling?
2. Can you identify the testis and the epididymis
3. Is the swelling transilluminable?
4. Is the swelling tender?
36. Cannot get above swelling • Cough impulse
• Reducible
• Testis palpable
• Opaque
Hernia
• No cough impulse
• Not reducible
• Testis not palpable
• Transilluminable
Infantile hydrocoele
37. Can get above
the swelling
Testis not
definable from
epididymis
Opaque Non-tender Chronic
haematocoele
Tender Torsion
Epididymo-orchitis
Acute haematocoele
Transilluminable Hydrocoele
Testis definable
from epididymis
Opaque Non-tender
Swelling of
testis
Tumour
Non-tender
Swelling of
epididymis
TB epididymis
Tender Epididymo-orchitis
Transilluminable Cyst of epididymis
39. Femoral hernia vs Inguinal hernia
Femoral hernia Inguinal hernia
Canal Femoral canal Inguinal canal
Common in Female Male
Reducible + ++
Strangulation ++ +
Three finger Test impulse on ring finger Impulse on index or middle finger
Cough impulse - +
Treatment Must be treated surgically Can be treated without surgery
43. Inguinal hernia
Direct Hernia Indirect Hernia
Elderly Age group Infants, children (congenital), young adult
due to weak abdominal muscle (acquired) Cause due to patent processus vaginalis
via Hasselbach triangle, transversalis fascia Anatomy via deep inguinal ring
swelling advance directly upwards towards
examiner (round, like plum in the groin)
Direction oblique motion from internal ring to neck of
scrotum
broad neck →less liable to strangulate Neck diameter Narrow neck
44. Physical Examination
Direct hernia Indirect Hernia
Oval Shape Complete (descend into scrotum) - Pyriform
Incomplete - Oval
No Descend into
scrotum
Yes
Yes - automatically Reduce on lying
down
No - manually
Reduces upwards and straight
backwards
How to reduce Reduces upwards, laterally and backwards
Controlled after reduction by
pressure over the superficial
ring
How to control Controlled after reduction by pressure over
the deep ring
Bulge Deep ring
occlusion test
Does not bulge
45.
46.
47. Inguinal hernia
Complications
1) Irreducible : due to tight inguinal ring
2) Obstructed : Lumen of hollow viscera is blocked
3) Strangulated : The blood supply to the content of hernia sac is cut off →
gangrene → perforation → peritonitis
4) Incarcerated : The block of the lumen of hollow viscera is due to thick fecal
matter / adhesions)
48. PREDISPOSING FACTORS CAUSING A HERNIA
● Preoperative factors
- straining factors that not corrected before the surgery
● Operative Factors
- Failure to ligate sac at neck, tension stitches especially in Bassini repair, use of
absorbable stitches in repairing inguinal canal
● Post operative factors
- infection, lifting heavy things within 3 months of operation, predisposing factors not
corrected
49. PREDISPOSING FACTORS OF RECURRENT HERNIA
● Infection of wound from previous hernia surgery
● Being too active too soon after surgery
● Chronic use of steroids
● Chronic acute cough
● Smoking
● Obesity
50. INVESTIGATIONS
performed when the patient may have symptoms suggesting hernia but no
hernia is found / have swelling suggestive a hernia but with clinical uncertainty
1) Ultrasound abdomen
2) CT scan abdomen
3) MRI
51. Surgical Approaches to Hernia
All surgical repairs follow the same basic principle:
1. Reduction of hernia content into abdominal cavity with removal of any
non-viable tissue and bowel repair if necessary;
2. Excision and closure of a peritoneal sac if present or replacing it deep to the
muscles;
3. Reapproximation of the walls of the neck of hernia if possible;
4. Permanent reinforcement of the abdominal wall defect with sutures or mesh.
52. Inguinal hernia
1. Herniotomy
- Remove sac and close the sac
2. Herniorrhaphy
- Add muscle strengthening
- repair of the stretched internal inguinal ring and transversalis fascia
- further reinforcement of the posterior wall of the inguinal canal
3. Hernioplasty
- Polypropylene mesh is used to cover the defect
- usually in direct and recurrent hernia
53. Other operations for inguinal hernia
● Open suture repair
● Open flat mesh repair
● Open complex mesh repair
● Open preperitoneal repair
● Laparoscopic repair
54. Open suture repair - Bassini, Shouldice, Desardia
➢ Surgeon enters inguinal canal by opening its anterior wall, the external
oblique aponeurosis.
➢ Spermatic cord is dissected free and presence of a lateral or a medial hernia
is confirmed.
➢ The sac of a lateral hernias separated from cord, opened and any contents
reduced.
➢ Sac is then sutured closed at its neck and excess sac removed.
➢ If there is a medial hernia, then it is inverted and transversalis fascia is suture
plicated.
➢ Sutures are now placed between conjoint tendon above and inguinal ligament
below, extending to pubic tubercle to the deep inguinal ring.
➢ The posterior wall of inguinal canal is thus strengthened.
55.
56. Open flat mesh repair
Lichtenstein described as a tension-free, simple, flat, polypropylene mesh repair.
➢ The initial part of operation is identical to Bassini’s.
➢ Once hernia sac has been removed and any medial defect closed, a piece of
mesh, measuring 8X15cm, is placed over posterior wall, behind spermatic
cord, and is split to wrap around the spermatic cord at the deep inguinal ring.
➢ Loose sutures hold the mesh to inguinal ligament and conjoint tendon.
2 major advantages:
- Lowered hernia recurrence rates
- Accelerated postoperative recovery
57.
58. Laparoscopic Inguinal hernia repair
2 Techniques:
- Total extraperitoneal approach (TEP), more widely used
- Transabdominal preperitoneal approach (TAPP)
Advantages:
- Reduced pain
- More rapid return to full activity
- Reduced incidence of wound complications of infection, bleeding and seroma
- Benefit in bilateral cases & recurring hernia after open surgery
59. Femoral Hernia
TREATMENT
SURGERY is a must in all cases because there is risk of strangulation
3 open approaches
● low approach (Lockwood) - below the inguinal ligament
● the inguinal approach (Lotheissen) - through the inguinal canal
● high approach (McEvedy) - mainly above the inguinal canal
Laparoscopic approach
- TEP, TAPP approach with standard mesh inserted
- Not for emergency cases or irreducible hernia
60. Femoral Hernia
Complication of surgery
- bleeding (may be due to accidental damage to inferior epigastric or iliac vessel)
- urinary retention
- seroma (due to excessive inflammatory response to sutures or mesh)
- wound infection
- recurrence
- chronic pain (pain present three months after surgery)
- testicular infarction due to testicular artery (rare, most serious complication)
62. • Incomplete descends of testis. It arrested at some path
of its normal path to scrotum
63. INCIDENCE
• 4% of boys: born with unilateral or bilateral undescended testes
• 2/3 of these: reach scrotum during the first 3 months of life
• Testicular maldescent at the age of 1 year is around 1%.
• Missed in neonatal period and only discovered later in life.
• Higher incidence in preterm infants because the testis descend through
the inguinal canal during the third trimester.
64. EMBRYOLOGICAL DEVELOPMENT
OF TESTIS
Testes develop in the retroperitoneum below
the kidneys at around the 10th thoracic level.
● A. 5th
week: Testis begins its primary
descent guided by gubernaculum d/t
testosterone secreted by foetal testis;
kidney ascends.
● B. 8th
-9th
weeks: Kidney reaches adult
position.
● C. 7th
– 9th
month: Testis migrates downwards
towards the deep inguinal ring through inguinal
canal; gubernaculum thickens and shortens.
● D. Postnatal life. Testis in the scrotum
65.
66. COMPARISON: UNDESCENDED & ECTOPIC TESTIS
UNDESCENDED TESTIS
● Testis arrested in its normal pathway
● Usually, testis undeveloped
● Scrotum undeveloped & empty
scrotum
● Associated with indirect inguinal
hernia
ECTOPIC TESTIS
● Testis deviates from its normal path
● Fully developed testis
● Scrotum empty but usually fully
developed
● Never associated with indirect inguinal
hernia
67. CLINICAL FEATURES
1. Symptoms
- parents seek advice for the baby because of empty scrotum
- patient notice during adolescence / in adult life-infertility
2. Local examination
- If both testes are undescended → the scrotum is small and hypoplastic
- If only one testis → markedly asymmetrical
- Palpate for testis → may be impalpable or palpable (below superficial inguinal
ring)
- In undescended testis, testis is smaller in size and soft. In retractile and ectopic
testis, size is normal and lying superficially.
- If the testis can be felt, it is small and does not remain in the scrotum after
manipulation
68.
69. Three maneuvers help to gain the length required to bring the
testis down into the bottom of the scrotum
1st
: identify, separate and ligate patent processus vaginalis
2nd
: divide the coverings of spermatic cord + cremaster muscle
3rd
: divide the lateral fibrous bands just inside the internal inguinal ring
* Although effective, tiny vas and testicular vessels are vulnerable to
injury.
• Palpable undescended testes
undergo a single stage
orchidopexy
• Impalpable undescended testes
usually require a two stage
70. BENEFITS
• Fertility. To optimise spermatogenesis, the testis needs to be in the
scrotum below body temperature at a young age.
• Reduce the risk of malignancy because it is histologically
abnormal.
• Cosmetic and psychological – a prosthetic testis can be
inserted to replace an absent one
71. SURGICAL TREATMENT
1. ORCHIDOPEXY
● Usually performed before 12 months of
age
● The testis and spermatic cord are
mobilised and the testis is repositioned
in the scrotum
● Testis is placed in pouch constructed
between the dartos muscle and the skin
72. 2. ORCHIDECTOMY
● surgical removal of one or both testicles
● Should be considered if the incompletely descended
testis is atrophic, particularly in post pubertal boy if the
other testis is normal
SURGICAL TREATMENT
73. COMPLICATIONS
● Infertility
● Malignancy
- cancer risk for adults is 5-10 times greater. Most common cancer is seminoma.
● Hernia
- 90% boys with undescended testis have patent processus vaginalis.
● Testicular torsion
- Due to developmental abnormality between testis and its mesentery
75. VARICOCELE
● Collection of dilated and tortuous veins in the pampiniform plexus
surrounding the spermatic cord
● Usually occur in 15% of younger men, often around puberty
● If occur in older men, underlying retroperitoneal disease should be sought,
including renal carcinoma extending into left renal vein
● 98% are left-sided:
- Left spermatic vein is more vertical
where it connects to left renal vein
- Left renal vein can be compressed
by the colon
- Left testicular vein is longer than
the right
- Lacks of terminal valve
76. Signs and symptoms
➢ Mostly asymptomatic
➢ Clinical features: Dragging
discomfort that is worse on
standing at the end of the day
➢ Aching pain in scrotum and groin
➢ Examination shows typical “bag of
worms”
77. Clinical features
Inspection Single/ multiple Usually unilateral
Cough impulse May be positive
Site Scrotal area below inguinal ligament, usually
left side, testis hang lower than unaffected
side (in longstanding cases)
Skin Dilated tortuous vein (look like a bag of worm)
Palpation Relation to inguinal Able to get above the mass
Relation to testis Testis can be felt separately
Surface Feels like a bag of worm
Consistency Soft
Trans-illuminable Non-trans illuminate
78. Management
● Only needed treatment if symptomatic
● Transfemoral radiological embolization of the
testicular vein
- In significant discomfort
- Using spring coil or sclerosant
● Surgical ligation of testicular vein
- Can recur
79. HYDROCELE
● Abnormal collection of serous fluid in tunica
vaginalis of the scrotum or along the spermatic
cord
● Hydrocele fluid contains albumin and fibrinogen
80. Classification
(a) Vaginal hydrocele: fluid accumulates in tunica vaginalis and not extend up to cord
(b) Infantile hydrocele: distal part of processus vaginalis is obliterated, does not
connect with abdomen but it remains patent in both cord and scrotum
(c) Congenital hydrocele: proximal part of processus vaginalis has not obliterated and
directly connected with peritoneum
(d) Hydrocele of the cord: fluid accumulates around the spermatic cord. Difficult to
distinguish from irreducible inguinal hernia as it may extend up to superficial ring, a
traction of testis may pull the mass together
81. Aetiology
PRIMARY HYDROCELE SECONDARY HYDROCELE
Connection with peritoneal cavity
via patent processus vaginalis
Interference with lymphatic
drainage
Defective absorption of fluid Excessive production of fluid
Importance: Usually benign and
presence since childhood
Importance: Local pathologies
(testicular tumours, torsion,
orchitis, trauma, after inguinal
repair)
82. Clinical Features
➢ Painless swelling
Inspection:
Single/multiple Usually unilateral (suspect of testicular malignancy if presence
in young adults)
Cough impulse Negative
Site Scrotal area below inguinal ligament, determine the part of
accumulation (tunica vaginalis/spermatic cord)
Size May be very large
Shape Globular (if large enough, there is narrow part proximal before
enlarge and the lump may protrude anteriorly)
Skin Normal, with prominent vein on scrotal skin
83. Clinical Features
Palpation:
Relation to inguinal Able to get above mass
Relation to testis Usually inseparable from testis (unless hydrocele of
cord)
Surface Smooth
Consistency Soft unless calcified, mixed with blood, large lump
Transillumination
test
Positive unless secondary infection, mixed with blood,
calcified
85. Management
★ Non-surgical
➢ Watch and wait - reassure for small hydrocele but u/l malignancy must be
excluded by US of testis
➢ Aspiration under US guidance - to relieve symptoms but tend to reaccumulate
again (not recommended for suspected testicular tumor to prevent needle tract
implantation)
★ Surgical
➢ Lord’s plication - Small incision through scrotum to
lift up testis. Sac is plicated with a series of
interrupted suture to the junction of testis and
epididymis
➢ Jaboulay’s operation - Longitudinal incision and
the sac is everted. Excess sac is excised and
remainder replace behind the cord
86. ● Testicular torsion is a condition whereby
the testicle twists in such a way that its
blood supply becomes compromised
● If left untreated, the blood flow to the
testicle ceases and the testicle dies.
● A urological emergency
● Often involves the left testicle
● Most common cause of testis loss
● Testis survival rate is high around 90% in
patients who undergo detorsion within 6
hours from the start of pain
TESTICULAR TORSION
87. ● Torsion of the testis is uncommon because the
normal testis is anchored and cannot rotate.
● For torsion to occur, one of several abnormalities
must be present:
- Inversion of the testis is the most common
predisposing cause.
- The testis is rotated so that it lies transversely or
upside down.
- High investment of the tunica vaginalis causes
the testis to hang within the tunica like a clapper
in a bell.
- Separation of the epididymis from the body of
the testis permits torsion of the testis on the
pedicle that connects the testis with the
epididymis.
Pathophysiology
89. Clinical Features
● Typically, sudden agonising pain in the groin and the lower abdomen.
● Nauseated and may vomit.
● Negative Prehn Sign - elevation of scrotum does not relieves pain
● Torsion of a fully descended testis is usually easily recognised:
- The testis seems high and the tender twisted cord can be palpated above it.
- Abnormal horizontal position
- Negative cremasteric reflex.
• Early: swelling, tender
• Late: hydrocele, erythema
• After days: woody-hard, atrophy
to fibrous nodule
90. Investigations & Management
● The management of the case should be determined primarily on
clinical grounds.
● If there is any doubt as to the diagnosis, then urgent scrotal
exploration is indicated.
- Doppler ultrasound scanning: Confirm the absence of the blood supply to
the affected testis.
91. Investigations & Management
Exploration for torsion should be performed through a
scrotal incision.
● If the testis is viable when the cord is untwisted, it
should be prevented from twisting again by fixation
with non-absorbable sutures between the tunica
vaginalis and the tunica albuginea.
● The other testis should also be fixed because the
anatomical predisposition is likely to be bilateral.
● An infarcted testis should be removed
(orchidectomy) – the patient can be counselled later
about a prosthetic replacement.
92.
93. EPIDIDYMO-ORCHITIS
■ Occurs when epididymitis (inflammation confined to the epididymis)
extends into testis and causes testicular tenderness and enlargement
■ Pathophysiology
1. Primary infection of the urethra and prostate
2. Infection reaches the epididymis via vas
deferens
3. Infection spreads to the testis
■ Acute: <6w
■ Chronic: >6w
94. Aetiology
●In young sexually active men:
○Chlamydia trachomatis
○Neisseria gonorrhoea
●In older men:
○Urinary tract infection
○BPH
○Secondary to an indwelling urethral
catheter
95. Clinical Features
● The development of an ache in the
groin and a fever can herald the onset
of epididymitis.
● Epididymis and testis
- Swell and become painful.
● The scrotal wall
- Red, oedematous and shiny, may
become adherent to the epididymis.
● Abscess and discharge of pus may occur
96. Investigations
● Urinalysis & urine culture
- Show leukocytes and may show a formal urinary tract infection.
●Ultrasound
- Initial assessment of epididymitis and will identify abscess formation.
●Urethral swabs & culture
- For chlamydia and gonorrhoea in patient with discharge
●Early morning urine specimen for Mycobacteria
●Acid fast bacilli for M. Tuberculosis
●In adolescents the differential diagnosis is testicular torsion and if there is
any clinical doubt as to the diagnosis then testicular exploration should be
performed.
97. Management
❖ Antibiotic tx
1. Start empiric tx based on causative organism
■ UTI source (eg. Enteric organism): fluoroquinolone, levofloxacin
■ STI source (eg. Chlamydia/ gonorrhea): ceftriaxone, doxycycline
2. If symptoms not improve within 72 hours, consider other diagnosis.
❖ Symptomatic mx
1. Scrotal elevation
2. NSAIDs
3. Apply cold pack
❖ Surgical intervention
1. Usually not indicated
2. Only done when suspect abscess formation
98. Complications
● Resolution may take 6–8 weeks to complete.
● Occasionally, an abscess can form that needs surgical drainage.
● Other complications
○Testicular atrophy,
○Development of a chronic epididymitis
○Infertility.
99. TESTICULAR TUMOR
■ They are the most solid malignancy affecting males between age
of 15 and 35 years old
■ Prognosis: excellence - survival rate 95% (very sensitive to
chemotherapy)
■ Risk factors include:
– History of Cryptorchidism (undescended testis)
– Family hx of testicular tumour
– Klinefelter’s syndrome ( XXY)
– HIV infection
– Chronic orchitis
– Repetitive trauma to testis
– Infertility
101. Seminoma
■ Metastasise: mainly via lymphatics
(hematogenous is uncommon)
■ Lymphatic drainage of testis is to para-aortic
lymph nodes.
■ The contralateral para-aortic lymph nodes are
sometimes involved by tumour spread, but the
inguinal lymph nodes are affected only if the
scrotal skin is involved.
■ A seminoma typically has a cut surface which is
homogeneous and pinkish cream in colour. It
appears to compress neighbouring testicular
tissue.
102. Non-seminomatous Germ Cell Tumor
(NSGCTs)
■ Embryonal Carcinoma
- Highly malignant tumours that occasionally invade cord
structures.
■ Yolk Sac Carcinoma
– Tumours with this component secrete alpha
fetoprotein (AFP).
■ Choriocarcinoma
– Often produces human chorionic gonadotrophin (HCG).
This is a highly malignant tumour that metastasizes
early via both the lymphatics and the bloodstream.
■ Teratoma
– These tumours contain more than one cell type with
components derived from ectoderm, endoderm, and
mesoderm. Tumour can be mature or immature
(undifferentiated primitive tissue)
103.
104. Clinical Features
■ Symptoms
– Painless testicular lump
– Sensation of heaviness (2-3 x normal size)
– Metastasis;
■ Intra-abdominal disease: abdominal pain, epigastric mass
■ Lungs: chest pain, dyspnea, hemoptysis (late stage)
■ Signs
– Transillumination negative
– Intra-testicular solid mass
– Gynaecomastia (in 5% of cases)
– Epididymis difficult to palpate when it is flattened or incorporated
in the growth.
– Vas never thickened
– Normal rectal examination
105. Investigations
● In suspected cases:
- Ultrasound of testis (mandatory investigation in all
cases of suspected testicular tumour)
● In confirmed cases:
- staging for management
- Before orchidectomy done: Measure tumor markers (AFP &
HCG)
- After orchidectomy: Monitor tumor markers to monitor
response to treatment
● Chest x-ray: will occasionally demonstrate the ‘classical’
cannonball metastases
● CT of chest and abdomen; detecting metastatic disease and for
monitoring the response to therapy
106. Staging
STAGE I The tumour is confined to the testis
STAGE II Nodal disease is present but is
confinedto nodes below the diaphragm
Stage III Nodal disease is present above
the diaphragm
Stage IV Non-lymphatic metastatic
disease (most typically within the
lungs)
