Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

3 scrotal swellings


Published on

Published in: Technology, Health & Medicine
  • Be the first to comment

3 scrotal swellings

  1. 1. Scrotal swellingsProf Mostafa Sakr
  2. 2. • (A) Painful Scrotal Swellings• Testicular torsion• Epididymitis (chronic: specific or non-specific)• Hematocele• Rupture testis• Complicated Hernia• Some testicular tumors (10%)• Torsion of testicular appendix
  3. 3. • (B) Painless Scrotal Swellings• Testicular tumours• Varicocele• Hydrocele• Spermatocele• Hernia• Syphilitic gumma
  4. 4. • Diagnosis of scrotal swellings• To determine the nature of a scrotal swellingaspects need to be assessed.– Can you get above the swelling?– Can the testis and epididymis be identifiedseparately?– Does the swelling transilluminate?– Is the swelling tender?
  5. 5. • A. Swellings not confined to the scrotum(inguinoscrotal)• Hernias– May be reducible with cough impulse– Testis is palpable• Infantile hydrocele– Irreducible– No cough impulse– Testis impalpable•
  6. 6. • B. Swellings confined to scrotum• Testicular tumours:• Incidence: 2/100.000• Special characteristics:• Curable cancer• It has sensitive markers: (alpha-fetoproteins,beta-HCG )• iii- Lymphatic drainage follows the blood supplyto para-aortic lymph nodes.
  7. 7. • Classification:• I- Germ cell tumor• -Seminoma 30% (Classic, Anaplastic, Spermatocytic)• -Embryonal carcinoma 30%• -Teratoma 35% (Differentiated, intermediate,undifferentiated)• -Chorion epithelioma 1%• -Mixed tumor 15%• B- Non germ cell tumor:• Leydig-cell tumour, Sertoli-cell tumour and others.
  8. 8. • Etiology:• Premitive or immature cells (totipotential) Abnormal differentiation  spermeogensis,embryogensis, vetillogenesis.
  9. 9. • Predisposing factors:• l.Cryptorchidism• 7-10% of patients with testicular tumors have priortesticular maldescent.• 2. Trauma• Repeated minor trauma was suggested as apredisposing factor.• 3. Hormonal imbalance• 4. Atrophy• Post-mumps orchitis atrophy is a potential causativefactor
  10. 10. • Pathology:• The tumor starts as in situ growth, spreadlocally to peritubular tissue, then destroytesticular structure and lately the tumorinvades the tunica albuginea which resists themalignant invasion.
  11. 11. • Metastasis:• Tumor of the testis proper spread along thelymphatic vessels to paraaortic lymph nodes..
  12. 12. • Seminoma:• Differentiation into line of spermeogensis.• Cell of origin:• The germinal epithelium of seminiferous tubules.• Gross description:• Cut surface is grayish white, lobulated homogenous without hemorrhageor necrosis. The tumor has no capsule. However, the tumor is distinct fromthe normal tissue.• Microscopic:• Monotonus sheets of uniform cells with delicate connective tissue. Thecells have clear or granular cytoplasm with large central hyperchromaticnucleus. Malignant foreign body giant cells or syncytiotrophoblast arecommon, granulomatous reaction may be present, (the degree ofanaplasia differentiate anaplastic from classic type.
  13. 13. Cut section in Seminoma.
  14. 14. • Spermatocytic type (4-8%):• The tumor is large yellowish soft slightlymucoid. The cells are variable in size, thecytoplasm is more deeply stained. The nucleusis deeply granular with condensed chromatin-like spermatogonia. Stroma is scanty,lymphatic infiltration and granulomatousreaction are present. This tumor has betterprognosis.
  15. 15. • Teratoma• Cell of origin: Totipotential cells. It gives elementsof more than one germ layer.• Gross: Large swelling, its cut surface reveals cystswith mucinous material. Solid tissue, muscle,cartilage, bone are interposed between cysts.• Microscopicaly:• Ectoderm—squamous epith, normal tissue• Endoderm—gastrointestinal, respiratory tissue• Mesoderm—bone, cartilage and muscle tissue.
  16. 16. • Chorion epithelioma• Cell of origin: Totipotential cell  Differentiation intothe line of vetillogensis• It is highly malignant tumor.• Gross: Testis is hemorrhagic• Microscopically: cytotrophoblast, uniform mediumsized cells, distinct cell border and single uniformnucleus. Around these cells, the syncytiotrophoblastform its cap in villous-like structures. There aremultinucleated cells with many hyperchromaticirregular nuclei in vaculated eosinophillic cytoplasm.
  17. 17. • Embryonal carcinoma• Differentiation into line of embryogenesis• Cell of origin:Totipotential cells.• Gross description:• It is the smallest germ cell tumr. Cut surface is variegatedappearance with grayish white smooth or granular bulgingsoft tissue, it has no capsule. There are extensivehemorrhage and necrosis.• Microscopic:• Cells are of variable size and arrangement. Some are largepleomorphic with distinct cell borders. Nuclei are alsopleomorphic, mitotic figures are common.
  18. 18. • Embryonal carcinoma• Differentiation into line of embryogenesis• Cell of origin:Totipotential cells.• Gross description:• It is the smallest germ cell tumr. Cut surface is variegatedappearance with grayish white smooth or granular bulgingsoft tissue, it has no capsule. There are extensivehemorrhage and necrosis.• Microscopic:• Cells are of variable size and arrangement. Some are largepleomorphic with distinct cell borders. Nuclei are alsopleomorphic, mitotic figures are common.
  19. 19. • Clinical manifestations (common to all tumors):• The earlier the diagnosis and treatment, the better isthe prognosis.• Symptoms and signs:• 1. Painless testicular swelling• 2. Dull aching pain in the testis or in 10% acute pain• 3. 10% manifest with metastasis; e.g. neck mass,respiratory problems, gastrointestinal, bone fractures,CNS manifestations etc.• 4. Gynecomastia 5% (hormonal imbalance).
  20. 20. • Examination:• Start with the normal side, tumor is usuallypainless, hard, and heavy or the testis isexpanded. It may spread to epididymis. Smallhydrocele may be present (secondary).Sonography is accurate, examination of theabdomen is essential.
  21. 21. • Diagnosis:• -It is based on clinical examination andultrasound showing heterogenousvascularized or huge mass. No preoperativebiopsy needed to avoid soiling of scrotal skinwith malignant cells.• -Preoperative tumor markers.
  22. 22. • Staging system:• Stage l: confined to testis• Stage ll: spread to regional node• Stage lll: beyond retroperitoneal area.• Metastatic Survey:• Chest X-ray CT scan Tumormarker
  23. 23. • Marker Oncofetal:• Alpha-Fetoprotein• Beta-HCG• CEA (carcinoembryonic antigen)• Cellular enzymes (LDH, PLAP)
  24. 24. • Treatment:• Urgent high inguinal orchiectomy• Followed by:• 1- Seminoma—irradiation 2500 rads in 3weeks• 2- Nonseminomatous germ cell tumor +retroperitoneal lymph nodes dissection.
  25. 25. D. D.• Epididymo-orchitis– Testis and epididymis definable– Testis tender• Testicular tumour– Testis and epididymis definable– Lump within testis– Testis non tender• Epididymal cysts– Testis and epididymis definable– Lump separate– Testis non tender
  26. 26. • Vaginal hydrocele• - Testis and epididymis not definable• - Transilluminates brightly• Torsion testis• - Testis and epididymis not definable• - Testis tender• Gumma• - Testis and epididymis not definable• - Irregular non-tender lump
  27. 27. • Testicular torsion• Definition• It is a surgical emergency due to twisting ofthe cord, leading to obstruction of venousblood supply to the testes leading tosecondary edema and congestion which willcause arterial obstruction and necrosis andgangrene of the testes.
  28. 28. • Etiology• If the testis has a narrow mesentery, it will move freelyaround its axis like a clapper bell thus being liable totorsion. The abnormality is usually bilateral. It occursusually at puberty or if a tumor develops in the testisdue to increase in the testis size.•• Differential diagnosis• Strangulated inguinal hernia, acute epididymoorchitis,scrotal abscess, hematocele and mumps orchitis.
  29. 29. • Types• I. Neonatal Testicular torsion• (Extravaginal torsion, Torsion of the cord)•• Mechanism• In neonates, the gubernaculum has still notcompletely been attached to the scrotal wall, and thetestes and the gubernaculum freely rotate inside thescrotum, thus the entire testes, epididymis and tunicavaginalis twist together in a vertical axis on thespermatic cord above.
  30. 30. • Clinical picture• The infant is restless, reluctant to feeding.• Hard, large scrotal mass, -ve transillumination.•– Treatment: It is controversial• No treatment the testis is already necrotic.• Surgical orchiectomy with contra lateralorchiopexy to avoid sympathetic orchipathia ofthe other side and protect against its delayedtorsion.
  31. 31. • II. Pubertal testicular torsion• (Intravaginal torsion)•• Age of incidence 12—18 years•• Precipitating factors of torsion• Contraction of the cremasteric muscle.• Straining or lifting heavy objects.• Coitus or masturbation.•
  32. 32. •• Clinical picture• Sudden onset acute testicular pain and swelling.• Severe tenderness.• Nausea and vomiting.• Transverse lie of the testis.• Scrotal elevation will increase pain.• Secondary hydrocele may develop.
  33. 33. • Treatment• Manual detorsion (done from medial tolateral) is not recommended as it is not a finalsolution and torsion may recur, also may beincomplete so the pain is relieved but thetestis is still ischemic.• Surgical exploration• Affected testis if viable detorsion and orchiopexy, ifnot viable do orchiectomy.• Contralateral testis orchiopexy.
  34. 34. • III. Torsion of testicular appendages• The most common appendage susceptible to torsion is theappendix testes.• Clinical picture• Similar to pubertal testicular torsion.• The twisted appendix may be palpable before scrotalswelling development as a 3—5 cm tender mass above theupper pole of the testis with a characteristic blue dot signon the overlying skin.• Local anesthesia may be given for proper examination.• Treatment  Surgical excision.
  35. 35. • Hydrocele• It is abnormal quantity of peritoneal fluidbetween the visceral layers of the tunicavaginalis.• Procesus vaginalis obliterated except aroundtestis.• Usually painless, unless underlying disease ispainful.
  36. 36. • Types– Communicating– Encysted– Funnicular– scrotal• May be primary or secondary.• Diagnosis:– Testis not felt.– Can get above it.– Transluminant.– U/S.• Treated by Excision and Eversion
  37. 37. • Epididymitis– Uncommon in adolescents - be wary aboutmaking the diagnosis– Usually has a more prolonged history than torsion,less pain and with urinary symptoms– Tenderness is greatest over the epididymis
  38. 38. • Idiopathic scrotal oedema– Usually occurs in boys less than 10 years old– Presents with scrotal redness and oedema– Pain is slight and testis feels normal.