Houseman level

1. Anatomy

6. ACUTE vs. CHRONIC scrotal swelling
Acute Chronic
•Torsion of spermatic cord/testis
•Torsion of appendix, epididymis
•Acute epididymitis/orchitis
•Mumps orchitis
•Henoch-Schönlein purpura (painless)
•Trauma
•Insect bite
•Thrombosis of spermatic vein
•Fat necrosis
•Hernia
•Folliculitis
•Dermatitis, acute
•Hydrocele (painless)
•Hernia (painless)
•Varicocele
•Spermatocele
•Sebaceous cyst
•Tumor (painless)

7. Acute
• Characteristic
Pain
Swelling
Erythema
Sudden onset
• Always an EMERGENCY!!!

8. Why EMERGENCY?
• Potential for testicular loss and infertility
• Legal action can be taken
• Accurate diagnosis limited by similarity of
presentation and physical findings of different
causes
• Radiological techniques is helpful, but may
delay treatment
• Operation may be needed for Dx and Tx
purposes

9. Chronic
• Long standing
• Slow growing (>6 weeks)
• Pain/painless
• Incidental finding

10. Testicular torsion
• Torsion of the testis (spermatic cord) → strangulation of gonadal blood
supply → testicular necrosis and atrophy.
• Window of opportunity to salvage - within 6 hours!
• Acute scrotal swelling in children indicates torsion of the testis until
proven otherwise
_________________________________________________________
• Acute-onset agonising pain over hemiscrotum, groin, lower abdomen
• Nausea and vomiting
• Scrotal swelling with erythema
• High lie of testis, palpable thickening tender cord
• May occur at rest or may relate to sports or physical activities (sometimes
upon straining at stool, coitus, during sleep)
• May describe similar previous episodes, which may suggest intermittent
testicular torsion (spontaneous detorsion)
• No voiding problems or painful urination
• Difficulty in ambulation

11. • Predisposing causes
1. Inversion of testis
– transverse lie/upside down
2. High investment of tunica vaginalis
3. Separation of epididymis from body (long mesorchium)
– torsion without involving cord, confined to pedicle that connect testis
with epididymis
• 2 types of torsion:
• Extravaginal (5%)
- testis rotates freely prior to fixation of testis
- more common in neonates
• Intravaginal (16%) : Bell Clapper deformity
- lack of fixation (testis freely suspended within tunica vaginalis)
- peak incidence at adolescence age 13

12. • Incidence
– Most common between 10-25yo (1:4000)
• Pathophysiology :
Violent contraction of abdominal muscles → contraction of cremaster
→ favors rotation around vertical axis
• Torsion of 3-4 turns : irreversible changes (necrosis)
within 2 hours
• Torsion of 1 turn (360:) : well tolerated for 12 hours (20% viability)
necrosis after 24 hours
• Torsion of 90: : well tolerated for 7 days
L P SONDA, J LAPIDES in Surgical Forum (1961)

14. • O/E
– Extremely tender, enlarged
– High riding testis
– Reactive hydrocele
– Scrotal wall erythema
– Ecchymosis
– Cremasteric reflex
• if present, no torsion
• if absent 66% rule in torsion
• Ix
– UFEME : TRO UTI/epididymorchitis, ↑leucocytes in 30% patients
– FBC : ↑TWC in 60% patients
– US Doppler scrotum/testis
– Contrast MRI : evidence of torsion knot or whirlpool patterns
– Nuclear testicular scan/scintigraphy
• to ddx torsion from acute epididymitis by demonstrating cold spot and ring
signs.
* Radiologic techniques are helpful but may delay treatment*

15. US Doppler scrotum/testis
• Sensitivity 80 - 90%
Specificity 100%
• The case on the left shows a testicular torsion of the left testis.
• Complete absence of intratesticular blood flow and normal
extratesticular blood flow on color Doppler images is diagnostic, if
the flow is normal in the contralateral testis.

16. Nuclear testicular scan/scintigraphy
- Technetium-99 (99mTc-pertechnetate) to trace testicular blood flow
- Requires 1-2 hours
- 86-100% accuracy

18. • Management
1. Alleviation of symptoms
– Analgesic : IV/IM pethidine
– Antiemetic : IV stemetil 10mg, IV maxolon
– Anxiolytic : IV valium
2. Manual Detorsion
• Rotate testicle in medial to lateral direction “open the book”
• usually 1-2 complete turns
• relief of pain
• return of blood supply to testicle (confirmed with US)
• additional time before OR
• patient may not tolerate.
3. Surgical exploration
• Bilateral orchidopexy – to prevent future torsion
• Orchidectomy + contralateral orchidopexy
4. Placement of testicular prosthesis – after 6 months of orchidectomy via
inguinal incision

20. • Prognosis
– < 6 hours, 90% salvage
– > 6 hours, 20% viability likelihood for orchidectomy
– > 24 hours, 100% loss and atrophy
• Complications
– Testicular atrophy : may occur days-to-months after
the torsion has been corrected.
– Severe infection of the testicle and scrotum is also
possible if the blood flow is restricted for a prolonged
period.

21. Epididym-/orchitis
• Most common cause of acute
scrotum(75-80%)
• Acute : < 6 weeks (CDC, STD treatment guidelines)
• Young men – hx of STD exposure
(Chlamydia trachomatis, Ureoplasma urealyticum,
Neisseria gonorrhea)
• Children : UTI, urinary tract structural
anomalies (E. coli, Streptococci, Staphylococci, Proteus)
• Older men : BPH, post vasectomy, post urological operative
procedure/instrumentation, indwelling catheter, infectious
prostatitis, TB
• Orchitis : Syphillis, leprosy
• Viral cause : Mumps (18% males), usually a/w parotid swelling

22. • Chronic tuberculous epididymo-orchitis usually
insidious onset a/w “cold” abscess discharge
• Syphillis
– usually affects body of testis
1. Bilateral orchitis : congenital syphillis
2. Interstitial fibrosis → painless destruction of testis
3. Gumma : unilat. painless slow growing swelling
• Leprous orchitis : testicular strophy in 25%
male lepers.

23. • S/Sx
– Acute progressive onset of scrotal/ groin pain
(>24hr)
– Gradual swelling, erythematous, shiny scrotum
– Febrile fever
– Dysuria
– Difficulty in ambulation
– Urethral discharge
– Hx of recent instrumentation/indwelling CBD

24. • O/E
– Scrotal swelling (secondary hydrocele), enlarged,
erythematous and indurated
– Indistinguishable testis (in later stage)
– Cremasteric reflex is usually present
– Prehn sign positive : elevation of the scrotum may
provide relief of pain.
– Pyuria

25. • Ix :
– UFEME : ↑leucocytes > 10 visual field
– MSU C&S/pus C&S : bacterial growth
– Venereal disease screening : for sexually active men
– Immunofluorescent antibody test, if suspected mumps
– US scrotum/testis
– Flex CU : to detect structural anomalies
– Scrotal exploration or aspiration (rare)
• If torsion cannot be ruled out
• Complications eg. abscess, pyocele, testicular infarction
• Failed conservative treatment in 48-72 hours

26. US scrotum/testis (sensitivity 82-100%, specificity 100%)
• The case on the left shows the typical features of
epididymitis.
• Swollen, heterogeneous, hyperemic
• Hydrocele
• Scrotal wall thickening.
• With color doppler there is increased flow.
A normal epididymis has only limited colorflow.

27. • Diagnostic Criteria for Epididymitis
– Gradual onset of pain
– Dysuria, discharge, or recent instrumentation/CBD
– History of genitourinary abnormality
 (UTI, neurogenic bladder, hypospadias, etc.)
– Fever > 38:C
– Tenderness and induration at epididymis
– Abnormal UFEME (>10 leucocytes visual fields/RBC)
• 3 or more findings present - definite Epididymitis
• 2 findings present - probable Epididymitis
• 1 finding present - possible Epididymitis

28. • Management
1. Antibiotic therapy : if UFEME/MSU C&S positive
for infection
– Suspect STD : IV rocephine + T. doxycycline x 10/7
– Suspect UTI : IV/T. ciprobay x 10/7
– Others : Azithromycin, Bactrim, Gentamicin,
2. Bed rest/scrotal elevation : if UFEME/MSU C&S
negative → sterile chemical epididymo-orchitis
(structural anomalies)
3. Supportive therapy : ice packs, cool Sitz bath
4. Analgesia : opioids, NSAIDs
5. Orchidectomy : if complications developed

29. • Complications
– Abscess
– Pyocele
– Testicular infarction
– Testicular atrophy
– Infertility

30. • Prognosis
– Resolution of sx in 2-4 weeks if properly treated
– Chronic epididymoorchitis may have frequent mild
attacks, may have lumps in scrotum due to
fibroplasia
– May have threat of infertility

31. Torsion of testicular/epididymal appendage
• Remnant of Wolffian(epididymis)/Mullerian(testis) duct
• Can be twisted → torsion
• o/e : testis palpable with normal lie, edematous, torsed
appendage palpable over upper pole of testis, “blue-dot sign”
if ecchymotic
• US Doppler : normal testicular perfusion with hyperemia over
appendage
• Self limiting (infarct → atrophy)

33. Testicular trauma
• Damage occurs when the testis is forcefully
compressed against the pubic bones
• Traumatic epididymitis : noninfectious
inflammatory condition occurs within a few days
after a blow to the testis. Treatment is same like
nontraumatic epididymitis.
• Scrotal trauma can also result in intratesticular
hematoma, hematocele or laceration of the
tunica albuginea (testicular rupture).
• US Doppler : imaging technique of choice.

34. Degree of testicular trauma
1. Blunt (85%) : direct external force to testicle
2. Penetrating (15%) : sharp objects, high velocity missiles
3. Degloving : Scrotal skin sheared off
• Genital self-mutilation : if testis vital, reimplantation is
possible
• Pathophysiology : rupture → intratesticular hemorrhage
in tunica vaginalis → HEMATOCELE! → extends up to
epididymis → bleeding → SCROTAL HEMATOMA!

35. • O/E
– Swelling
– Tenderness
– Ecchymosis
– Scrotal wall thickening
• Palpable testis : unlikely rupture
• Difficulty in palpation : US urgent to determine
degree of testis injury

36. • Management
1. Bed rest
2. Scrotal support
3. Pain relief
4. Testicular debridement
5. Closure of tunica albuginea
• Penetrating trauma : urgent exploration to assess
degree of injury and control intratesticular hemorrhage
• Degloving injury : often need debridement, skin closure
may not be possible

37. • Indications for scrotal exploration include the
following:
– Uncertainty in diagnosis after appropriate clinical and
radiographic evaluations
– Clinical findings consistent with testicular injury
– Disruption of the tunica albuginea
– Absence of blood flow on US Doppler studies
• Complications
– Testicular infection
– Testicular atrophy
– Testicular necrosis
– Infertility
– Disruption of male hormonal functions

38. Incarcerated inguinal hernia
• Irreducible inguinal hernia a/w pain
• A surgical emergency
• Scrotal swelling, groin
pain/swelling, abdominal pain, constipation,
fever, nausea/vomiting
• Ix : FBC, US scrotum, CT
• Mx : surgical exploration,
herniotomy/hernioplasty

39. Hydrocele
• A collection of serous fluid in the tunica vaginalis
• Congenital : occurs in infants due to patent processus
vaginalis  peritoneal fluid can enter the scrotum
Primary. (idiopathic)
• Develop slowly
• Large
• Hard & tense
• No defined cause
• Over 40s
Secondary
• Develop rapidly
• Small
• Lax
• Underlying cause
• younger age group(20-40)

40. • Congenital hydrocele: processus vaginalis is patent &
connects to the peritoneal cavity. In children <3yrs
• Infantile hydrocele: the tunica and processus
vaginalis are distended to the superficial inguinal
ring. There is no connection. Occurs in all ages
• Hydrocele of the cord: swelling near the spermatic
cord. Ddx hernia, lipoma of the cord

41. • O/E
often bilateral
• Can “get above it”
• Testes cannot be felt separately
• Transluminates
• Fluctuant
• Fluid thrill
• Not compressible or pulsatile
• Can’t be reduced
• Normal skin color & temp
• Not tender if primary (may be tender if secondary)
• Size can be reach up to 10-20cm in diameter
• Surface smooth

42. • Ix : US scrotum to ddx from other causes
• Management :
• If congenital hydrocele persists beyond the age of 1year, surgical treatment
is indicated. This involves the division and ligation of the processus.
• In an adult with primary hydrocele
Surgery
Opening the tunica vaginalis longitudinally
Emptying hydrocele
Everting the sac
Suturing it behind the cord thus obliterating the potential space
Aspiration  recurance
In elderly patient who are not fit for surgery
• Secondary hydrocele  treat the underlying cause

43. Testicular tumor
• Rare 1–1.5% of male cancers.
• mainly affects younger men of 30 – 40yo
• 90 - 95% arise from germ cells and are either
seminomas (45%) or nonseminomas(50%).
(Nonseminoma : choriocarcinoma, embryonal carcinoma, teratoma,
and yolk sac tumors)
• 5% are lymphomas, sertoli cell tumours or
leyding cell tumours.
• Prognosis is good particularly if there was no
lymph node involvement

44. • Incidence and frequency
– Seminomas in 30-40y.
– Teratomas in 20-30y.
– Imperfectly descended testes have a 20-30 times
increased incidence of malignancy.

45. Recommended pathologic classification (EUA, 2011)
Germ cell tumours
• Intratubular germ cell neoplasia, unclassified type
• Seminoma (including cases with syncytiotrophoblastic cells)
• Spermatocytic seminoma (mention if there is a sarcomatous component)
• Embryonal carcinoma
• Yolk sac tumour
• Choriocarcinoma
• Teratoma (mature, immature, with malignant component)
• Tumours with more than one histologic type (specify percentage of individual components)
Sex cord/gonadal stromal tumours
• Leydig cell tumour
• Malignant Leydig cell tumour
• Sertoli cell tumour (lipid-rich variant, sclerosing, large cell calcifying)
• Malignant Sertoli cell tumour
• Granulosa (adult and juvenile)
• Thecoma/fibroma group of tumours
• Other sex cord/gonadal stromal tumours (incompletely differentiated, mixed)
• Tumours containing germ cell and sex cord/gonadal stromal (gonadoblastoma)
Miscellaneous nonspecific stromal tumours
• Ovarian epithelial tumours
• Tumours of the collecting ducts and rete testis
• Tumours (benign and malignant) of nonspecific stroma

46. • Classification
1. Germ cell tumors (90%)
- Seminoma 90%
- Embryonal carcinoma 20%
- Choriocarcinoma <1%
- Teratoma 5%
- Teratocarcinoma 40%
(teratoma + embryonal carcinoma)
2. Gonadal stromal tumor (5%)
- Leydig cell tumor
- Sertoli cell tumor
3. Secondary tumor (5%)
• Lymphoma
• Leukemia

47. Risk factors for testicular cancer
Epidemiologic risk factors
• History of cryptorchidism
• Klinefelter syndrome
• Testicular cancer in first-grade relatives
• Contralateral tumour
• Testicular intraepithelial neoplasia or infertility
Pathologic prognostic risk factors for occult metastatic disease (stage I)
1. Seminoma
• Tumour size (4 cm)
• Invasion of the rete testis
2. Nonseminoma
• Vascular/lymphatic invasion or peritumoural invasion
• Proliferation rate (MIB-1) >70%
• Percentage embryonal carcinoma >50%
Clinical risk factors (metastatic disease)
• Primary location
• Elevation of tumour marker levels (AFP, B-HCG)
• Nonpulmonary visceral metastasis*

48. • Dx is made based on
1. Clinical examination of the testis
2. General examination to exclude enlarged
nodes or abdominal masses
3. US to confirm testicular mass.

49. Signs
• can “get above it”
• Testes cannot be felt separately
• Harder than normal testis
• Dull to percussion  hydrocele
• No pain
• Irregular, different sizes
• Surface usually smooth (sometime irregular or
nodular)

50. Symptoms
• Painless swelling of the testis
• Heaviness in the scrotum
• Maybe history of trauma delays diagnosis
• Tiredness, LOW ,LOA
• Abdominal pain if lymph nodes are enlarged
• Swelling of legs caused by lymphatic or
venous obstruction
• Infertility
• Secondary hydrocele

51. • O/E
– Painless unilateral mass in the scrotum or the
casual finding of an intrascrotal mass.
– Gynaecomastia (common in nonseminomatous
tumor)
– Back and flank pain (rarely)

52. Ix :
 US testis
 CXR – to see cannon ball lesion if metastasized
 Tumour markers: AFP, βHCG, LDH
 CT TAP
 CT brain
 CT spine
 Bone scan
 US liver

53. • Serum tumour markers : prognostic factors used in diagnosis
and staging (LDH).
• The lack of an increase does not exclude
• testicular cancer
• LDH levels are elevated in 80% of patients with advanced
testicular cancer, therefore should always be measured in
advanced cancer
• Tumour markers must be reevaluated after orchidectomyto
determine half-life kinetics.
• The persistence of elevated serum tumour markers 3 wk after
orchidectomy may indicate the presence of disease, whereas
its normalisation does not indicate absence of tumour.
• Tumourmarkers should be assessed until they are normal, as
long as they follow their half-life kinetics and no metastases
• During chemotherapy, the markers should decline;
persistence has an adverse prognostic value.

55. Management
• Inguinal exploration and orchidectomy
• If the diagnosis is unclear, a testicular biopsy
(enucleation of the intraparenchymal tumour) should
be taken for HPE
• If metastasized : delay orchidectomy
1. If seminoma: Start radiotherapy plus
chemotherapy.
2. If teratoma: combination chemotherpay 3
drugs(etoposide, vinblastine, methotrexate,
bleomycin, cisplastin)

56. Organ-preserving surgery
• Synchronous bilateral testicular tumours,
metachronous contralateral tumours, or in a
tumour in a solitary testis with normal
preoperative testosterone levels, provided
tumour volume is <30% of testicular volume
• Radiotherapy may be delayed in fertile
patients who wish to father children
• must be carefully discussed with the patient