Hernia[1]

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GROIN SWELLINGS
By
Dr Ahmed Abdel Kahaar Aldardeer
Lecture of general surgery
Sohag university

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Groin is the area above and below the inguinal ligament

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Anatomy
 Inguinal canal:
-Spermatic cord (round ligament in female) and ilio-
inguinal nerve
-4 cm long
-Passes downwards and medially,
from deep to superficial,
from internal to external inguinal rings,
Parallel to and immediately above the inguinal
ligament.

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of the inguinal canalBoundaries

superior wall
(roof):
internal oblique
transversus abdominis

anterior wall:
aponeurosis of
external oblique
aponeurosis of
internal oblique
(inguinal canal)
posterior wall:
transversalis fas
conjoint tendon

inferior wall
(floor):
inguinal ligament
lacunar ligament

Inguinal canal

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Abdominal incisions

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Microscopic anatomy of the testis

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Contents of spermatic cord
1-Testicular artery.
2-Ductus deferens.
3-Artery of the ductus deferens (arises from inferior
vesical artery(.
4-Cremasteric artery (arises from the inferior
epigastric artery(.
5-Pampiniform plexus (formed by up to 12 veins,
drain into right and left testicular veins(.
6-Sympathetic nerve fibers on arteries.
7-Genital branch of the genitofemoral nerve
supplying the cremaster muscle.
8-Lymphatic vessels draining the testis and closely
associated structures.
9-vestige of processus vaginalis.

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Hesselbach’s Triangle
• Defined by three
borders:
• Rectus abdominis
(medially)
• Inguinal Ligament
(inferiorly)
• Inferior epigastric
vessels (superiorly
and laterally)

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Processus vaginalis

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Inguinoscrotal swellings:
1)     Inguinal hernia (direct and indirect).
2)     Hydrocele (congenital, infantile).
3)     Encysted hydrocele of the cord.
4)     Hydrocele of the hernia sac.
5)     Varicocele.
6)     Lymphocele.
7)     Diffuse hydrocele of the cord.
8)     Funiculitis.
9) Lipoma of the cord

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Hernia Definition:
Protrusion of a viscus or part of a viscus through
an opening in a cavity in which it is normally
contained (external hernia), or between two
adjacent cavities or into a subcompartment of
a cavity (internal hernia).

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Types of abdominal hernia:
 Inguinal hernia
 umbilical & paraumbilical
 Epigastric
 Femoral
 Incisional
 Other rare hernia… Richter’s, litter’s,
spigelian, madyl’s, pantaloon,….

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1)Inguinal hernia
 80% of all external hernias
 Occurs at all ages (most common in infants
and elderly)
 20 times more common in men than women
 60% on the Rt. side

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Causes:
(site of weakness +increase intra abdominal
pressure)
Causes of weakness:
Congenital:
•Patent processus vaginalis
•Failure of closure of umbilicus
Acquired:
•Loss of tissue strength & elasticity
•Surgical trauma
•Enlargement of a foramen
•Nerve damage
Causes of increase
intra abdominal pressure
•Carrying heavy object
•Cough constipation
• Pregnancy, obesity
•Ascites

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Clinical findings
 A lump which is present on standing and
straining and disappear on recumbancy
 If obstructed: colic, vomiting, distension and
absolute constipation
 If strangulated: constant pain over the hernia
(red, tense and tender), fever, tachycardia and
-ve cough impulse

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Symptoms
-The commonest symptoms are discomfort & pain.
--The patient complaints of a dragging, aching sensation in the
groin.
-If hernia become very painful & tender, its probably
strangulated
Many hernias cause no pain & the patient presents having
noticed a swelling in the groin or in the scrotum.
Intestinal obstruction is associated with a colicky pain.
Large hernia may interfere with bowel activity & cause a change
in bowel
habit.
-Persistent coughing & difficulty with micturition.

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Diagnosis
• Diagnosed on examination
• Very difficult to differentiate direct /
indirect
• May also use ultrasound in equivocal
cases

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Inguinal Hernia
 Most hernias can be diagnosed based on the
history and clinical examination.

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Herniography

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Right oblique inguinal hernia

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Relation of the hernia to the pubic tubercle
Inguinal hernia Femoral hernia

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Indirect
inguinal hernia
Its sac extends
above and medial
to the pubic
tubercle
Femoral hernia
Its neck lies
below and lateral
to the pubic
tubercle

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Relation of the hernia to the testis
Complete inguinal Congenital

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Obstructed left congenital hernia

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Internal ring test

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Palpation
Direct hernias are coming through the back wall of the inguinal
canal so pressure over the entrance to the canal will not control
them. However, in indirect cases the only passage for bowel is
through the deep ring itself and so pressure will control these.

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Right direct inguinal hernia

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External ring test

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Irreducible
Hernia
The content of hernia sac cannot be replaced into the
abdomen.
) incarceration, obstruction & strangulation (
Incarcerated
Hernia
Contents are literally imprisoned in the sac of the hernia
but are alive & functioning normally.
An incarcerated hernia is not tender.
Strangulated
Hernia
The blood supply to the contents of the sac has been cut
off & they are dead & dying.
Strangulated hernia is acutely tender.

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Indirect Direct
Site Pass through int. ring to
the ext. ring above
pubic crest and tubercle
Through post.
Wall of the canal
Age Any age but usually
young
older
Cause congenital acquired
Bilaterality 20% 50%
Protrusion on
cough
oblique straight

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Indirect Direct
On standing Doesn’t reach full
size immediately
Reaches full size
immediately
On lying down May not reduce
immediately
Reduce
immediately
Descent into
scrotum
common rare
Control by
pressure over the
internal ring
control Doesn’t control
Neck of sac narrow wide

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Indirect Direct
strangulation common unusual
Relation to inferior
epigastric vessels
lateral medial
Recurrence after
surgery
uncommon More common

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Anatomy
Direct / Indirect (or Femoral)

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Differential diagnosis:
 Sebaceous or epidermoid cyst
 Lipoma
 Fibroma
 Tumour(muscle)
 Aneurysm
 Varicosity
 enlarged LN
 Ectopic testis or ovary

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Diagnosis of a hernia:
1( Types.
2( Complete or not.
3( Complicated or not.
4( Content(omentocele,enterocele(.
5( Other hernia orifice.
6( Condition of musculature.
7( Predisposing factors.
8( Clinical fitness.

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*Weak abdominal musculature:
1-Divercation of recti
2-Old age
3-Malgaigne`s bulges
4-Recurrent hernia
5-Multiple hernias
6-Direct inguinal hernia
7-External ring test ------ wide ring , weak
posterior wall
8-Obesity
9-Debilitating disease , hypoalbuminemia,
corticosteroid therapy, DM,….

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D.D OF FEMORALE SWELLINGS
Enlarged Inguinal Lymph Nodes
Saphena Varix
Inguinal hernia
Femoral Hernia
Femoral Artery Aneurysm
Lipoma
Septic arthritis
Cold abscess—psoas abscess
Undescended testicle
Posoas bursa
Obturator hernia

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The Nyhus classification of groin hernias:
Type 1 ----------------------------------------
Indirect inguinal hernia with normal
internal ring
Type 2-----------------------------------------
Indirect inguinal hernia with
enlarged internal ring
Type 3---------------------------------------- Posterior wall defect
A----------------------------------------
B-----------------------------------------
Direct inguinal hernia
Indirect inguinal hernia with dilated
Internal ring and posterior wall
defect
C----------------------------------------- Femoral hernia
Type 4-----------------------------------------
Recurrent hernia

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Scrotal swellings:
1 -Skin:
Oedema, cellulitis, boil, sebaceous cyst, warts & epithelioma.
2-Tunica vaginalis : Hydrocele (:primary or secondary).
Haematocele.
Pyocele.
3-Testis:
Torsion.
Orchitis.
Gumma.
Seminoma.
Teratoma.
4- Epididymis.
Epididymitis.
TB epididymis.
Spermatocele .

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1) Cord.
Hydrocele of hernia sac.
Diffuse hydrocele of the cord.
Varicocele.
Lymphocele.
Funiculitis.
Lipoma.
2) Urethra.
Periurethral abscess.
Bilharzial mass.
Extravasation of urine.

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Painful scrotum:-(history and physical examination, laboratory
studies and radiological examination).
1)-Torsion testis --- immediate surgery and bilateral
orchiopexy.
2)-Epididymo-Orchitis----- I.V antibiotics, bed rest
and testicular elevation.
3)-Scrotal gangrene, abscess----debridement and
drainage , I.V antibiotics and hemodynamic stabilization.
4)-Incarcerated hernia---reduction and repair
5)-Hydrocele----surgery if large and symptomatizing
6)-Varicocele----treatment if symptomatizing and
subfertility.
7)-Testicular tumors---Staging and treatment.
8)- Scrotal Trauma ----evacuation of hematoma.

WWW.SMSO.NETLymphedema of the penis

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Position of examination of the external genitalia

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Examination of the perineum

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Palpation of the spermatic cord

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Examination of the urethral opening

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Palpation of the external ring

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Knee chest position Left lateral position
Position of PR examination

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Bipolar test for fluctuation

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Transillumination test

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Transillumination test for Epididymal cyst

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Examination of epididymis

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Encysted hydrocele of the cord

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Hernia Repair: Historical Overview
-------------------------------------------
Eduardo Bassini (1844-1924): own technique 1877•
Bassini modifications (Halsted,Kirschner,Houdard..(•
Chester McVay (1911-1987): own technique 1948•
Edward Shouldice (1890-1965): technique 1945-51•
Lloyd Nyhus (°1923): type-related techniques 1955•
Irving Lichtenstein (°1920): tension-free techn.1986•

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Anesthesia
 General
 Spinal
 local

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STEPS
 Inguinal incision : parallel and one inch above
medial 2/3 of inguinal ligament
 Inguino-scrotal incision : for strangulated
oblique hernia

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STEPS
 Division of external oblique aponeurosis in
same direction of skin incision
 Isolation of spermatic cord with preservation
of ilio-inguinal nerve
 Dissection of hernial sac which lies anterior to
other contents of cord ( vas deferens ,
testicular vessels, lymphatics and nerve
fibers )

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HERNIOTOMY
 Dissection of hernial sac is done down to the neck of
sac which is identified by :
 Narrowest part of sac
 Surrounded by collar of fat
 Inferior epigasric artery is medial to neck
 Herniotomy by transfixion of neck of sac and
removal of sac above the ligature
 In infants herniotomy alone is enough (no need for
repair)

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The sac is opened and explored, a finger is passed through the
mouth of the sac exploring for concomitant direct inguinal
hernia.

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The neck of the sac is transfixed and ligated as high as possible and
the sac is excised half an inch distal to the ligature.

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HERNIORRAPHY
( Repair)
 In children only narrowing of internal ring is done
 plication of fascia transversalis
 Bassini repair : suture of conjoint tendon to inguinal
ligament
 Bloodgood's repair : triangular flap is taken from lower
part of rectus sheath and sutured to inguinal ligament
 Shouldice repair : division of fascia transversalis
transversely then overlapping the lower part by the upper part
( double breasting) behind cord.

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Tanner slide modification

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Halsted's`s repair

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Bloodgood`s repair

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repairShouldice

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Sliding hernia repair

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HERNIOPLASTY
 Synthetic mesh is put over fascia transversalis in
space between conjoint tendon and inguinal ligament
 The mesh is formed of either one layer or formed of 2
layers
 The mesh is fixed in place by few non-absorbable
sutures
 Some surgeons use it in only recurrent cases, old age,
large defects or weak musculature

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HERNIOPLASTY
Fascia lata repair Mesh repair

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Lichtenstein Repair
 Popularized the use of polypropylene mesh in
primary hernia repairs
 Mesh is laid over the undisturbed inguinal
floor, posterior to the spermatic cord sutured
to the shelving edge of the inguinal ligament,
internal oblique fascia and the pubis

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STEPS
 Suturing external oblique aponeurosis
 Closure of skin with drain

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Complications of Hernia Repairs
 Major
 Haemorrhage
 Testicular atrophy
 Bowel injury
 Bladder injury
 Major vessel injury
 Minor
 Wound infection
 Urinary retention
 Recurrence
 Nerve injury
 Small-bowel obstruction

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Imperforate hymen Neonate with a bulging
perineum due to mucocolpos

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This patient showed manifestations of granuloma inguinale,
also known as Donovanosis, involving swelling of the penile
shaft with accompanying subcutaneous granulomas in the
inguinal region, bilaterally.

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This image shows an extensive chancre located on the
penile shaft due to a primary syphilitic infection caused
by Treponema pallidum bacteria

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Granuloma inguinale

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Persistent Cloaca perineum

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DUPLICATION OF THE PENISDUPLICATION OF THE PENIS

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 There are two types of hernia repair surgeries:
 1-Open hernia repair surgery. During open surgery, the
hernia is repaired through an incision in the groin. Open
surgery is safe, effective, and has been done for many years.
 2-Laparoscopic hernia repair. it is a newer method for
repairing an inguinal hernia in adults. A surgeon inserts a thin,
lighted scope through a small incision in the abdomen.
Instruments to repair the hernia are inserted through other
abdominal incisions.

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hernia repair surgeries
 There are two types of hernia repair surgeries:
 1-Open hernia repair surgery. During open surgery, the
hernia is repaired through an incision in the groin. Open
surgery is safe, effective, and has been done for many years.
 2-Laparoscopic hernia repair. it is a newer method for
repairing an inguinal hernia in adults. A surgeon inserts a thin,
lighted scope through a small incision in the abdomen.
Instruments to repair the hernia are inserted through other
abdominal incisions.

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Inguino-scrotal Hernia

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Direct inguinal hernia

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Complication:
 Irreducibility
 Obstruction
 Strangulation

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2)Femoral hernia
 More common in females because of wider
pelvis
 Usually in middle-aged and elderly (rare in
children)

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Anatomy
 Femoral canal:
- 1.5 cm
- at the medial
extremity of
femoral sheath
- it contains a plug
of fat and a lymph
node

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Anatomy
 Boundaries of the femoral ring:
a) anteriorly:
inguinal ligament
b) medially:
Gimbernat’s ligament
c) laterally:
femoral vein
d) posteriorly:
pectineal ligament

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Femoral Hernia-Significance
 Femoral hernias compromise about 6% of
hernias. This is about 1/10 the incidence of
inguinal hernias. About 85 % of direct and
indirect hernias are male. However about 85%
of femoral hernias occur in females.
 Femoral hernias are a not uncommonly missed
source of SBO. Always check the inguinal
area carefully for femoral hernias which are
easily missed unless actively looked for. You
will save a life!

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Femoral hernia- etiology
 All are acquired.
 Are secondary to an expanded femoral ring.
 Probably due to increased intraabdominal
pressure.As an example of this femoral
hernias are much more common in
nulliparous women

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Femoral hernia -Diagnosis
 Diagnosis by physical exam.
 A fixed mass is noted just below the inguinal
ligament . If incarcerated chronically it will
be medial to the femoral vessels.
 Differential diagnosis includes lymph node,
lipoma or saphenous varicosity
 The masses may be differentiated by clinical
characteristics

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Femoral hernia -Diagnosis
 Femoral hernia – Chronically incarcerated. Mobile
inferiorly, medially and laterally but appears fixed to
the inguinal ligament.
 Femoral hernia-Reducible. Will be obvious due to the
ability to reduce the mass and the gurgling sensation
if bowel is present within it
 Lymph node- Usually more mobile in all directions
.It is not fixed at the top. Also more superficial. If
fixed usually deep.
 LIpoma –Can be lifted off the deep fascia
 Saphenous varix-Collapse completely on lying
down . Do not have as firm a character as femoral

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Femoral Hernia- Diagnosis
 CT scan or Ultrasound may be useful in some
cases.

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femoral hernia
All femoral hernias need to be treated surgically
as they have a high risk of becoming
strangulated
Principles:
 Dissection of the sac
 Reduction / inspection of the contents
 Ligation of the sac
 Approximation of the inguinal and pectineal
ligaments

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Femoral hernia- Surgical Repair
 Anatomy is key. External iliac vessels run
along the surface of the iliopsoas muscle in
the pelvis, pass between the iliopubic tract
and Coopers ligament and course beneath the
inguinal ligament The opening of femoral
canal is a musculoaponeurotic ring consisting
of coopers ligament inferiorly,the femoral
vein laterally and the ileopubic tract medially
and superiorly.

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1-Low approach or LockwoodLockwood
operation.
2-High approach or Lotheissen`sLotheissen`s
operation.
3-Combined approach or Mc EvedeyMc Evedey
operation.

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Femoral Hernia Repair- Primary From
Below
 Original approach was inferior to inguinal
ligament with excision of sac and closure of
inguinal ligament to pectineal fascia and
Coopers ligament from below.
 Approximately 5% recurrence rate.
 Advantage is simple approach . Poor
exposure intestine.

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Femoral Hernia Repair- Inguinal
Approach
 Hernia is approached via inguinal incision
and Coopers Ligament repair performed.
 Advantage is lower recurrence rate of femoral
hernia and ability to approach intestine in
more direct manner. Reported low recurrence
rate.
 Disadvantage is repair under tension and
painful repair with longer recovery

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Femoral Hernia Repair-Extraperitoneal
Approach
 Transverse incision 4 cm above pubic
tubercle. Expose the Femoral ring
preperitonealy. Coopers ligament sutured to
ileopubic tract.
 Good exposure to incarcerated bowel. Low
recurrence rate reported -1%

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Femoral hernia repair-Mesh Plug
Approach is from below inguinal ligament .
Hernia is exposed , sac opened ,bowel reduced.
Rolled mesh or plug is inserted into canal and fixed
into position with sutures.
Hernia canal completely obliterated.
Must be careful not to damage vein

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Femoral hernia repair-Laparoscopic
 Same approach as for inguinal . Either TEP or
TAPP.
 Advantage is good exposure and low
recurrence rate.
 Disadvantage is need for general anesthesia,
more extensive surgery. Difficult to handle
edematous or compromised bowel.

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Richter’s hernia
 Only part of the wall of small intestine
herniates through the defect

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Lumbar hernias occur in the quadrilateral that is bounded
above by the 12th rib, below by the iliac crest, behind by the erector
spinae muscle and in front by a vertical line drawn from the tip of
the 12th rib to the iliac crest.
This area encompasses the 2 anatomical triangles, which form the
commoner sites for lumbar hernias.
*The inferior lumbar triangle (Petit's) is bounded by the posterior
free margin of the external oblique muscle in front, the Latissimus
dorsi behind and the iliac crest below. The floor is formed by the
internal oblique muscle and the lumbar fascia.
*The superior lumbar triangle (Grynfeitt-Lesshaft's) is bounded
above by the 12th rib and the sacrospinalis muscle, behind by the
erector spinae group and in front by the internal oblique. The
Latissimus dorsi forms the roof of the triangle.

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Bilateral irreducible lumbar hernia

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D.D of lumbar hernia:
1-Lipoma
2-Fibroma
3-Cold abscess
4-Retro peritoneal tumor
5-Chronic abscess

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Infant with gluteal hernia

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Obturator hernia
 Rare.Primarily older women
 Presentation-Acute pain and small bowel
obstruction.
 Howship- Romberg Sign-Pain extending
down medial thigh.Hernia mass rarely
palpable
 Frequently have h/o previous attacks

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Obturator hernia
 Surgical approaches- Abdominal approach
probably best. Allows for bowel resection if
necessary.Best place to cut obturator
membrane is inferor margin. May need mesh.

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Strangulated hernia

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4)Umbilical Hernia
Definition
Treatment

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5)Epigastric Hernia
1-Opening or weakness in the linea alba
from the xiphoid process to the
umbilicus.
2-The umbilicus is normal in its shape

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5)Epigastric Hernia

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6)Incisional Hernia
*occur in the area of any prior surgical incision
*present as a bulge or protrusion at or near the area of
the prior incision scar
* It may be paralytic or cicatricial

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Incisional hernia-Risk Factors
 Obesity-Up to 20% rate of hernia reported after
bariatric surgery
 Wound Infection-Bucknell found a 23% hernia rate
after wound infection
 Increased intra-abdominal pressure-Such as ascites,
ileus or SBO,coughing and vomiting
 Malnourishment /Hypoproteinemia(makela et al)
 Emergent operation
 Anemia
 COPD/Pulmonary complicatios

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Incisional hernia –Risk Factors Type of incision- Transverse stronger then vertical.
Carlson found 10.5% rate for midline vertical vs
7.5% rate for transverse and 2.5% for paramedian
incision
 Suture material Non-
absorbable-May serve as nidus for infection Also has
cutting effect on tissue over the long term resulting in
late hernia.Polyglactin suture(long lasting absorbable)
has been recommended to avoid this.
 Continuous vs interrupted- No significant difference
shown

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Incisional Hernia

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Treatment of incisional hernia
-palliative abdominal belt may be used.
-pre-operative reduction of weight.
*TYPES OF OPERATIONS USED:*TYPES OF OPERATIONS USED:
-Keel operation
-Cattell`s operation
the neck of the sac from inside
the edges of the sac
posterior rectus sheath
the muscles
anterior rectus sheath
-Anatomical repair
-Hernioplasty

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7)Para umbilical Hernia
*Acquired condition that occurs next to the
umbilicus or more commonly above the
umbilicus
*Occur when the abdominal wall stretched due
to obesity and pregnancy

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Para Umbilical Hernia

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8)Congenital diaphragmatic Hernia

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9)Congenital diaphragmatic Hernia

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Testicles that do not naturally descend into the
scrotum are considered abnormal throughout the
patient's life.
These undescended testicles have an increased
likelihood of developing cancer regardless of
whether or not they are brought down into the
scrotum.
Undescended testicle

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Incidence:Incidence:
-it occurs in approximately one in every 200 males
-in approximately 10% of cases it is bilaterally.
**factors responsible for testicular descent**factors responsible for testicular descent
1 -Gubernaculum----- it is a fibro muscular band connecting the lower pole of the
testis to the bottom of the scrotum guiding the testis into the scrotum.
**LOCKWOOD THEORY
the gubernaculum has head and five tails, the main tail attached to the base of the
scrotum while the other tails that will become agenetic are attached to the following sites:
Superficial inguinal pouch, femoral triangle, perineum and base of the penis
-if the main tail rupture or not will developed one of the other tails developed and the testis
will be in an ectopic site.
-Gubernaculum is under the effect of HCG hormone

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2-Human Chorionic Gonadotrophin HCG
It stimulate the development and growth of the testicle and it becomes heavier and descent
3-Intra abdominal pressure—squeezing the testis through the rings
4-Elongation of the upper half of the body leading to relative caudal shift in position of the
testis.

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Right undescended testis the hemiscrotum is underdeveloped

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Possible sites for maldescended and Ectopic
testis

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The undescended testis is
at increased risk of:
-torsion
-tumour
-trauma
-infertility

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Examination of UDT

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THE testis is oval , firm , slippery with sickening testicular sensation when squeezed

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Epididymo-Orchitis
 Definition
 symptoms and signs
 Investigations
 treatment

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Definition of Epididymo-Orchitis
“An inflammation of the tissues of the
epididymis and testis”
The commonest cause of this is infection..

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Symptoms & Signs
Symptoms: Painful scrotal swelling
Signs: A scrotal swelling which you can get above
and which is
- hot
- tender
- erythematous

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Investigations
 Urethral swab and first void urine: for gonorrhoeae and
chlamydia infection.
 Midstream urine for microscopy, culture and sensitivities.
 All patients with sexually transmitted epididymo-orchitis
should be screened for other sexually transmitted
infections. Sexual contacts should also be evaluated.
 Ultrasound: useful to help distinguish acute epididymitis
from testicular torsion if immediately accessible but must
not delay intervention or exploration if testicular torsion is
suspected4
.

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Treatment
An appropriate broad-spectrum antibiotic is used, such
as
ciprofloxacin.

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Torsion of the testicle
this condition occurs when the spermatic cord twists
upon itself, leading to vascular compromise and
testicular loss with prolonged ischemia.
-the peak incidence seen in the 12-18 years,but all
ages are susceptible
-testicular torsion was 10 times more common in
patients with undescended testes.
-Bilateral torsion is said to account for fewer than
5% of all cases.
* Testicular torsion can be classified into:
ExtravaginalExtravaginal or IntravaginalIntravaginal based on whether the
twisting is above or below the reflection of the tunica
vaginalis into the spermatic cord.

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Torsion of testicular appendix

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A-Extravaginal torsion
B-Intravaginal torsion

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•-Congenital anomaly; bell clapper deformity
•-Undescended testicle
•-Sexual arousal and/or activity
•-Trauma
•-Exercise
•-Active cremasteric reflex
•-Cold weather
Predisposing factors

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Predisposing factors
Bell clapper deformity

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Risk factors for torsion Torsion of the testis

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Diagnosis
-Sudden onset of sever, unilateral testicular pain ,with
swelling of the testicle.
-High riding of the affected testicle.
-Swelling and redness of the scrotum.
-Pain in the groin or abdomen
-Associated nausea and vomiting
-Elevation of the testis exaggerate the pain--- -ve Prehn`s
sign.
-Loss of cremastric reflex.
-The affected testicle assumes a retracted horizontal lie.
-Scrotal duplex raveled no testicular blood flow.
-Technetium-99m scan will show a cold spot which
represents decreased perfusion in the affected testis.

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Neglected left testicular torsion in a 17 years old male

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Management
-Urgent surgical exploration
-The nonviable testicle should undergo orchidectomy
--while evidence of viability should prompt detorsion
with orchiopexy and fixation of the contralateral
testicle
-manual detorsion may be attempted with nerve
block of the spermatic cord,
As torsion occurs away from septum dartos –
clockwise on the right and counter clockwise on the
left viewed from the foot of the bed , detorsion occurs
on the opposite direction.

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Perform the operation through the midline scrotal raphe.
Enter the ipsilateral scrotal compartment; then, deliver and
untwist the testis.
Evaluate the testis for viability.
Remove the necrotic testis to avoid prolonged, debilitating
pain and tenderness. Retention of a necrotic testis may
exacerbate the potential for subfertility, presumably because
of development of an autoimmune phenomenon.
To prevent subsequent torsion, fix viable gonads to the scrotal
wall with 3-4 nonabsorbable sutures. Perform both exploration
and anchoring of the contralateral testis through the same
incision

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Intra operative finding of testicular torsion

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Hydrocele
Definition:
“A hydrocele is a collection of fluid within the tunica
vaginalis”

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Hydrocele
Vaginal hydrocele
It is the most common type of hydrocele.
The tunica vaginalis surrounding the testis is distended with fluid
and usually appears as Pyriform or globular swelling,

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Pathogenesis of Hydrocele
The fluid collects because of an imbalance between
production and absorption.
The tunica vaginalis normally produces around
0.5ml of fluid a day.

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Normal scrotum Communicating
hydrocele
Non-communicating
hydrocele
Types of hydrocele

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Hydrocele
Epididymal cyst Varicocoele

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hydrocele
Because one of the causes of a hydrocele is
testicular tumour, it is important to arrange a
scrotal ultrasound
 Conservative management if the hydrocele is
small and causing little in the way of symptoms
 Aspiration +/- injection of a sclerosing agent

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Hydrocele History & Examination
History: A painless swelling in the scrotum.
Onset may be gradual or sudden.
Examination: A scrotal swelling which you can get above
The testis cannot be palpated separate to the
swelling
The lump transilluminates

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Hydrocele Investigation
Because one of the causes of a hydrocele is testicular
tumour, it is important to arrange a scrotal ultrasound
to rule out this as an underlying pathology

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Hydrocele Treatments Include:
 Conservative management if the hydrocele is small
and causing little in the way of symptoms
 Aspiration +/- injection of a sclerosing agent
 Surgery: evertion of the tunica vaginalis
Jaboulay--- excision of the tunica
Lords ----plication of the tunica vaginalis

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Epididymal Cyst
 Definition
 Symptom & signs
 Examination
 Management

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Epididymal Cyst Definition
“ A cystic swelling arising from the epididymis”

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Epididymal Cyst History & Examination
History: Painless scrotal swelling
Onset usually gradual
Examination: Scrotal swelling which you can get above
Testis palpable separate from the lesion
The cyst transilluminates
The transilluminated appearance of the cyst is classically
described as a “Chinese Lantern”

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Chinese Lantern appearance of an Epididymal cyst

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Epididymal Cyst
Simple surgical excision of the cyst
Aspirating will not work because the cyst is
multiloculated
As for hydroceles, conservative management is
perfectly reasonable if the patient is
asymptomatic

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Epididymal Cyst Management
Simple surgical excision of the cyst
Aspirating will not work because the cyst is
multiloculated
As for hydroceles, conservative management is
perfectly reasonable if the patient is
asymptomatic

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Spermatocele
It is a retention cyst due to obstruction of one of the vasa efferentia.
The fluid inside is pearly white and contains dead spermatozoa
Clinical picture:
A scrotal swelling which has the following characteristics:
-painless and tenderness.
-rounded or oval in shape and soft or cystic in consistency.
-small in size and unilateral.
-+ve transillumination.
-at the upper pole of the testis, separated from it by a groove, described
as the third testis.
**Excision is the best treatment if it cause symptoms.

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Spermatocele
Spermatocele is a cyst-like mass within the scrotum
that contains fluid and dead sperm cells.

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Varicocoele
 Definition
 Symptoms might a patient complain of
 Common signs on physical examination
 Why is it important to image the kidneys?
 Management

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Varicocoele Definition
“A varicocoele is a dilatation of the veins of the
pampiniform plexus”

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Hippocrates (460-377 B.C.) – clinical description:
“bag of worms”

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Varicocele most commonly occur on the left. Whereas
the right internal spermatic vein drains into the vena
cava, the left internal spermatic vein drains into the left
renal vein and therefore is significantly longer than the
right vein,resulting in greater transmission of pressure
to the pampiniform plexus.
Grading OF Varicocele
Grade I –Varicocele is palpable with valsalva
maneuver
Grade II – is palpable in the standing position.
Grade III– is visually apparent through the scrotal
skin as a bag of worms.

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Varicocoele Symptoms & Signs
Symptoms: Scrotal swelling
Far more common on left than on right
Dragging / aching sensation in the groin /
scrotum
Signs: Scrotal swelling which you can get above
Swelling feels like a “Bag of worms”

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Significance of Varicocoele
A left sided-varicocoele may arise as a result of
obstruction to venous drainage caused by a renal
tumour
Therefore all patients with a varicocoele should
undergo imaging (usually ultrasound) of their
kidneys

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Complications of Varicocele:
1-Decreased testicular volume.
2-Impaired sperm quality.
3-Decline in Leydig cell function.
*Surgical repair of Varicocele has shown to produce:
-Decrease further damage to testicular function.
-Improve spermatogenesis.
-Improve Leydig cell function.
Indications of surgery:
Varicocele associated with ipsilateral testicular
atrophy
Testicular pain
Abnormal semen parameter, men with infertility

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Left third degree Varicocele

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Varicocoele: Methods of Treatment
The two main methods are:
1 Surgical ligation
-Retro peritoneal or Palomo approach
-Inguinal approach
-Sub inguinal approach
-Laparoscopic approach
-Microsurgical approach
2 Embolisation under X-Ray control

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Squamous cell carcinoma of the scrotum

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Agenesis of the scrotum in a
6-month-old child

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Testicular Tumours

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Testicular Histology

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RISK FACTORS
1-Prior testicular tumour
2-positive family history
3-Cryptorchidism
4-infertility
5-intersex syndromes
6-DES exposure during gestation
7-white races
8-Testicular microlithiasis
9-Never married
10-Trauma

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Classification of Testicular tumors
1 Germ Cell Tumours
a –Seminoma
b-non seminomatous
-Embryonal carcinoma
-Yolk sac tumors
-Teratoma
-Choriocarcinoma
c-Mixed germ cell tumors
Seminoma + Teratoma
2 Non germ cell tumours: a-Sertoli cell tumors
b-Leydig cell tumors
c-Granulosa cell tumour
3 Others e.g. Lymphoma, leukaemia , metastasis

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STAGING OF TESTICULAR TUMORS

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Remember
40% of testicular tumours are mixed, i.e. they
have both seminomatous and non
seminomatous elements

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Peak Age Incidence
Seminomas 40 years
NSGCTs 30 years

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Symptoms & Signs
 Painless scrotal swelling.
 Chance discovery.
 Testis feels “heavier”.
 Pain in approximately 10% of cases.
 Scrotal swelling which you can get above.
 Loss of testicular sensation.
 The lump is craggy & does not transilluminate.
 May be associated with 2ry hydrocele.
 Thickening of the cord.
 May have palpable liver due to metastases.
 Palpable supraclavicular L.N.
 Respiratory symptoms(cough, hemoptysis).
 Retro peritoneal mass.

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Rt testicular seminoma Paraaortic L.N enlargement
Left supraclavicular
L.N enlargement

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Gynecomastia 2ry to testicular Tr

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Patterns of Spread
Metastases can spread by both lymphatic
and hematogenous routes. Direct extension
through the tunica albuginea with involvement of
the scrotal skin is a rare and late finding . Most
germcell tumors spread first via the lymphatics
rather than hematogenously. A notable exception
is choriocarcinoma, which has a proclivity for
early hematogenous spread.

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Seminoma. High-power photomicrograph (original magnification,
x100; hematoxylin-eosin stain) shows sheets of tumor cells with pale-
staining cytoplasm separated by delicate stroma containing a

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Investigations
Radiology: Ultrasound of testis
CT of abdomen to assess spread
Chest X Ray for metastases
Blood Tests: AFP (alpha foeto-protein)
β−hCG (human chorionic
gonadotrophin)
LDH (lactate dehydrogenase)
The blood tests are known as tumour markers.

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Abdominal computed tomographic (CT) scans
demonstrate testicular metastases to the paraaortic
lymph nodes.

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US image shows a well-marginated uniform
hypoechoic mass in the posterior aspect of the testis

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Tumor Markers
Alpha-fetoprotein is a protein produced early in gestation by the fetal
liver, gastrointestinal tract, and yolk sac. Not surprisingly, the level of
-fetoprotein is elevated in yolk sac tumors and mixed germ cell tumors
with yolk sac elements. In rare cases, it may be elevated in teratomas with
enteric mucous glands or nests of hepatoid cells.
Human chorionic gonadotropin is a glycoprotein produced by the
syncytiotrophoblasts of the developing placenta, and its level is elevated
in tumors containing syncytiotrophoblasts (seminomas or
choriocarcinomas(.
The levels of one or both of these tumor markers will be elevated in more
than 80% of patients with nonseminomatous germ cell tumors at the time
of diagnosis. Obtaining serial serum levels of these tumor markers helps
quantify response to treatment and helps predict recurrence before it
becomes radiologically evident.
Lactate dehydrogenase is produced by multiple organs throughout the
body and is a much less specific marker. It does, however, correlate with
the bulk of the disease and is used in staging.

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Surgery
An inguinal orchidectomy is performed
i.e. the testis is taken out through an incision in the
groin
This is because the lymphatic drainage of the testis is
to the para-aortic nodes. An incision in the scrotum
risks spreading the tumour to the superficial inguinal
lymph nodes which drain the scrotal skin

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Treatment of Seminoma
Stage 1 Orchidectomy + Irradiation to para aortic L.Ns
Stage 2 Orchidectomy+ Irradiation to para aortic
+mediastinal L.Ns.
Stage 3 Orchidectomy + Irradiation to paraortic
+mediastinal L.Ns+ chemotherapy.
Stage 4 Chemotherapy using Cisplatinum
Treatment of Teratoma
Teratoma is les sensitive to irradiation.
Stage 1 treated by orchidectomy +follow up.
Stage 2-4 treated by orchidectomy+ chemotherapy.

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