This topic is very important in day - today practice. Mainly this topic can be kept in clinical cases as well as OSCE's. for Final MBBS - Students. This PPT covers most of them in detail as far as possible.

2. Learning Outcomes
 Discuss the embryology & surgical anatomy of testis.
 List the scrotal lesions.
 Describe the causes, clinical features, complications &
treatment of various scrotal & testicular conditions.
 Outline the types of testicular tumours & explain the etiology,
clinical features, staging & treatment of testicular tumours.

3. Embryo & Descent
 Testes develop RP below
kidneys - 5th
week of IUL.
 The gubernaculum forms
within fold of the peritoneum.
 Envagination of peritoneum
(PV) develops adjacent to
gubernaculum.

5. Scrotum - Layers
 Skin
 SF - Dartos muscle
 Ext.spermatic fascia
 Cremasteric Fascia
 Int.spermatic fascia
 Tunica vaginalis

6. Surgical Anatomy - Testis
 Lt lies lower than Rt.
 It is 1 ½ inches long / 1 inch
broad and ¾ inch thick.
 An adult testis weighs about 10-
15gm.
 Epididymis lies along the lateral
parts of the posterior border.
 Epididymis continues as vas
deferens.

7. Structure - Testis
 Seminiferous tubules – are about 400-
600 in each testis, with an average of 2-3
tubules per lobules. It is made up of 2
cell types namely :-
> The spermatogenic cells – vast majority
> The sustentacular cells or cells of Sertoli.
 Interstitial cells [ Cells of Leydig ] – are
found in small clusters in between the
seminiferous tubules. They secrete
testosterone and small amount of
oestrogen.

8. Surgical Anatomy - Testis
 Testicular artery - branch of abdominal
aorta given off at the level of L2 vertebra.
 The venous plexus emerging from the testis
is called the pampiniform plexus. Finally
they fuse to form a single vein, which drain
into IVC – Rt side & Lt renal vein – Lt side.
 The lymphatics drain into pre-aortic & para-
aortic of lymph nodes at the level of L2
vertebra.
 Testis is supplied by sympathetic nerves
arising from T10 segment of spinal cord.

9. Types
Infections
Fournier’s gangrene

11. Epididymitis
 Infection reaches the epididymis
via the vas.
 Mode of infection.
 Dysuria & fever is more common.
 Scrotal swelling / tender & thickened
epididymis.
 Sec.hydrocele may be present.
 Urine : pyuria, bacteriuria, or a
positive urine culture (Gram-
negative bacteria)

12. Epididymitis
 Bed rest for 1 to 3 days then
relative restriction.
 Scrotal elevation, the use of an
athletic supporter.
 Parenteral antibiotic therapy
should be instituted when UTI is
documented or suspected.
 Reassurance – required.

13. Orchitis
 Inflammation of testis.
 Mode - Blood / Lymph / Epididymis
 Causes - V / B / F / L / S
 Testicular pain radiates - groin
 Fever / Scrotal swelling / tender
 Sec.hydrocele is common
 Trt : Antibiotics / Analgesics / DEC

14. Idiopathic Gangrene - Fournier's
 Vascular gangrene of infective origin.
 Common - Old age / Immunosuppressed pts.
 Causes - Minor injuries / Follow procedures.
 Sudden pain in the scrotum / pallor and pyrexia.
 Cellulitis spreads until the entire scrotal coverings
slough, leaving the testes exposed but healthy.
Treatment :
 Broad spectrum Antibiotics
 Wide excision of all necrotic scrotal skin.
 Skin grafting later.

15. Hydrocoele
 Formation of fluid between the
two layers of the TV.
 Mostly idiopathic.
 Defective adsorption – by TV.
 Excessive production of fluid.
 Interference - drainage of fluid
 Comm. with the peritoneal

16. Types of Hydrocoele
 Congenital
 Acquired
> Primary
- Vaginal hydrocele
- Infantile hydrocele
- Encysted hydr. of cord
- Funicular hydrocele
> Secondary

17. Features - Hydrocoele
 One can get > swelling
 Mild discomfort / pain
 Transillumination +
 Fluctuation positive
 Dull on percussion
 Testis cannot be
palpated separately.
 Testicular sensation – N

18. Secondary Hydrocoele
 Due to disease of the
testis / epididymis.
 Causes – I / I / T
 It is usually small / lax
 Testis is usually palpable
separately from the
swelling.
 Subsides – primary
lesion resolves.

19. Complication & D / D
 H aematocele
 H ernia of hyd.sac [rare]
 I nfection – Pyocele
 C alcification of the sac
– long standing cases
 A trophy of testis
 R upture – T / S
 Inguinal hernia
 Epididymal cyst
 Testicular tumour
 Scrotal edema [ Filariasis ]
 Spermatocele

20. Treatment
 Sub-total excision - Large
hydrocele / thick sac
 Evacuation & Eversion -
when sac is small
 Lord’s Plication - thin sac &
containing clear fluid
 Jaboulay’s operation -
Partial excision & eversion

21. Spermatocoele
 It is a unilocular / retention
cyst formed in epididymis -
blockage of sperm conducting
mechanism of the epididymis.
 This is an acquired condition.
 It is situated in the head of
epididymis.
 The testis can be felt separated
from the swelling.
 It is soft / cystic / transilluminant.
 Aspiration / Excision.

22. Varicocoele
 It means dilated / tortuousity of the veins of
the spermatic cord.
 Usually asymptomatic. Frequent between 15
and 25 years of age
 Dragging discomfort
 Scrotum on the affected side hangs lower
than normal
 On palpation, felt like ‘a bag of worms’
 Positive cough impulse – Thrill like
 On lying down, it is reducible (disappear)
 Smaller and softer.

23. Left Side Common – Why?
 LTV – LRV - Rt. Angle
 Absence / incomp. valves > LTV
 Loaded sigmoid colon - press
 LTA – arches over LTV - 15% of
cases
 L.SRV – also drains – LRV and
circulatory adrenalin may cause
constriction of the testicular vein
 LRV pass between the aorta
behind & SMA in front and may
be compressed by these 2
vessels

24. Varicocoele - Treatment
 Palamo’s Operation – Supra-ingiunal
extragenital ligation of the testicular vein.
 Inguinal approach – Classical approach =
Inavissevich Approach - Easier and safer.
 Sub-inguinal approach – It is sub-inguinal
approach at SIR outside the EOA. Cord is
easily identified.
 Scrotal approach – In case of Grade – IV,
veins have to be excised through this
approach.
 Laporascopic approach - presently accepted,
good approach.

25. Torsion Testis
 Inversion of the testis - 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”.
 Gap between epididymis & the body
of the testis permits the testis to
twists over epididymis.
 Heavy straining – vig.contraction of
cremaster – attached spirally.

26. Torsion Testis
 It is most common between 10 and
25 yrs.
 Symptoms vary with the degree of
torsion.
 Signs related to Torsion –
Deming’s / Angell’s / Prehn’s sign
 Right testis rotates in clockwise
direction where as Left testis rotates
in anticlockwise.
 Doppler U/S - confirm the absence
of the blood supply - affected testis.
 If there is any doubt about the
diagnosis, the scrotum should be

27. Torsion Testis
 Prompt exploration, untwisting and
fixation is the only way to save the
torted testis.
 The patient should be counselled
and consented for orchidectomy
before exploration.
 The anatomical abnormality is
bilateral & the contralateral testis
should also be fixed.
 Other structure in scrotum which can
undergo torsion is ‘Appendage of
testis’.

28. Idiopathic Scrotal Oedema
 It is an oddity that occurs between
the age of 4 and 12 years and
must be differentiated from torsion.
 The scrotum is very swollen but
there is little pain or tenderness.
 The swelling may extend into the
perineum, groin and penis.
 The underlying tetis is normal.
 It is thought to be an allergic
phenomenon; occasionally there is
eosinophilia.
 The swelling subsides after a day
or so but may recur.

29. Testicular Tumour
 99% - are malignant.
 Life time prevalence of getting
testicular tumour is 0.2%.
 Very common in Scandinavia. More
common in higher socio-economic
group.
Pre-disposing factors –
 Undescended testis / Testicular
atrophy
 Cryptorchidism
 Klinefelter’s syndrome – [44-XXY] –
prone to Seminoma testis

32. Seminoma
 Starts in the mediastinum of testis and
lower pole.
 Grossly – it is lobulated / fleshy /
homogenous / creamy or pinkish in color.
 It spreads - into the para-aortic lymph
nodes and then to left supraclavicular
lymph node. Through blood, it spreads to
lungs / bone / brain / liver.
 Types of Seminoma
 Typical / Classic form – It is most
common type. Occurs in middle age.
 Spermatocytic – It occurs in older people.
Good prognosis.
 Anaplastic type – High potentiality to
spread.

33. Teratoma
 It arises from totipotent cells - ecto/ meso/
endo
 Grossly tumor surface is irregular, cut
section shows solid and cystic spaces with
areas of hemorrhage.
 It spreads mainly in blood, less common in
lymphatics.
Histologically there are 4 types –
 Teratoma differentiated [1%]
 Malignant Teratoma intermediate [30%] –
common {Teratocarcinoma}
 Malignant Teratoma anaplastic [15%] –
secretes AFP. {Embryonal carcinoma}
 Malignant Trophoblastic [1%] – shows high
level of β HCG. {Choriocarcinoma}

34. Interstitial Cell Tumours
Leydig Cell tumour [2%] = Masculinises
 Prepubertal tumour
 Sexual precocity – infant Hercules
 Benign – spreads to lymph nodes &
lung
 Radioresistant & Chemoresistant
 Treated by surgery
Sertoli Cell tumour [1%] = Feminises
 Post-pubertal tumour
 Feminizing effect – gynaecomastia /
loss of libido / aspermia
 Treatment is surgery

35. Clinical Features
 Testis is enlarged / firm / heavy with loss
of testicular sensation [ early stage only ]
 Pain - [ 30%] / In 10% of cases it present
identified incidentally / 3% - bilateral.
 Secondary hydrocele is common
 Cremaster is hypertrophied & thickened
 Vas / prostate & Seminal vesicles - N
 Para-aortic lymph nodes are enlarged.
 Inguinal nodes are involved if tumour
breeches the tunica albuginea to spread
to scrotum.

36. Investigations
 No FNAC / No scrotal approach /
No incision biopsy.
 Chest X-ray – to look for lung secondaries
 U/S abdomen – to see nodal status like
para-aortic nodes & liver secondaries. CT –
abd is better.
 U/S scrotum – to see echogenicity of testis &
tumour within.
 Tumour markers.
AFP β-hcg LDH
↑ T ↑ S ↑ 80% - S
↑ 60% - NSGCT
↓ ↓
 Both are elevated in NSGCT – Teratoma –
65%

37. Staging

38. Treatment
 Through inguinal approach. Clamp is
applied to the cord at / above the level of
the deep inguinal ring. High
orchidectomy is done – “Chevassou
manoeuver”.
 Seminomas are radiosensitive. So after
high orchidectomy, RT is given to
increase the cure rate & to ↓ relapse.
 In teratoma, Retroperitoneal Radical
lymph node dissection [ RPLND ] is
beneficial after high orchidectomy.
 Chemotherapeutic drugs - are
Bleomycin / Etoposide / Cisplatin. [BEP]

40. References

41. “ In torsion testis, testis always twists away from midline ”