INTRASCROTAL PATHOLOGIES: Hydrocele, Testicular Torsion and Epididymo - Orchitis

1. adejare i e INTRASCROTAL PATHOLOGIES: Hydrocele, Testicular Torsion and Epididymo - Orchitis Dr Adejare I E Senior Registrar Urology Unit Department of Surgery OAUTHC

2. adejare i e Outline Hydrocele Introduction Classification Clinical presentation and diagnosis Complications Treatment

3. adejare i e Hydrocele Introduction Collection of fluid in the tunica vaginalis A very common cause of scrotal swelling The diagnosis can often be made on physical examination alone Tunica vaginalis is the remnant of the processus vaginalis

4. adejare i e Classification Anatomic Vaginal hydrocele Hydrocele of the cord Communicating hydrocele Infantile hydrocele Aetiologic Congenital Persistence of the processus vaginalis Often seen in neonates, infants and childhood Primary/ Idiopathic Due to defective absorption of fluid Secondary Increased fluid production Epididymo orchitis Testicular tumour Torsion Trauma Reduced absorption Post hernoirraphy, varicocelectomy filariasis

5. adejare i e

6. adejare i e Clinical presentation and diagnosis Depends on the anatomic / aetiological type Vaginal History Most common in middle to late adulthood Slow growing and painless Present for many years before presentation Features of its aetiology if secondary Examination Scrotal swelling (can get above the swelling) No cough impulse Testis palpable if lax, may not be palpable if tense Transilluminates brilliantly

7. adejare i e Communicating hydrocele neonate, young infant or child. May present in adolescence History Enlarges with increased intra abdominal pressure, change in position Can be emptied Examination Soft/tense scrotal swelling, Testis may or may not be palpable Transilluminates brilliantly Infantile hydrocele Similar pathology to communicating hydrocele Doesn�t empty

8. adejare i e Hydrocele of the cord Mobile, smooth , oval Moves downwards if the testis is pulled downwards Differential Inguinal hernia, lipoma of the cord Investigations Scrotal ultrasound If the diagnosis is not clear Testis is not palpable Secondary hydrocele is suspected

9. adejare i e Complications Infection haematocele

10. adejare i e Treatment Surgery Communicating hydrocele/ hydrocele of the cord Groin incision High ligation of the patent processus vaginalis Vaginal Trans scrotal approach Hydrocelectomy Lord�s Jaboulay�s

11. adejare i e Intra operative photograph : Vaginal Hydrocele

12. adejare i e Non operative Communicating hydrocele before 12 � 18 mo of age Elderly patients who cannot tolerate anaesthesia Drainage with a cannula Injection of sclerosant

13. adejare i e Testicular torsion Introduction Twist of the cord with subsequent ischaemia May lead to loss of the testis Classification Intravaginal torsion Cord twists within the tunica vaginalis Occurs in adolescents and adults Extravaginal torsion Cord twists outside of the tunica vaginalis Occurs in neonates/ prenatal

14. adejare i e Pathology/ Aetiology Cord twists on itself May be up to 720 degrees Predispositions High investment of tunica vaginalis Horizontal lie Long mesoorchium Undescended testis

15. adejare i e Pathogenesis Twist of the cord Venous and arterial occlusion Anaerobic respiration with hypercarbia, hypoxia and acidosis Ischaemic pain Oedema and haemorrhage set in Irreversible ischaemic injury by 4 hours Degree of twisting determines the salvagability of the testis Reduction of the twist leads to ischaemic reperfusion injury

16. adejare i e Clinical features Intravaginal Pubertal males Most occur during sleep May be precipitated by trauma/ athletic activity Testicular pain Sudden onset Nausea and vomiting Pain referred to the ipsilateral lower abdominal quadrant Usually no urinary symptoms or fever

17. adejare i e High riding testis in a right testicular torsion

18. adejare i e Examination High riding testis with foreshortened cord Abnormal testicular lie Swelling Absent cremasteric reflex Pain increased on elevating the testis Investigation A clinical diagnosis Doppler ultrasound Radionuclide imaging When in doubt, explore

19. adejare i e Treatment Scrotal exploration EXPLORE AND FIX BOTH TSETIS Marginal viability Warm sponge 100% oxygen Remove necrotic testis

20. adejare i e Necrotic testis

21. adejare i e Epididymo orchitis Inflammation of the epididymis and testis May be acute or chronic testis

22. adejare i e Pathogenesis/ Aetiology Retrograde From the urinary tract via the ejaculatory ducts and vas Starts at the tail of the epididymis and spreads to the rest of the organ and the testis Young boys/ infants UTI/ genitourinary congenital anomaly Uncircumcised Elderly men LUTO from BPH, CAP Catheterisation + associated infection Sexually active men < 35 years Usually secondary to sexually transmitted infections Adult males Secondary prostatitis

23. adejare i e Chronic prostatitis Result from Inadequately treated acute epididymitis Recurrent epididymitis Tuberculosis and other chronic granulomatous infections Bacteriology Paediatric/ Elderly patients Coliforms Sexually active men Heterosexual Gonococcus and Chlamydia Homosexual E. Coli and H. Influenzae

24. adejare i e Diagnosis History Recent onset testicular pain Lower quadrant abdominal discomfort Nausea/ Vomiting Dysuria, urethral discharge Examination Swollen tender epididymis and testis Prehn�s sign Fever Urethral discharge Tender prostate

25. adejare i e Investigation Urethral swab/ smear for mcs Urine for m/c/s Doppler USS Infants/ Elderly patients Imaging Abdominal/ Pelvic ultrasound Cystourethrography IVU Urethrocystoscopy

26. adejare i e Treatment 4 � 6 week trial of antibiotics Elevation of the scrotum/ scrotal support Analgesia, antibiotics Scrotal exploration if in doubt