scrotal swellings 2- torsion testis
TRANSCRIPT
SCROTAL SWELLINGSCase No:2
PROBLEM ORIENTED CASE BASED LEARNING
Dr.B.Selvaraj MS;Mch;FICSProfessor of Surgery
Melaka Manipal Medical collegeMelaka Malaysia 75150
OVERVIEW
• Various causes(Differential diagnosis) of scrotal swellings• Classical clinical vignette with probable diagnosis• The diagnosis in detail- only one pathology in each
episode• Mind map of the diagnosis• Tabular column of differential diagnosis depicting their
characteristic features to differentiate them from your diagnosis• References and feedback
Causes of Scrotal Swellings ACUTE PAINFUL
• Torsion testis• Acute epididymo-orchitis• Torsion of testicular
appendages
CHRONIC PAINLESS
• Hydrocele• Epididymal cyst• Spermatocele• Chronic epididymo-
orchitis• Testicular tumor• Varicocele
Classical Clinical vignette Torsion Testis
• A 14-year-old boy presents with acute onset of right scrotal and RLQ pain for the past 4 hours. He additionally reports nausea and one episode of vomiting. He denies any similar past pain and reports no history of trauma.• O/E: the skin overlying the right side of the scrotum appears
to be slightly erythematous and edematous. The right testicle appears to be lying significantly higher in the scrotum as compared to the left testicle.• The entire right testicle is exquisitely tender to palpation,
whereas the left one is nontender• He has an absent cremasteric reflex on the right.
Torsion Testis- Etiopathogenesis
• Twisting of testis along with spermatic cordStrangulationNecrosis• Common in neonates and in puberty• Inversion of testis• Strong muscular exertion or blunt trauma can trigger it• Undescended testis undergo torsion frequently• High insertion of tunica vaginalis- bell clapper deformity-predisposes• There are 3 types of torsion- Extravaginal, intravaginal and mesorchial• Extravaginal in neonates, intravaginal in adolescents
Torsion Testis- Types
In Neonates In Adolescents Bell clapper deformity
Torsion Testis- Clinical Features
• Sudden severe pain in hemiscrotum or both sides• Nausea & vomiting• Scrotal skin edematous and erythematous• Testis exquisitively tender• Affected testis at higher level because of twisting Deming’s sign• Normal testis lying horizontally Angel’s sign• Pain not relieved on elevation of scrotum Prehn’s sign• Cremastric reflex absent in affected side
Torsion Testis- Clinical Features
Torsion Testis- Clinical Features
Torsion Testis- Clinical Features
Torsion Testis- Differential Diagnosis
Torsion Testis- Doppler USG
Torsion Testis- Doppler USG
Central testicular blood flow Normal Testis
No Central testicular blood flow but excessive peripheral blood flow
• Ipsilateral side Exploration, detorsion and fixation orchiopexy Detorsion is away from median raphae of scrotum like opening a book• Contralateral side Exploration and fixation orchiopexy• In doubtful cases and nonavailability of Doppler USG
Better to explore rather than unduly delay the treatment• Testicular salvage rate is 100% if surgery is done within 6
hrs and it is 20% if surgery is delayed > 24 hrs
Torsion Testis- Treatment
• Hydatid of testis & epididymis Remnant of obliterated Mullerian ducts• Sudden Swelling and redness of hemiscrotum• Tender Testis• ‘Bluedot sign’ +ve• Cremastric reflex intact
Torsion of Testicular appendages
Torsion of Testicular appendages “Blue dot sign”
• Explore & Excise torsed appendages in early cases• In delayed cases >48 hrs conservative treatment with antibiotics & anti inflammatory drugs
Torsion of Testicular appendages Treatment
• Inflammation of epididymis & Testis due to infection or trauma• Sudden onset of pain in a hemiscrotum• Commonly associated with UTI or trauma• Thickened & Tender epididymis• Pain relief by elevation of hemiscrotum Prehn’s sign• Can be treated conservatively with antibiotics and antiinflammatory drugs
Acute epididymo-orchitis
Acute Epididymo-orchitis Doppler USG
USG Scrotum• Thickened Epididymis• Reactive Hydrocele• Thick scrotal wall
Doppler USG• Excessive blood flow to
Epididymis• Normal testicular
parenchymal blood flow
Testicular Torsion- Mindmap
Scrotal Swellings- Algorithm
Scrotal Swellings Ex & Px
Hx Sx Dx Tx
1. Hydrocele Primary-IdiopathicSecondary- under lying pathology
Painless big swelling; not reducible
No cough impulseGet above swelling+Transilluminant+
ClinicalIn doubt- USG of scrotum
Lord’s operationJaboulay’s operation
2. Epididymal cyst & Spermatocele
Degenaration of epididymis, occlusion of pathway
Swelling in scrotum resembles 3rd testis
Testis palpable separately; Chinese lantern appearance
ClinicalUSG of scrotum
ConservativeExcision
3. Varicocele IdiopathicAbsence of valves in testicular vein
Worm like in upper scrotum; infertility
Disappears on lying down; Bag of worms appearance
ClinicalUSG color doppler
VaricocelectomyInguinal or Retroperitoneal
4. Testicular torsion & Epididymo- orchitis
Abnormal fixation and lie of testisUTI & trauma
Severe pain& swelling scrotumNausea & vomiting
Tender hemi scrotum; cremasteric reflex absent
ClinicalUSG color doppler
Explore,detorse, orchiopexy or orchidectomyConservative
5. Testicular carcinoma
UDT, Kieinfelter’s Germ cell- Seminoma & Non seminomaNon germ cell tumor
Painless heavy swelling
Not reducibleHard in consistencyTestis felt separately
Clinical; No FNACUSG OF scrotum
High orcidectomy with or without RPLND+ RT+CT
D/D for Scrotal Swellings (Compare & Contrast) (Vertical Reading)
References
• Hunt & Marshall’s clinical problems in surgery 2nd edition• Clinical surgery made easy- a
companion to PBL by Mohan De silva 1st edition• 100 cases in surgery 2nd edition• Case files surgery 4th edition• Clinical scenarios in surgery-
decision making 1st edition• Surgery- a case based clinical
review 1st edition
• Surgery Review by Carlos Pestana• Clinical surgery pearls by
Dr Dayananda Babu 2nd edition• NMS casebook surgery 2nd edition• General Surgery- Correlations &
clinical scenarios 1st edition• Surgery review by Makary 3rd edition• Short practice of surgery by Bailey and
Love 26th edition• Shelf life surgery 1st edition
Feedback & Suggestions
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