gus2 - k8 - scrotal swelling
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8/11/2019 GUS2 - K8 - Scrotal Swelling
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م ي ح ر ل ن ح ر ل م Scrotal Swellingsس
Div. of Urology, Dept.of Surgery Medical Faculty,
University of Sumatera Utara
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Common Causes of Scrotal Swellings
HydroceleEpididymal CystVaricoceleEpididymo-orchitis
Testicular Tumour
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Hydrocele
• Fluid collections within the tunica vaginalisof the scrotum or along spermaticcord.
• Persistent developmental connections alongthe spermatic cord or Imbalance of fluidproduct versus absorption.
• Little risk of clinical consequence.
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Pathogenesis
The fluid collects because of an imbalancebetween production and absorption.
The tunica vaginalis normally produces around0.5ml of fluid a day.Pathophysiology
– Proc. Vaginalis is a diverticulum of theperitoneal cavity.– It descends with the testis into the
scrotum (28 th gestational week).
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History & ExaminationHistory: A painless swelling in the scrotum.
Onset may be gradual or sudden.
Examination: A scrotal swelling which you can get aboveThe testis cannot be palpated separate to theswellingThe lump transilluminates
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Investigation
Because one of the causes of a hydrocele istesticular tumour, it is important to arrange a
scrotal ultrasound to rule out this as anunderlying pathology
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Treatments
• Conservative management if the hydrocele issmall and causing little in the way of symptoms
• Aspiration +/- injection of a sclerosing agent• Surgery: Ligation of PPV in children
Jaboulay
LordsBoth the Jaboulay and the Lords procedure involve
incising the tunica vaginalis to allow the hydrocelefluid to be absorbed by the scrotal lymphatics.
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Differentials– Orchitis– Testicular torsion– Indirect inguinal hernia– Traumatic injury to the testical
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Epididymal Cyst
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Definition
“ A cystic swelling arising from the epididymis”
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Management
Simple surgical excision of the cyst
Aspirating will not work because the cyst ismultiloculated
As for hydroceles, conservative management isperfectly reasonable if the patient is asymptomatic
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Varicocoele
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Definition
“A varicocoele is a dilatation of the veins of the pampiniform plexus”
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Symptoms & Signs
Symptoms: Scrotal swellingFar 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 ofobstruction to venous drainage caused by a renal
tumour
Therefore all patients with a varicocoele shouldundergo imaging (usually ultrasound) of theirkidneys
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Methods of Treatment
The two main methods are:
1 Surgical ligation
2 Embolisation under X-Ray control
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Epididymo-Orchitis
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Definition
“An inflammation of the tissues of theepididymis and testis”
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Treatment
An appropriate broad-spectrum antibiotic isused, such as ciprofloxacin.
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Ciprofloxacin
This is a fluoroquinolone antibiotic
It acts by inhibiting an enzyme called DNA gyrase inreproducing bacteria. This is one of the enzymesresponsible for unwinding DNA during replication
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Testicular Tumours
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Classification
You might sensibly start classifying testicular tumours intobenign and malignant. In fact benign solid tumours ofthe testis are extremely rare.
The classification of malignant tumours is complicated bythe fact that there are different classification systems
used in the UK and USA and consequently it’s easy to getconfused if you read textbooks from the differentcountries.
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divided into:
1 Germ Cell Tumours2 Other tumours, the commonest of which is
lymphoma, which is the commonesttesticular malignancy in the older patient.
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Germ cell tumours can be divided into
1 Seminomas2 Non-seminomatous germ cell tumours
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But 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 yearsNSGCTs 30 years
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Symptoms & Signs
Symptoms: Painless scrotal swellingChance discoveryTestis feels “heavier”
Signs: Scrotal swelling which you can get aboveThe lump is craggy & does nottransilluminate
May be associated with hydroceleMay have palpable liver due tometastases
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InvestigationsRadiology: Ultrasound of testis
CT of abdomen to assess spreadChest X Ray for metastases
Blood Tests: AFP (alpha feto-protein)b-hCG (human chorionic
gonadotrophin)LDH (lactate dehydrogenase)
The blood tests are known as tumour markers.
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SurgeryAn inguinal orchidectomy is performed
i.e. the testis is taken out through an incisionin the groin
This is because the lymphatic drainage of the
testis is to the para-aortic nodes. An incisionin the scrotum risks spreading the tumour tothe superficial inguinal lymph nodes whichdrain the scrotal skin
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Other Treatments
If the tumour has metastasised, otheroptions for treatment include:
Radiotherapy for seminomaChemotherapy for NSGCTs
Sometimes a combination of the two isrequired