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Scrotal Swelling
Scrotal Swelling
Hydrocele
Fluid collections within the tunica vaginalis
of the scrotum or along spermaticcord.
Persistent developmental connections along
the spermatic cord or Imbalance of fluid
product versus absorption.
Little risk of clinical consequence.
Pathogenesis
The fluid collects because of an imbalance
between production and absorption.
The tunica vaginalis normally produces around
0.5ml of fluid a day.
Pathophysiology
Proc. Vaginalis is a diverticulum of the
peritoneal cavity.
It descends with the testis into the scrotum
(28th gestational week).
Common Causes
Congenital
(PPV)
Acquired
Idiopathic
Tumour
Trauma
Infection
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
Treatments
Conservative management if the hydrocele is
small and causing little in the way of symptoms
Aspiration +/- injection of a sclerosing agent
Surgery:
Ligation of PPV in children
Jaboulay
Lords
Both the Jaboulay and the Lords procedure
involve incising the tunica vaginalis to allow the
hydrocele fluid to be absorbed by the scrotal
lymphatics.
Differentials
Orchitis
Testicular torsion
Indirect inguinal hernia
Traumatic injury to the testical
Epididymal Cyst
Definition
A cystic swelling arising from the
epididymis
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
Varicocoele
Definition
A varicocoele is a dilatation of the veins
of the
pampiniform plexus
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
Methods of Treatment
The two main methods are:
1
2
Surgical ligation
Embolisation under X-Ray control
Epididymo-Orchitis
Definition
An inflammation of the tissues of
the epididymis and testis
Treatment
An appropriate broad-spectrum
antibiotic is used, such as
ciprofloxacin.
Ciprofloxacin
This is a fluoroquinolone antibiotic
Testicular Tumours
Classification
You might sensibly start classifying testicular tumours into
benign and malignant. In fact benign solid tumours of
the testis are extremely rare.
The classification of malignant tumours is complicated by
the fact that there are different classification systems
used in the UK and USA and consequently its easy to get
confused if you read textbooks from the different
countries.
divided into:
1 Germ Cell Tumours
2 Other tumours, the commonest of which
is lymphoma, which is the commonest
testicular malignancy in the
older patient.
Seminomas
Non-seminomatous germ cell
tumours
But Remember
40% of testicular tumours are mixed,
i.e. they have both seminomatous
and non
seminomatous elements
Investigations
Radiology:
Blood Tests:
Ultrasound of testis
CT of abdomen to assess spread
Chest X Ray for metastases
AFP (alpha feto-protein)
b-hCG (human chorionic
gonadotrophin)
LDH (lactate dehydrogenase)
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
Other Treatments
If the tumour has metastasised, other
options for treatment include:
Radiotherapy for seminoma
Chemotherapy for NSGCTs
Sometimes a combination of the two is
required
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