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undescended testis and acute scrotum 2023.pptx
1. UNDESCENDED TESTIS
& ACUTE SCROTUM
Presenter Dr Tezera s. (GSR III)
Moderator Dr Fiseha
(Ass.Prof. General and Pediatric surgeon)
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3. OBJECTIVES
• To understand the general approach to undescended testis and its
management
• To understand the approach to the most common causes of acute
scrotum
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Dr. Tezera.s
5. INTRODUCTION
• Any anomaly disrupting normal testicular descent leads to
cryptorchidism.
• Most undescended testes are located in the inguinal canal
• In most cases, the undescended testis is located near the neck of
the scrotum,
• intra-abdominal testes are relatively uncommon, occurring in 5% to
10% of cryptorchid boys
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6. EMBRYOLOGY
• Testicular development and descent depend on a coordinated
interaction among endocrine, paracrine, growth, and mechanical
factors
• Up to 7 to 8 weeks’ gestation, the fetal testis and ovary occupy similar
positions and are held by the cranial suspensory ligament (upper pole)
and the gubernaculum (lower pole).
• The different phases of testicular descent are hormonally regulated.
• The early phase of abdominal testicular descent is regulated separately
from the migratory inguinoscrotal phase.5,
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7. • Two important hormones in testicular descent are insulin like factor 3
(INSL3) and testosterone
• Two important anatomic players are the gubernaculum testis and the
cranial suspensory ligament (CSL).
• Androgens prompt the involution of the CSL,
• INSL3, the gubernaculum undergoes two phases: outgrowth and
regression.
• MIF, by causing resorption of Müllerian structures and clearing
anatomic roadblocks to descent, and calcitonin gene–related peptide
(CGRP).
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10. INCIDENCE OF UNDESCENDED TESTES
• occurs in approximately 3% of term male infants and
• in up to 33–45% of premature and/or low birth weight (<2.5 kg) male
infants.
• The majority of testes descend within the first 6–12 months such that
at 1 year, the incidence is down to 1%.
• rate of secondary testicular is between 2% and 45%.
• two-thirds to three-quarters of cases are palpable,
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Dr. Tezera.s
11. • Usually within the inguinal canal or distal to the external
• Anomalies associated with UDT include a patent processus
vaginalis and epididymal abnormalities.
• Specific syndromes with higher rates of UDT include prune-belly
syndrome, gastroschisis, bladder exstrophy, Prader–Willi, Kallman,
Noonan, testicular dysgenesis, and androgen insensitivity
syndromes.
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Dr. Tezera.s
12. CLASSIFICATION OF UNDESCENDED TESTES
• Undescended testis is best defined as a testis that cannot be
manipulated to the bottom of the scrotum without undue tension on the
spermatic cord.
• The clearest classification divides testes into palpable and non
palpable,
• A retractile testis
• Ascending UDTs
• An ectopic UDT
• An acquired UDT
• Monorchia, or anorchia if both testes are absent.
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Dr. Tezera.s
13. DIAGNOSIS
• A careful history and physical examination
• Examination should be conducted in warm surroundings
and with the child relaxed.
• in both the supine and frog-legged sitting position.
• Inspection
• Appearance of scrotum
• Inguinal swelling
• Palpation
• Palpability, position, & size of testicles
• Associated findings
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14. • If neither testis is palpable, anorchia, androgen insensitivity syndrome,
or a chromosomal abnormality must be differentiated from bilateral
nonpalpable UDT.
• A phenotypically male newborn with bilateral nonpalpable gonads,
even in the presence of an otherwise normal-appearing penis, could
represent a masculinized 46,XX baby with congenital adrenal
hyperplasia (CAH).
• In such cases, a karyotype is warranted
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15. • To avoid unnecessary surgical exploration in a 46XY patient with
anorchia, studies to determine the presence of viable testicular tissue
should include serum MIF, inhibin B, FSH, LH, and testosterone.
• If the child is <9–12 months of age, in the absence of viable testes,
serum MIS and inhibin B should be undetectable.
• If the baseline FSH level is elevated in a boy younger than 9 years,
anorchia is likely and no further evaluation is recommended.
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16. • If baseline LH and FSH levels are normal and hCG stimulation results
in an appropriate elevation of testosterone, functioning testicular tissue
is likely to be present and the patient should undergo exploration.
• If testosterone levels do not increase appropriately, nonfunctional
testicular tissue may still be present and exploration should still be
considered.
• The hCG stimulation test does not distinguish between normal
nonpalpable testes and functioning testicular remnants.
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Dr. Tezera.s
17. • Imaging studies are rarely helpful in determine the presence or
location of an UDT
• Their routine use is not recommended.
• Multiple studies have shown that the experienced surgeon/examiner
has a higher sensitivity in locating the UDT than does US,CT, or
MRI
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18. COMPLICATIONS
• Temperature Effects
• Endocrine Effects
• Germ Cell Development
• Fertility
• Inguinal Hernia
• Malignancy
• Torsion of a Cryptorchid Testis
• Trauma
• Psychological Factors
• Testicular-Epididymal Fusion
Abnormality
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19. Management
Hormone Treatment
• based on the premise that the undescended testis is caused by
deficiency of the hypothalamicpituitary-gonadal axis
• testosterone
• hCG
• and luteinizing hormonereleasing hormone (LHRH).
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20. Surgical Treatment
• Orchidopexy is recommended at 6 to 9 months.
• This is because the first signs of damage to the testes are identified
at about 6 months of age
• in centers with less experience in small children, surgery between 12
and 18 months may be safer.
• Children presenting with a concomitant inguinal hernia should have
the orchidopexy done together with the inguinal herniotomy.
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21. Orchiopexy
• The operative approach for UDT depends on whether the testis is
palpable or not
• It is important to re-examine the patient under anaesthesia
• Unilateral and bilateral palpable UDT are managed similarly.
• Routine biopsy of the testis at the time of surgery is not recommended
• For the unilateral palpable UDT that presents after puberty, orchiopexy
or orchiectomy can be offered.
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22. Palpable Undescended Testes: Unilateral or
Bilateral
• The mainstay of therapy for the palpable UDT is orchiopexy with
creation of a subdartos pouch.
• This may be performed through a standard two-incision (inguinal
and scrotal) approach, or a single-incision high scrotal approach.
• With the standard inguinal method, the success rate is as high as 95%.
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23. Standard Inguinal Orchiopexy Approach
• Transverse skin incision over
internal ring
• Open external oblique
apponeurosis
• Deliver testis & open PPV
distally near testis
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24. • Separate hernial sac from cord
structure and ligate sac
• Create subdartos poach by
passing your finger inferiorly to
scrotum
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25. • Pass clamp through scrotum into
inguinal canal
• Grasp adventitial tissue of testis
and bring testis to dartos poach,
then fix it.
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26. Trans- scrotal orchidopexy
• For testis that are close to or can
be drawn to the scrotum
• A- Bianchi Incision
• B- Transvers low scrotal
• C- Midline
• Efficacy and complication rates
are similar to those of standard
inguinal orchidopexy
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27. Unilateral Non palpable Undescended
Testis
• Re-examine the patient after induction of anesthesia
• Approached through diagnostic laparoscopy or inguinal exploration
• Inguinal expl: if viable testis is found, orchidopexy
• Laparoscopy/laparotomy : Intra-abdominal viable testis, atrophic or
Vanishing
• Fowler- Stephen’s orchidopexy
• Single stage laparoscopic orchidopexy
• Microvascular orchiopexy
• Orchiectomy
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28. Bilateral Non palpable Undescended
Testis
• Endocrinologic, genetic or imaging evaluation testicular tissue
• Exploration
• only one viable testicle mx as unilateral, non palpable
UDT
• bilateral viable testes
• Bilateral orchiopexy if easy
• If difficult, one side may be fixed first, with the
contralateral side fixed six to 12 months later
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29. Secondary Undescended Testis
• An uncommon complication of inguinal hernia repair, orchidopexy ,
or hydrocelectomy
• Scarring from the previous procedure makes dissection difficult
• Mobilizing the entire cord and scar en bloc along with a strip of
external oblique aponeurosis
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31. Complications of Orchidopexy
• Failure of testis to reach scrotum
• Secondary atrophy of the testis
• Retraction of testis out of scrotum
• Occlusion of vas deferens
• Hemorrhage
• Wound infection
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34. Introduction
• The term acute scrotum is defined as sudden onset scrotal
pain with or without swelling and erythema.
• Early recognition and prompt management
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35. Spermatic cord Torsion
• results from twisting of the spermatic cord that compromises testicular
perfusion, resulting in infarction.
• There appears to be a 4–8-hour window before significant damage
occurs once torsion develops.
• Emergency exploration is indicated beyond this window because
testicular viability is difficult to predict
• Emergency exploration is indicated beyond this window because
testicular viability is difficult to predict.
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36. Classification
Intravaginal
• More common
• 12-16 yrs
• Left side more commonly
• “bell-clapper” deformity
Extravaginal
• Perinatal event
• Spermatic cord twists proximal
to tunica vaginalis
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37. Clinical Presentation
• Torsion of the testis is common in adolescence, but before puberty
torsion of a testicular appendage is more common
• two peaks of incidence : early neonatal period and in adolescent boys
aged 13 to 16.
• Presented with sudden onset of pain in the testis, lower abdomen, or
groin, associated with nausea and vomiting.
• Physical examination may reveal an enlarged testis that is retracted up
toward the inguinal region with a transverse orientation and an
anteriorly located epididymis.
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38. • Depending on the duration of the testicular torsion, the hemiscrotum
can show varying degrees of swelling and erythema, which may
obliterate landmarks and make the examination more difficult
• The cremasteric reflex is often absent with testicular torsion, but
presence of the reflex does not exclude it.
• Investigation only when diagnosis is difficult
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39. Treatment
• Immediate scrotal exploration using a median raphe skin incision
• The symptomatic hemiscrotum is entered first; testis delivered,
detorsed and put in a warm moist gauze
• The un affected testis is fixed by a non-absorbable suture at 3 points
• Then the affected testis relooked
• Viable: orchidopexy ,clearly non-viable: orchidectomy
• Manual detorsion can be attempted if a delay to the OR is un
avoidable
• In an open book (medial to lateral) rotation, reverse direction if not successful
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40. Perinatal Testicular Torsion
Prenatal
• Most (75%)
• Hard, non tender scrotal mass
with dark skin at birth
• Decision for exploration is
controversial
Postnatal
• 25%
• acutely inflamed, tender,
erythematic scrotum
• Mgt- exploration
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42. Torsion of Testicular Appendages
• Mostly prepubertal
• Mostly during the age of 7-10
• Present with sudden onset scrotal pain and nausea
• The appendage can usually be palpated and is exquisitely and focally
tender.
• The examiner may be able to elicit differential tenderness between the
upper and lower poles of the affected testis.
• Classically called the “blue dot” sign
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44. • Torsion of these appendages is self-limited
• It is best treated with nonsteroidal anti-inflammatory medications and
comfort measures such as warm compresses.
• The pain resolves as the appendage infarcts and necroses.
• It may become a calcified free body within the tunica vaginalis.
• exploration
-When diagnosis of testicular torsion can’t be ruled out
-When symptoms are prolonged & failed to resolve spontaneously
• Management: excision
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45. EPIDIDYMITIS
• True bacterial epididymitis is rare in children, accounting for 10–15% of
patients with an acute scrotum.
• The scrotal pain and swelling typically have a slow onset, worsening over
days
• Examination reveals induration, swelling, and tenderness of the
hemiscrotum.
• A positive urinalysis and culture, or urethral swab in sexually active
adolescents, confirms the diagnosis.
• Neisseria gonorrhoeae and Chlamydia -in sexually active boys,
• coliforms and Mycoplasma species, are more likely in younger children.
• appropriate antibiotic therapy is initiated and adjusted according to the
culture results.
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46. TESTICULAR TRAUMA
• Testicular trauma in children is rare.
• Diagnosis -complete history and paying close attention to factors
suggesting sexual abuse.
• swollen ,markedly tender and bruising of the scrotum.
• The most common injury is a hematoma of the testis.
• US should be obtained to evaluate for rupture of the tunica albuginea,
which is an indication for operative repair.
• A large hematoma in the space between the tunica vaginalis and the
tunica albuginea should be evacuated to avoid pressure necrosis of the
testis.
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In most cases, the undescended testis is located near the neck of the scrotum, just outside or a little lateral to the external inguinal ring, in the “superficial inguinal pouch,” which is the misplaced tunica vaginalis.
7 to 8 weeks’ gestation, the fetal testis and ovary occupy similar positions and are held by the cranial suspensory ligament (upper pole) and the gubernaculum (lower pole).
maternal exposure to estrogens such as diethylstilbestrol (DES) has also been associated with cryptorchidism.
Outgrowth refers to rapid swelling of the gubernaculum, thereby dilating the inguinal canal and creating a pathway for descent. Mice with homozygous mutant INSL3 have been found to have poorly developed gubernacula and intra-abdominal testes.10 Next, during regression, the gubernaculum undergoes cellular remodeling and becomes a fibrous structure.11 It is believed that intra-abdominal pressure then causes protrusion of the processus vaginalis through the internal inguinal ring, transmitting pressure to the gubernaculum and fostering testicular descent.
A retractile testis is a normally descended testis that retracts into the inguinal canal as a result of cremasteric contraction; it is not an UDT. An ectopic UDT is one that has deviated from the path of normal descent and can be found in the inguinal region, perineum, femoral canal, penopubic area, or even contralateral hemiscrotum.
preferably by 12 months of (corrected gestational) age is indicated. Support for this approach is based on the following rationale: (1) spontaneous descent is unlikely in full-term males after 2 to 6 months of age, (2) testicular growth is restored after early orchidopexy at 9 months as compared with 3 years of age, and (3) orchidopexy for abdominal testes may be easier in young infants, soon after mini-puberty.
In one retrospective review of 215 non palpable testes, only 34% were located distal to the internal ring
Fowler- Stephen’s orchidopexy : Single stage or 2 stage; involves ligation of the spermatic vessels, which makes the testis dependent on the vasal and cremasteric arteries for viability; 90% success rate
