TESTICULAR TORSION & HYDROCELE

Presented by : Nur Insyirah bt Abdullah K4/20th Oct 2013

ANATOMY

Spermatic cord consists of: 1) testicular artery, 2) ductus deferens artery, 3)cremasteric artery , 4) genital branches of genitofemoral nerve, 5) autonomic nerve , 6) lymphatic vessel , 7) pampiniform (venous) plexus, 8) ductus deferens

The internal spermatic, or testicular, artery arises from the aorta. The testicular artery is the chief source of blood to the testis. The artery of the ductus deferens (deferential artery) emerges from the inferior vesicular artery. The external spermatic, or cremasteric, artery springs from the inferior epigastric artery.

TESTICULAR TORSION

INTRODUCTION
Testicular torsion refers to the torsion of the spermatic cord structures and subsequent loss of the blood supply to the ipsilateral testicle. This is a urological emergency; early diagnosis and treatment are vital to saving the testicle and preserving future fertility. It can occur at any age, but accounts for 90 per cent of acute testicular pain in adolescent males between the ages of 13 and 21.

PATHOPHYSIOLOGY
Torsion occurs when an excessively mobile testis rotates on its cord structures, impairing venous return, which leads to venous congestion and oedema. This results in reduced arterial blood inflow, with subsequent ischaemia and infarction of the testis if left uncorrected

Divided into 2 main types (depending on the the anatomical details of the axis of torsion. 1) Intravaginal torsion

TYPES OF TESTICULAR TORSION

The most frequent in adolescent boys, occurs when the axis of rotation is within the tunica vaginalis.

2) Extravaginal torsion
Occurs due to the tunica vaginalis having an abnormally long attachment to the testis. Thus the rotation is external to the tunica vaginalis, which itself is also torted. This variety of testicular torsion occurs mainly in children.

Males with a horizontal lie to their testes, the so-called bell-clapper deformity are more prone to developing testicular torsion. This anatomical variant arises as a result of the manner in which the tunica vaginalis is reflected on the testis and is bilateral in nature, thus explaining the risk of subsequent contralateral torsion in patients who have experienced a testicular torsion. Suffering from intermittent testicular torsion. These patients typically present to primary care complaining of acute, severe unilateral testicular pain, which typically resolves itself within

CLINICAL MANIFESTATIONS
Acute, severe unilateral scrotal pain, pain duration less than 24 hours

Pain radiating to lower abdomen

Nausea and vomiting Absence of infective symptoms and signs such as dysuria,frequency ,pyrexia

PHYSICAL EXAMINATION
Scrotal erythema, edema, and testicular swelling Testis may also high riding position Testis may lie horizontally Tenderness of the testis Elevation of testis when patient in supine position may worsen the pain (Prehns sign). This may be a useful sign to differentiate the diagnosis from epididymoorchitis, in which the pain gets better with elevation Absent of cremasteric reflex (if absent,99% TT)

INVESTIGATION
Dipstix

urinalysis (the only mandatory test in testicular torsion and usually is negative)

Other tests eg FBC time consuming and unreliable

Doppler ultrasound

DIFFERENTIAL DIAGNOSIS
Epididymitis Orchitis

Epididymo-orchitis
Testicular appendages torsion Trauma Hernia

MANAGEMENT
1. Manual detorsion (no longer done and it is painful if we do)
Most torsions twist inward and toward the midline; thus, manual detorsion of the testicle involves
twisting outward and laterally. Only 1/3 of testicular torsion that twist outward.

Torsion of the right testicle:

-

Physician is positioned in front of the standing or supine patient

-Holds the patient's right testicle with the left thumb and forefinger.
-Rotates the right testicle outward 180 in a medial-to-lateral direction. Torsion of left testicle: -uses the right thumb and forefinger rotates the patient's left testicle in an

CONT.
Rotation of the testicle may need to be repeated 2-3 times for complete detorsion. Pain relief serves as a guide to successful detorsion, but restoration of blood flow must be confirmed following the maneuver. Other signs suggestive of successful manual detorsion include resolution of the transverse lie of the testis to a longitudinal orientation, lower position of the testis in the scrotum, and return of normal arterial pulsations detected with a Doppler stethoscope Subsequent elective orchiopexy is recommended, to prevent recurrent torsion

2. SURGERY FOR TESTICULAR TORSION (ORCHIOPEXY)

1) Incision : Either a midline raphe incision or bilateral transverse scrotal incisions 2) Enter the ipsilateral scrotal compartment, incise the tunica vaginalis, and then deliver the testicle for examination. - The spermatic cord is then untwisted. - Evaluate the testis for viability. - If viability is in question, place the testicle in warm sponges and reevaluate after several minutes.

- If the testis is necrotic, perform an orchiectomy to avoid prolonged, debilitating pain and tenderness.

3) To prevent subsequent torsion:

- Fix viable gonads to the scrotal wall with 3-4 nonabsorbable sutures. - A dartos pouch can be made, into which the testicle is placed. Always perform contralateral orchiopexy when testicular torsion is confirmed intraoperatively, in order to prevent future torsion of that testicle. * Signs of a viable testis after detorsion include a return of color, return of Doppler flow, and arterial bleeding after incision of the tunica albuginea.

If < than 6 H from the onset if we detorse it, the salvage rate > than 90% If we detorse it > 24 H, the testis unlikely to survive almost 0 %

3.TESTICULAR PROSTHESIS REPLACEMENT

Patients

requiring an orchiectomy because of a nonviable testis may benefit from the placement of a testicular prosthesis.

Delay this placement, usually for 6 months, until healing is complete and inflammatory changes resolve. Perform the prosthetic placement through an inguinal incision

HYDROCELE

INTRODUCTION
Hydrocele comes from the Greek hydros (water) and kele (mass).

Defined as a collection within the tunica vaginalis of the testis

ETIOLOGY
A hydrocele can be produced in 4 different ways: 1. by excessive production of fluid within the sac (e.g: secondary hydrocele) 2.by defective absorption of fluid ( for most primary hydrocele) 3. by interference with lymphatic drainage of scrotal structure 4. by connection with the peritoneal cavity via a patent processus vaginalis (congenital)

CLASSIFICATION
1. Congenital 2. Primary 3. Secondary

CONGENITAL
Due to patent processus vaginalis 1. Communicating hydrocele

2. Vaginal hydrocele
3. infantile hydrocele 4. Hydrocele of the cord

1. CONGENITAL/COMMUNICATIN G HYDROCELE
The processus vaginalis is patent and connect with the peritoneal cavity The communication is too small to allow herniation of abdominal content Diagnosis present since birth,when patient liss it will disappear, in erect posture appear again

2. VAGINAL HYDROCELE
Processus vaginalis patent up to the top of the testis, where it is shut off from the tunica vaginalis Swelling in the inguinal region rather than scrotal

Testis can be felt

Swelling reduced when lies down

3. INFANTILE HYDROCELE
Opposite to the vaginal hydrocele- the processus vaginalis shut off from the peritoneal cavity at the deep inguinal ring Seen in infant and adult

Cystic swelling

4. HYDROCELE OF THE CORD/ ENCYSTED HYDROCELE

Central portion of processus vaginalis remain patent- upper and lower and obliterated Oval cystic swelling in relation to spermatic cord

Testis felt separate

PRIMARY AND SECONDARY HYRDOCELE

CILINICAL FEATURES
Scrotal swelling Swelling is usually painless Swelling worsen throughout the day Congenital hydrocele in infants may fill during the day and empty while lying down at night. Fluctuate Translucent /transilluminated Can get above the swelling Testes cannot be felt separately A hydrocele of the cord moves downwards when traction is applied to the testis.

TRANSILLUMINATION TEST

DIFFERENTIATION BETWEEN HYDROCELE AND INGUINAL HERNIA

Hydrocele Palpate cord above the mass Translucent Fluctuate Fluid thrill Yes Yes Yes Yes Inguinal hernia No No No No

Testis palpable
Reducible Bowel sound Cough impulse

No
No No No

Yes
Yes Yes Yes

IMAGING
Inguinal-scrotal imaging ultrasound This study is indicated to confirm the diagnosis. May be useful to identify abnormalities in the testis, complex cystic masses, tumors, appendages, spermatocele, or associated hernia.

MANAGEMENT
A hydrocele that occurs during infancy may spontaneously resolve with the closure of the processus vaginalis and, therefore, surgical treatment should be withheld until after the first year of life. Treatment may be necessary for a very large or enlarging hydrocele or for an associated indirect hernia.

CONT.
Adults do not require therapy for hydrocele unless complications are present, such as discomfort and disability from the bulky mass or a tense hydrocele that cause pain and may diminish circulation and lead to atrophy.

JABOULAY/WINKLEMAN PROCEDURE
Opening and eversion of tunica sac Most commonly performed Results are good It is believed that the secretory surface which face outwards after surgery, secretes fluid that is absorbed by the scrotal lymphatics and passes to the inguinal channels, providing an alternate route for drainage.

LORD PROCEDURE
Plication of the sac Use for small hydrocele with a thin small sac

PPV LIGATION
Ligation of patent processus vaginalis through small groin incison For congenital hydrocele that persist Similar to herniotomy

THAN K YOU

Varicocele? Testicular cancer? u/s detect 99% of testicular malignancy, We cannot do FNAC in malignancy becoz there will be tumour seedling along the needle tract. Then what u need to do? Surgical exploration, do high ligation up to