Scrotal Pathology

1
Scrotal Pathology

• Jarrett Kruska
• Dept. of Urology
• University of Oklahoma Health Sciences Center

2
Scrotal Anatomy

• Skin
• Dartos Muscle
• 3 fascial Layers
• External Spermatic Fascia (external oblique)
• Cremaster Muscle (internal oblique)
• Internal Spermatic Fascia (transversalis fascia)
• Scrotum is divided into 2 sacs by a septum

3
(No Transcript)
4
Scrotal Anatomy

• Blood Supply
• Arterial
• from the femoral, internal pudendal, and inferior
  epigastrics
  
• Venous
• paired with the arteries

5
Testicular Anatomy

• Size- 4x3x2.5 cm
• Fascial coverings
• tunica albuginea
• invaginates posteriorly to form the mediastinum
• septae from the mediastinum form 250 lobules
• visceral and parietal tunica vaginalis
• anterior and medial location

6
Testicular Anatomy

• Seminiferous Tubules
• Each lobule contains 1-4
• 60 cm long
• Converge at the mediastinum
• Efferent Ducts
• Epididymis

7
(No Transcript)
8
Testicular Anatomy

• Blood Supply
• Arterial
• internal spermatic (aorta)
• artery of the vas (internal iliac)
• cremasteric artery (inferior epigastric)
• Venous
• pampiniform plexus of the spermatic cord
• forms spermatic vein at the internal ring
• right drains into the vena cava
• left drains into the left renal vein

9
Seminiferous Tubules

• Basement membrane supporting
• Sertoli Cells
• Androgen Binding Protein
• Spermatogenic Cells
• Spermatogonia
• Leydig Cells
• within the stroma between the seminiferous
  tubules
  
• Testosterone

10
Testis Descent

• 3rd month-Located retroperitoneally
• Gubernaculum extends from the lower pole through
  the abdominal musculature and terminates in the
  scrotal swelling
  
• The tunica vaginalis is a remnant of the
  peritoneum that herniates along the anterior
  aspect of the gubernaculum
  
• Passes through the inguinal canal behind the
  processus vaginalis
  
• Scrotal Sac by the 9th month

11
Disorders of the Scrotum

• Hypoplasia of the scrotum
• accompanies cryptorchidism
• Bifid scrotum
• presents with midscrotal or perineal hypospadias
• Skin Diseases
• Dermatitis, Drug reactions, Psoriasis

12
Disorders of the Scrotum

• Superficial Infections
• Arthropods
• Peduculosis Pubis (Lice)-itching
• Treat with 1 lindane cream for 8 hours, then
  wash
  
• Treat all sexual contacts
• Wash all clothes and bedding
• Scabies-itchy papules persisting for weeks after
  treatment
  
• Treat with 1 lindane cream and family members 6
  years old
  

13
Disorders of the Scrotum

• Superficial Infections
• Fungal Infections (Tinea Cruris)
• Characterized by marginated, elevated scaly
  patches on the inner thighs and groin with an
  active border.
  
• Scrotal involvement rare
• Intense pruritis
• Microscopic exam in KOH soln reveals hyphae
• Tx with Miconazole, Clotrimazole, Ketoconazole
  creams

14
Disorders of the Scrotum

• Superficial Infections
• Candidiasis (candida albicans)
• Erythematous, weeping, circumscribed lesions on
  the inner thighs with peripheral satellite
  pustules
  
• Scrotal involvement common
• Pregnancy, diabetes, obesity, and
  immunosuppression are predisposing factors.
  
• Broad-spectrum antibiotic therapy may be followed
  by candidiasis
  
• Tx with nystatin powder or azole cream
• Ketoconazole orally will cure most cases

15
Disorders of the Scrotum

• Superficial Infections
• Bacterial Infections
• S. aureus is the most common cause
• Gram stain shows gram positive cocci in clusters
• Folliculitis begins as a superficial infection of
  a follicle and extends deeply. Tx with
  penicillinase-resistant penicillin.
  
• Impetigo starts as a superficial blister that
  opens, leaving a crusted, weeping erosion. Tx is
  the same as folliculitis.

16
Disorders of the Scrotum

• Superficial Infections
• Viral Infections
• Condylomata acuminata-HPV
• Usually moist and macerated
• Examine by soaking with 5 acetic acid.
  Magnification will reveal subclinical lesions
  
• Tx podophyllum resin, liquid nitrogen,
  fulguration
  
• Molluscum contagiousum-poxvirus
• STD characterized by 5-15 smooth, firm, papules
  with a central umbilication.
  
• If extensive, indication of immunosuppression
  (HIV)
  
• Tx with excision, cryotherapy, fulguration.

17
Disorders of the Scrotum

• Superficial Infections
• Viral Infections
• Herpes Simplex type II
• Initial infection presents as painful,
  widespread, symmetric, blistering with a duration
  longer than 2 weeks.
  
• Culture or a Tzanck preparation confirms
  diagnosis
  
• Tx with Acyclovir
• Recurrent infection presents as localized,
  grouped blisters with few systemic symptoms
  lasting 1 week.
  
• Treatment with Acyclovir for 5 days at onset of
  symptoms will decrease duration of symptoms

18
Disorders of the Scrotum

• Fourniers Gangrene
• MEDICAL EMERGENCY
• Symptoms include swelling and erythema of the
  genitalia with fever, chills, malaise.
  
• PE may reveal crepitus which can extend along the
  fascial planes superiorly to the axillae and
  inferiorly to the perineum.
  
• Feculent odor
• Predisposing conditions-diabetes, urethral
  stricture, trauma, infection, and GI dis
  (perirectal abscess)
  

19
Disorders of the Scrotum

• Fourniers Gangrene (continued)
• Bacterial culture-polymicrobial
• esp. Bacteroides and Clostridium
• Mortality-as high as 45
• Therapy
• early and aggressive
• broad-spectrum antibiotics
• repeated surgical drainage and debridement of
  necrotic tissue

20
Congenital Anomalies of the Testis

• Anomalies of Number
• Anorchidism
• very rare
• careful search using U/S, CT, MRI and
  Laparoscopy
  
• Polyorchidism
• less than 100 cases
• R/O spermatocele or spermatic cord tumor

21
Congenital Anomalies of the Testis

• Hypogonadism
• Primary testicular hypogonadism
• High urinary FSH levels, moderately low urinary
  17-ketosteroids, low serum testosterone
  
• Pituitary hypogonadism
• No FSH, low androgen levels
• enlarged sella turcica or visual field defects
• Features
• Tall with disproportionately long extremities
• delayed fusion of the epiphyseal plates
• small testes
• lack of development of secondary sexual
  characteristics
  
• sterility

22
Congenital Anomalies of the Testis

• Ectopy
• Testis strays from the path of normal descent
• may be due to abnormal connection of the
  gubernaculum
  
• Sites
• Superficial inguinal (most common)-anterior to
  ext. obl.
  
• Perineal (rare)-anterior to the anus
• Femoral-superficial to the femoral vessels
• Penile (rare)
• Transverse (rare)-both located in the same
  inguinal canal
  
• Pelvic (rare)-found by surgical exploration

23
(No Transcript)
24
Congenital Anomalies of the Testis

• Cryptorchidism
• Etiology
• Abnormal descent of the gubernaculum
• Intrinsic Testicular Defect-insensitive to
  gonadotropins
  
• Deficient maternal Gonadotropic Hormonal
  stimulation
  
• cause for bilateral cryptorchidism in premature
  infants
  
• Pathology
• Scrotum serves to keep testes 1 degree cooler
  than the body
  
• Spermatogenic cells are sensitive to body
  temperature
  
• Deleterious changes by 1 year
• massive collagen deposition by 4 years
• Leydig cells are not sensitive to temperature
• Important to place testes in scrotum by 1 year
• 10 of these testes are congenitally defective

25
Congenital Anomalies of the Testis

• Cryptorchidism (continued)
• Symptoms
• Testicular absence from the scrotum
• Signs
• atrophic scrotum on affected side
• testis nonpalpable or felt external to the
  inguinal ring
  
• unable to manipulate testis into scrotum
• inguinal hernia is often present
• Lab findings
• androgens and gonadotropins are moderately low in
  bilateral cases

26
Congenital Anomalies of the Testis

• Cryptorchidism (continued)
• Computed Tomography
• most useful in postpubertal patients
• Ultrasound
• useful if the testis is located in the groin
• Magnetic Resonance Imaging
• highly successful

27
Congenital Anomalies of the Testis

• Cryptorchidism (continued)
• Differential Diagnosis
• Retractile Testes
• common, requiring no treatment
• due to strong cremasteric contraction in cold
  weather, excitement, or physical activity
  
• normally developed scrotum
• able to return testis to normal location
• descends at puberty

28
Congenital Anomalies of the Testis

• Cryptorchidism (continued)
• Complications
• 25 associated with inguinal hernia and patent
  processus vaginalis
  
• Torsion of the spermatic cord occurs
  occasionally
  
• Cancer is 35-50 times more common
• Seminoma is most common
• Orchiectomy when found in a child 10 years or
  older

29
Congenital Anomalies of the Testis

• Cryptorchidism (continued)
• Treatment
• Hormone therapy
• optimal age is 5 years
• hCG injections 3 times a week for 3 weeks
• descent in one month 10-20
• Orchiopexy at age 1
• because histiologic changes occur by 1 year
• does not guarantee fertility
• if vascular pedicle too short, divide the
  testicular artery
  
• does not alter chance of developing cancer

30
Congenital Anomalies of the Testis

• Cryptorchidism (continued)
• Prognosis
• If placed in scrotum, adequate hormonal function
• 20 with unilateral UDT remain infertile

31
Disorders of the Spermatic Cord

• Spermatocele
• painless cystic mass superior and posterior to
  the testis
  
• usually
• arise from tubule connecting the rete testes to
  the epididymis
  
• transillumination differentiates from tumor
• no therapy

32
Disorders of the Spermatic Cord

• Varicocele
• 10 of young men
• dilation of the pampiniform plexus
• left side most common
• due to incompetent valves leading to poor
  drainage
  
• may be painful
• sudden development may be a late sign of renal
  tumor
  
• Exam
• mass of dilated veins posterior and above testis
  while standing
  
• dilation increases with Valsalva
• dilation abates while lying down
• testicular atrophy may be present

33
Disorders of the Spermatic Cord

• Varicocele (continued)
• Infertility
• sperm concentration and motility are
  significantly decreased in 65-75
  
• Reversal in a high percentage with varicocelectomy

34
Disorders of the Spermatic Cord

• Hydrocele
• collection of fluid within the tunica or
  processus vaginalis
  
• may develop rapidly secondary to injury,
  radiotherapy, infection, or testicular tumor
  
• chronic hydrocele is more common
• occurs in men 40 years
• unknown etiology
• grows gradually
• Communicating hydrocele of infancy
• due to a patent processus vaginalis
• form of indirect hernia
• bowel may be found within the sac
• most close spontaneously by age 1

35
Disorders of the Spermatic Cord

• Hydrocele (continued)
• Clinical Findings
• soft and small in the morning and larger and
  tense at night
  
• indication of communicating hydrocele
• painless unless accompanied by epididymitis
• transillumination differentiates from tumor
• Scrotal ultrasound confirms the diagnosis
• If hydrocele develops in a young man, careful
  exam necessary

36
Disorders of the Spermatic Cord

• Hydrocele (continued)
• Treatment
• None necessary if asymptomatic
• Surgery indicated if
• large and compressing blood supply
• bulky mass that is painful or unsightly

37
(No Transcript)
38
Disorders of the Spermatic Cord

• Torsion
• MEDICAL EMERGENCY
• Most common in adolescent males
• Causes strangulation of the blood supply
• Treatment mandatory within 6 hours of symptoms
• Etiology
• often associated with trauma (??)
• most often due to voluminous tunica vaginalis
  allowing rotation of testicle within the tunica.
  
• Initiating factor may be spasm of cremaster
  muscle
  

39
Disorders of the Spermatic Cord

• Torsion (continued)
• Symptoms
• sudden severe testicular pain
• swelling
• scrotal erythema
• Signs
• Swollen, tender testicle retracted upward
• epididymis is located anteriorly
• Prehn maneuver
• Differential Diagnosis
• Epididymitis, Orchitis, Trauma
• Color Doppler Ultrasound
• absence of arterial flow

40
Disorders of the Spermatic Cord

• Torsion (continued)
• Treatment
• Manual detorsion with subsequent bilateral
  orchiopexy
  
• Surgical detorsion with bilateral orchiopexy
• viable in 80 if
• Orchiectomy if obviously nonviable and 48 hours

41
Tumors of the Testis

• Rare 5000 cases/year
• 90-95 Germ cell tumors
• seminoma and nonseminoma
• 5-10 Non-germ cell tumors
• Leydig cell, Sertoli cell, gonodablastoma
• Right-sided more common
• 1-2 are bilateral
• 50 of these have a history of uni- or bilateral
  cryptorchidism

42
Tumors of the Testis

• Etiology
• Most commonly associated with cryptorchidism
• 7-10 of testicular tumors
• 5-10 of these occur in the contralateral,
  normally descended testis
  
• 1 in 20 intra-abdominal
• 1 in 80 inguinal
• Orchiopexy does not change incidence of tumor
  development
  
• Helps with tumor detection
• Exogenous estrogen to pregnant mother
• 3 to 5 times increased incidence
• Trauma
• Infection

43
Tumors of the Testis

• Pathology
• Seminoma 35
• Classic (85), Anaplastic (5-10), Spermatocytic
  (5)
  
• no difference in prognosis
• Never produces AFP
• hCG in 7
• Embryonal Cell Carcinoma 20
• accounts for elevated AFP
• Teratoma 5
• Choriocarcinoma
• produces hCG
• Mixed 40
• majority are teratocarcinomas (teratoma/embryonal
  cell)

44
Tumors of the Testis

• Metastatic Spread
• Choriocarcinoma
• early hematogenous spread to the lung
• All others
• Lymphatic spread to retroperitoneal lymph nodes
• lung
• liver
• brain
• bone

45
Tumors of the Testis

• Staging
• A - confined to the testis
• B1 - retroperitoneal LN
• B2 - retroperitoneal LN 5cm
• B3 - retroperitoneal LN 10cm
• C - spread beyond retroperitoneal LN

46
Tumors of the Testis

• Clinical Findings
• Symptoms
• painless enlargement of the testis
• 10 have sx related to mets
• back pain - retroperitoneal involving nerve
  roots
  
• cough and dyspnea - lung
• bone pain - skeletal mets

47
Tumors of the Testis

• Clinical Findings
• Signs
• testicular mass
• firm and non-tender
• epididymis is separable
• does not transilluminate
• hydrocele
• can conceal a tumor
• Abdominal exam
• bulky LN disease

48
Tumors of the Testis

• Clinical Findings
• Labs and Tumor Markers
• LFTs - hepatic mets
• Alk phos - bone mets
• Alpha-Fetoprotein
• 1/2 life 4-6 days
• elevated in NSGCTs
• Human Chorionic Gonadotropin
• 1/2 life 24 hours
• elevated in only 7 SGCTs

49
Tumors of the Testis

• Clinical Findings
• Imaging
• Scrotal U/S
• differentiates cystic lesions, epididymal
  lesions, hydrocele
  
• Chest X-ray
• CT abdomen and pelvis
• CT chest
• less specific
• CXR identifies 85-90 lung mets

50
Tumors of the Testis

• Treatment
• Radical Orchiectomy
• Inguinal exploration
• NEVER scrotal approach

51
Tumors of the Testis

• Treatment
• Low Stage Seminoma (A, B1)
• very radiosensitive
• 98 stage A tumors are cured with orchiectomy and
  retroperitoneal XRT
  
• 92-94 stage B tumors are cured
• High Stage Seminoma (B2, B3, C)
• Primary Chemotherapy
• Bleomycin, Etoposide, Platinol
• 75 stage C achieve a complete response
• residual mass is usually fibrosis (90)
• If 3 cm, RPLND should be considered

52
Tumors of the Testis

• Treatment
• Low Stage NSGCT
• Surveillance
• 75 of Stage A is cured with orchiectomy alone
• close follow-up with tumor markers, chest x-ray,
  CT
  
• relapses occur with 8 to 10 months
• RPLND
• high morbidity - impotence
• modified RPLND - 90 potency
• 96-100 cure for Stage A
• 90 5 year survival for Stage B1

53
Tumors of the Testis

• Treatment
• High Stage NSGCT
• Primary Platinum based chemotherapy
• If tumor markers normalize and residual mass on
  CT
  
• RPLND
• 20 tumor, 50 fibrosis, 30 teratoma
• 80 5 year survival