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Torsion of the testis

• Torsion of the testis is uncommon because the normal fully descended testis is well anchored and cannot rotate.

Predisposing Factors

• Inversion of the testis is the most common predisposing cause.

• Separation of the epididymis

• High investement of tunica vaginalis

Violent contraction of abdominal muscles causes contraction of cremaster as well ; the spiral attachment of cremaster favours rotation around the vertical axis. Straining at stool, lifting a heavy weight and coitus are all possible precipitating factors.

Clinical Feature

• Testicular torsion is most common between 10 -25 years.

• In torsion of the testis the testis lies higher and thickening of tender twisted cord which can be palpated. Whereas in epididymorchitis cords are not thickened.

• Testis will have a transverse lie.

• Unilateral absence of cremasteric reflex is most sensitive finding.

• Redness of the skin and pyrexia after 6 hrs.

• Vomiting

• Elevation of the testis reduces the pain of epididymorchitis and makes torsion worse.

Torsion of imperfectly descended testis cannot be easily recognised. An empty oedematous hemiscrotum on the side suggests that a tender lump at external inguinal ring is a torted testis.

Treatment

• In first hour it may be possible to untwist the testis by gentle manipulation.

  • Most testis twist in a lateral to medial fashion; therefore detorsion initially should be done in a medial to lateral motion.

  • The initial attempt should include one and one half rotations.

  • Any relief in pain is a positive end point and the success of the manoeuvre can be assessed with doppler US.

  • If the pain aggravates try rotating the opposite way.

• Exploration for testicular torsion

  • It can be performed through a scrotal incision.

  • If the testis is clearly viable the cord is untwisted, it should be prevented from twisting again by fixation by nonabsorbable sutures between the tunica vaginalis and tunica albuginea. It should be done both side as the anatomical variation may be bilateral.

Varicocele

• A varicocele is a varicose dilatation of the veins draining the testis.

Anatomy

• The veins draining the testis and the epididymis form a bulky plexus called the pampiniform plexus. The veins become fewer as they transverse the inguinal canal at or near the inguinal ring they join to form one or two testicular veins which pass upwards behind the peritoneum.

• The left testicular vein empties into left renal vein, the right into inferior vena cava below the right renal vein.

Clinical Features

• Commonly seen during adolescence or early adult hood.

• Left side is affected in 95%.

• The scrotum of the affected side lies lower than normal. Patient will have a vague annoying, dragging discomfort which is worse if the testis is unsupported by underwear.

• On palpation varicocele is felt as bag of worms.

• It has been said that varicocele causes infertility but statistical evidence supporting the claim is lacking.

Treatment

• Operation is not indicated for varicocele unless it causes symptoms.

• Simplest procedure is ligation of the testicular vein above the inguinal ligament where the pampiniform plexus has coalesced into one or two vessels.

EPIDIDYMO-ORCHITIS

• Inflammation confined to the epididymis is called epididymitis. When infection spreads to the body of the testis, the condition is known as epididymo-orchitis.

• Infection reaches the globus minus of the epididymis via the lumen of the vas from a primary infection of the urethra, prostrate or seminal vesicles.

• In men with outflow obstruction, epididymitis may result from a secondary urinary infection – a high pressure in the prostatic urethra causes reflux of infected urine up the vasa.

Clinical Features

• Fever , pain.

• The epididymis and testis appears to be swollen rapidly and become exquistely painful.

• The scrotal wall is red and edematous and shiny become adherent to the epididymis.

• Resolution is signalled of the scrotal skin and may take 6-8 weeks to complete.

• Acute epididymo-orchitis can follow any form of urethral instrumentation.

• It is more common when there is indwelling catheter and an associated infection of the prostrate.

• Acute epididymo- orchitis of the mumps develops in about 18% of males suffering from mumps.

Complication

• Abcess

• Testicular atrophy and infertility.

Treatment

• Bed rest

• Plenty of fluids

• Scrotal Support

• Doxycycline 100mg BD IN Chlamydial Infection + Ceftriaxone 250mg IM for gonorrhea.

Or

• Broad Spectrum antibiotic : Ciprofloxacin 500 mg BD or Levoflox 250mg OD for 10- 14 days (Age >40 yrs)

Idiopathic Scrotal Gangrene

• Idiopathic scrotal gangrene or Fourniers gangrene is characterised by

• Sudden appearance of scrotal inflammation

• Rapid onset of gangrene leading to exposure of the scrotal contents

• Absence of any obvious cause in over half the cases.

• It has been known to follow minor injuries or procedures in the perineal area such as bruise, scratch, urethral dilatation, injection of haemorrhoids or opening of a periurethral abcess.

Clinical Features

• Sudden pain in the scrotum, prostration, pallor and pyrexia.

• At first only the scrotum is involved but if unchecked, the cellulitis spreads until the entire scrotal coverings slough leaving the testes exposed.

Treatment

• Wide excision of the necrotic scrotal skin provides the best possible drainage and stops the spread of the gangrene.

• Antibiotics.

Hydrocele

• A hydrocele is an abnormal collection of serous fluid in some part of processus vaginalis, usually tunica.

• Hydrocele are almost invariably translucent and is possible get above the swelling.

• Hydrocele can be

  • Congenital

  • Acquired : Primary or idiopathic & Secondary to tumours.

• Complication

  • Rupture due trauma

  • Herniation of the hydrocele sac

  • Transformation into haematocele occurs if there is spontaneous bleeding into sac or as a result of trauma.

  • The sac may calcify.