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Scrotum Flashcards

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1
Q

Age ranges scrotal pathology

A

Torsion
Infancy and puberty less than 3 and from beginning of puberty

Hydatid
7-10 years

Idiopathic scrotal oedema
5-9 years

Infection
Infancy and puberty

Mumps
Rare before 10

HSP
3-15 years of age

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2
Q

Retraction foreskin and age ranges

A 
Oster Danish study 1965
1968 danish schoolboys
8% 6-6 year olds
6% 10-11 year olds
1% 16-17 year olds
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3
Q

Testicular descent embryology
At inguinal ring
In scrotum

A

Transabdominal descent week 10-15

Inguinoscrotal week 25-35

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4
Q

UDT prevalence

Right vs bilateral

A 
3% newborns
1% at 6 months
30% premature 
Right 70%
Bilateral 30%
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5
Q

UDT impalpable locations

A 
80% palpable 
20% impalpable of which
50% in canal
40% abdomen
10% absent
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6
Q

Ascending testicle risk if retraction and all testes

A

50 % retraction and 2% all testes May ascend

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7
Q

Age of orchidopexy

Complications

A 
6 months- 18 months
At 1 year risk of anaesthetic lower
Complications BAUS
Groin scrotal swelling pain 10-50%
2-10 %
Infection
Removal
High riding position

0.004-2%
Bleeding
Atrophy
Fertility 
Chronic pain
Repeat procedure
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8
Q

Risks of hydrocele PPV repair

A 
Recurrence 1-3% for neonate, 1% older kids
Iatrogenic UDT 1%
Injury to vas 0.33%
Atrophy up to 10% 
No change swelling almost all
Bleeding requiring treatment 2-10%
Infection 0.004-2%
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9
Q

Testicular survival with orchidopexy procedures

A

Groin 98%
One stage 70%
Two stage 90%

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10
Q 
Risk malignancy UDT
General RR
% of testicular cancer with UDT
RR if fixed 0-6 years old
RR if fixed over 13 years
A

Testicular cancer of which 10-15 % have UDT
RR is 3
RR is 2 if fixed 0-6 years old
RR 5 if fixed over 13

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11
Q

Circumcision complications

A 
Bleeding 1.5%
Local sepsis 8.5%
Oozing 36%
Discomfort more than 7 days 26%
Meatal scabbing or stenosis
Removal of too much or too little skin
Urethral injury
Amputation of glam
Inclusion cyst
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12
Q

Testicle development MIH secretion week

A

Week 7 by pre sertoli cells
Regression of Müllerian ducts begin week 8 in response to MIS and complete by 10-12 weeks
Testosterone allows each mesoneprhic duct develop into epididymis, vas and seminal vesicles

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13
Q

incidence of UDT

A

3-5% at term

born less than 37 weeks 30% incidence of UDT

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14
Q

2 nd stage descent of testes

A

25-35 weeks

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15
Q

risk factors for UDT

A

maternal smoking
dad or brother - family history first degree relative
low birth weight or IUGR

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16
Q

when will testes not descend further

% of boys at 6 months with UDT

A

6 months of age
most likely to descend within first 3 months
premature babies descent can occur any time 1st year of life
1% of boys at 6 months have UDT
1.5% of 3 months have UDT, not much change in this figure by 1 year

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17
Q

ectopic locations

A 
penile
contralateral scrotum
pre prenile
superficial inguinal pouch
perineum
femoral region
anterior abdominal wall
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18
Q

incidence bilateral UDT

right vs left

A

25%
right more common than left
right 70%
left 30%

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19
Q

semen parameters with UDT

paternity rate with unliat and bilat UDT

A

Oligospermia or azoospermia occurs in 75% of patients with bilateral UDT and 40% of unilateral UDT
Paternity in patients with unilateral UDT is similar to general population

Paternity rates 80-90% with history of unilateral UDT
Paternity rate 45-65% with history of bilateral UDT
Prospects fertility enhanced by early orchidopexy under 2 years

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20
Q

UDT and risk malignancy

A

RR 2 x to 10x vs normally descended testicle
higher risk if intrabdominal
early orchidopexy may reduce risk malignancy but not eliminate entirely
Nordic concensus and SRs - advise into scrotum 6-12 months

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21
Q

Fowler stephens success rate
when to do second stage
complications

A

60%
at 6 months, either open or with laparoscopic assitance

Atrophy 5% for inguinal up to 27% of two stage
Reascent
Injury Vas 1-2%

Testicular atrophy – 8% when testis lay beyond the external ring, 13% when in inguinal canal, 27% two stage fowler stphens, 5% for inguinal orchidopexy
Reascent of testis
Injury vas 1-2% - post ichaemic obliteration vas resulting from damage to blood supply likely unrecognised
Testicular volume influenced by initial position of gonad rather than age at surgery performed

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22
Q

surgery for UDT NICE, EAU

A

BAPS 6-18 months
EAU by 12 months
Nordic consensus statement 6-12 months

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23
Q

retractile testes age range most common

A

In clear-cut cases parents may be reassured that retractile testes are common, particularly between the ages of 3 and 7 years, and that surgical intervention is rarely required.

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24
Q

testicular descent

transadbominal

A

abdomen week 10-15

inguinoscrotal week 25-35

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25
co existing conditions with UDT
``` hypospadias, SB 100% prune belly CP exomphalos ```
26
causes of maldescent of testicle 4
Physical ob to descent Lack of intrabdominal pressure Hypopituitarism Mesenchymal defects
27
most common ectopic location | where is this
superficial inguinal pouch | between scarpa fascia and external oblique fascia
28
normal size pre pubertal testes
smaller than a malteaser sweet
29
definition retractile testicle
Retractile testes are those that move spontaneously out of the scrotum on a regular basis and or on initial examination but will return either spontaneously or with manipulation to a dependent scrotal position and remain there for a finite but ill defined period
30
cremasteric reflex and testosterone
reflex suppressed by T so absent in first six months due to perinatal T surge
31
risk of ascending testicle with retractile testes | follow up of retractile testicle
50% of retractile may ascend 2% of all testes may ascend Arrange yearly review until puberty is established as significant risk of ascent by urology or GP if willing May have 50% ascend
32
anaesthetic concern under age 1
Anaesthetic risk under 1 year equal to those over 70s should be undertaken by paediatric anaesthetist Testicular survival concerns before age of 1 have not been realised
33
benefits of early orchidopexy for UDT (5)
Reduced distance testes have to move outweighs risk to delicate vessels Early orchidopexy improves testicular growth cosmesis higher risk torsion malignancy (before 13) Pettersson NEJM fertility (before 2) risk hernia
34
management bilateral impalpable testes
20 times more common to have bilateral intra ab testis than bilateral absent testes Recommended to have laparoscopy than trying to assess whether testicular tissues with GnRH stimulation test
35
inguinal orchidopexy success rate
98% Single stage Fowler stephens 70% Two stage 60%
36
malignancy outcomes UDT
7/100,000 testicular cancer so still uncommon 5-10% in those with UDT RR = 3, Influence by syndromes, position, and dysplasia Maybe increased risk in CL testis Responsibility not to cause undue anxiety Reassure risk small Encourage monthly examination both testis from adolescence
37
malignancy paper age before or after 13
Pettersson NEJM 2007 Swedish The relative risk of testicular cancer among those who un-derwent orchiopexy before reaching 13 years of age was 2.23 (95% confidence inter-val [CI], 1.58 to 3.06), as compared with the Swedish general population; for those treated at 13 years of age or older, the relative risk was 5.40 (95% CI, 3.20 to 8.53)
38
fertility outcomes UDT
Historical data unilateral UDT does not affect paternity rates But is reduced for bilateral UDT Time to conception equal 3 gourps Sperm densities different but morphology and motility similar Early orchidopexy allows neonatal gonadocytes to adult dark spermatogonia which may improve sperm density in adulthood 96% normal semen parameters if orchidopexy under 12 months 66% if 12-24 months
39
differentiation of gonads | testicular descent phase 1 and 2 hormones
6th weeks undifferentiated 6-7 weeks under influence of SRY genes testes differentiate testicular descent under MIH occuring by 12 weeks from urogenital ridge to internal inguinal opening then second phase from 25-30 weeks under T, inguingal canal to scrotum
40
differentiation of gonads | testicular descent phase 1 and 2 hormones
6th weeks undifferentiated 6-7 weeks under influence of SRY genes testes differentiate testicular descent under MIH occuring by 12 weeks from urogenital ridge to internal inguinal opening then second phase from 25-30 weeks under T, inguingal canal to scrotum
41
``` stages of spermatogenesis draw diagram growth phase multiplication phase maturation phase ```
in neonatal gonocytes ages of 3 and 12 months give rise adult dark spermatogonia these then develop adult pale spermatogonia meiosis I transform into primary spermatocytes then meiosis II into secondary spermatocytes progress to spermatids then rise to spermatozoa
42
complications inguinal orchidectomy
10-50% Swelling of the groin and scrotum lasting several days 2-10% 1/10 to 1/50 Infection, removal, lie high in scrotum 0.004-2% 1/50 to 1/250 ``` Bleeding No guarantee or reduced fertility Atrophy Repeat procedure Chronic pain Anaesthetic risk ```
43
Fowler stephens laparoscopy | risk of testicular loss with 2 stage procedure
air flow 2 pressure 10 | 20%
44
patency of PPV at birth
90% patent at birth | in up to 80% of males and 60% of females, the process vaginalis is still present at birth
45
when does PPV obliterate
By 8 weeks of age, 63% of males will have a persistent processus vaginalis with obliteration occurring any time up until the age of two years. After this age, up to 40% of males continue to have a persistent process vaginalis with around half remaining asymptomatic throughout life.
46
incidence of neonatal hernia | when is risk of obstruction highest
1-5% of children | in neonate
47
management of incarcerated hernia
resuscitate, Analgesia Try to reduce hernia Try to control ext ring, put pressure on swelling and feel hernia reduce If unable to reduce despite maximal morphine analgesia, then proceed to emergency repair If hernia is reduced, quite common to wait 48 hours, let oedema settle and then expediated basis
48
rate of resolution of hydrocele | when to do surgery
90% resolve in 1st year spontaneously | fix over 2 years old
49
complications PPV ligation
``` Complications Recurrence in older child 1% Neonate 1-3% recurrence rate UDT in 1% iatrogenic Testicular atrophy more common in neonate up to 10% Injury to vas 0.33% ```
50
peak times testicular torsion | incidence torsion
<3 and shortly after puberty 13-15 | incidence 4.5 per 100,000 in age 1-25 years
51
contralateral bell clapper deformity
A recent study of 27 pubertal TT cases indicated that the contralateral testis was affected in 78% of the boys
52
testicular appendage torsion age group
7-10 years
53
mumps orchitis
usually after puberty rare before 10 4-5 days after mumps infection parotitis affects scrotum in 10-30% of patients who have mumps conservative treatment can result in testicular atrophy, reduced size seen in half of post pubertal patients with abnormalities of semen in a quarter, may be as a result of pressure necrosis effect on endocrine difficult to establish
54
idiopathic scrotal odema age range | association
5-9 YEARS testicle not tender, skin may be tender association with worms treat child and family
55
when do second stage fowler stephens
6 months later
56
HSP
3-15 years May rarely cause acute scrotum Painless rash, weals blotches petechiae, May get joint pain, VH, abdominal pain, can get intussepction, vasculitis of scrotum No need explore Conservative will get better
57
what are salvage rates of torsion after time frame
study
58
what is it called when near internal ring at laparoscopy
peeping testicle
59
examination of scrotum in UDT
look for underdeveloped scrotum if testicle never was there
60
when would do next stage of FS procedure | risk of need to remove testicle
6 months liklihood of survival 70% successful 20% risk removal
61
mumps orchitis percentage after mumps infection time interval rate testicular atrophy and semen abnormality
15-30% will get mumps orchitis in post pubertal boys occurs 4-8 days after parotitis half will have testicular atrophy quarter abnormal semen analysis sterility is rare
62
incidence UDT
2-4% of boys at full term | 30% premature
63
incidence 1 month | incidence 1 year
1% at 1 month | 0.8.% at 1 year
64
UDT familial risk
father affect 4.6 x RR | brother affected 6.9 x RR
65
principle of fertility in fixing UDT
Early orchidopexy allows neonatal gonadocytes to adult dark spermatogonia occuring at 3-6 months which may improve sperm density in adulthood 96% normal semen parameters if orchidopexy under 12 months 66% if 12-24 months
66
extravaginal torsion
neonatal torsion | testis and coverings twist entirely within the scrotum
67
intravaginal torsion
children and older adults | within the TA
68
resolving PPV by 1 year %
90% resolve by 1 year | surgery if persists over 2 yo
69
when intervene varicocele
if more than 20% size difference on US

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