Abnormalities of the testes and scrotum and their surgical management Dr. S. Vahidi

Undescended testis Definition: Testes located anywhere between the abdominal cavity and just outside the anatomic scrotum Abnormally position testis Cryptorchidism = hidden testis UDT Ectopic Un descended testis Multiple etiologies  diversity of this congenital disorders

Incidence One of the most common congenital anomalies at birth 3% of full-term male newborns 1.6-1.9% unilateral 30.3% in prematures Preterm- low birth weight -twin - small for gestational age 70-77% spontaneously descend, by 3 month. 1% at 1 year of age

Epidemiology Gestational age Birth weight Prematurity Genetic- hormonal- environmental

Classification Variation in testicular size & consistency Epididymial & vassal anomalies Patent processos vaginalis Cryptorctidism: paplable- non palaplable: Intra abdominal Absent (vanishing) Atrophic Missed on Ph.E.

Cryptorchidism Intra abdominal Intra canalicular Extra canalicular Supra Pubic Infra Pubic Ectopic Denis-browne pouch Transverse scrotal Femoral Perineal Prepenile

Retractile testis Over active cremasteric reflex Groin 3-7 years of age Infertility? Delayed spontaneous T. Ascent

Theories of Descent & maldescent 3 phase of descending Trans abdominal 23 week Trans inguinal Extra canalicular 23 week Endocrine factors Gubernaculum Epididymis Intra abdominal pressure Histopathology

Normal hypothalamic- pituitary-gonadal axis  testicular descent Endocrine factors Normal hypothalamic- pituitary-gonadal axis  testicular descent Androgenes: testosterone & DHT  inguinal-scrotal phase of descent Mullerian inhibiting substance (MIS)? Estrogen? Descendin: gubernacular specific growth factor

Gubernaculum Major factor responsible for testicular descent Physiologic mechanism? Testicular descent: Hormonal factors Mechanical factors Genito femoral nerve and calcitonin Gene- related peptide?

Epididymis Epididymal abnormalities  cryptorchidism Fertility in UDT Germ cell development EP. Anomalies

Intra abdominal pressure Defects or agenesis of abdominal wall musculars UDT Significant Role in trans inguinal descent

Histopathology Similar pathology in the contralateral descended testis Leidig cells Degeneration of sertoli cells Delayed disappearance of gonocytes Delayed appearavice of (Ad) spermatogonia Failure of primary spermatocytes to develop  Germ cells Similar pathology in the contralateral descended testis < 2 years of age

Consequences of UDT Infertility Neoplasia Hernia Torsion

Consequences of UDT Infertility Neoplasia Bilateral or unilateral UDT Early or delayed orchiopexy Neoplasia 10% of T. tumors arise from UDTs T. tumors in UDT: 1/2550 T. tumors in population: 1/100,000

Neoplasia (continued) Presentation time: puperty Orchiopexy affect the T. tumor? The age of orchiopexy and T. tumor? The location of T. & T. tumor Seminoma is most common T. tumor The cause of increased Risk: temprature or intrinsic pathologic process? Routine T. biopsy during child hood orchiopexy?

Hernia T. Torsion Patent processus vaginalis in >90% of UDT Patent processus vaginalis affect the hormonal treatment of UDT T. Torsion

Work-up of UDT 80% palpable 20% non palpable 20% absent 30% atrophic 50% intra abdominal

Work-up of UDT History Ph.E Paraclinic Workup in Bilateral UDT Preterm H. Perinatal H. Past medical & surgical H. Family H. Ph.E Other birth defect Genital examination Contralateral testis Paraclinic Accuracy of radiologic testing in UDT is 44% Workup in Bilateral UDT Hormonal workup (HCG stimulation test)- FSH- inhibin B- MIS

Definitive treatment should occur before 1 year of age Management of UDT Tenets of treatment Proper identification of the Anatomy- position- viability identification of coexisting syndrome Placement of the testis within the scrotum Permanent fixation and easy palpation No further T. damage Definitive treatment should occur before 1 year of age

Indication for orchiectomy in UDT Post pubescent males Contralateral normal T. Anatomically & morphologically abnormal Too far from scrotum

Hormonal therapy The lower position the better the success rate HCG GnRH or LHRH The lower position the better the success rate Reascent in 25% of patient Not indicated in: Ectopic T. Inguinal Hernia

HCG treatment GnRH 14-59% success rate 10,000 IU (1500 Iu/m2 im/2 week – 4 week) Complications: GnRH 19-32-65% success rate 1.2 mg/day for 4 weeks. (nasal spray) Overall efficacy of hormonal treatment < 20% Surgery remains the Gold standard in the management of UDT

Surgical management of UDT Standard orchiopexy Ancillary techniques for the high UDT Reoperative orchiopexy

Management of intra- abdominal testis Laparoscopy Fowler- stephenes orchiopexy Microvascular auto transplantation Complications of orchiopexy

Hydrocele Simple Hydrocele Communicating Hydrocele Hydrocele of the cord Abdomino scrotal hydrocele

Acute scrotum Acute scrotal pain – tenderness or swelling Diff diagnosis

Differential diagnosis of the acute subacute scrotum Torsion of the spermatic cord Torsion of the appendix testis Torsion of the appendix epididymis Epididymitis Epididymo-orchitis Inguinal hernia Communicating hydrocele Hydrocele Hydrocele of the cord Trauma/insect bite Dermatologic lesions Inflammatory vasculitis (henoch- schönlein purpura) Idiopathic scrotal edema Tumor Spermatocele Varicocele Nonurogenital pathology (e.g., adductor tendinitis)

Torsion of the spermatic cord (intravaginal) Golden time (4 hours) Degree of torsion Acute or gradual onset Severe or minimized pain Nausea & vomiting- the absence of cremasteric reflex Manual detorsion Doppler examination: false positive & false negative Color doppler: 89% sensitivity 99% specifity? Radinuclide imaging: sens 90% speci= 89%

Torsion (continued) Explore Both side Dartos pouch placement (no sutures) Sympathetic orchiopathy?

Intermittent torsion Torsion of the testicular and epididymal appendages Perinatal torsion of the spermatic cord (extra vaginal) No surgical exploration Exploration of contralateral T.? In postnatal torsion: exploration is needed (Bilateral)