1. Scrotal Diseases
Onur Sökücü

2. Testis Anatomy Spermatic cord contains: 1-Pampiniform Plexus
2-Vas Deferens
3-Testicular Artery
4-Nerves

4. Varicocele

5. What is Varicocele?
Varicocele is dilatation of the Pampiniform Venous Plexus in spermatic cord.
It is the most common cause of male infertility!
It leads to poor sperm production and decreased semen quality.
Left side predominance

6. Epidemiology Approximately: 16% of adolescents 15-20% of all males
40% of infertile males have varicocele.

7. Etiology
Varicoceles are much more common in the left testicle than in the right because of several anatomic factors:
The angle at which the left testicular vein enters the left renal vein
The lack of effective antireflux valves at the juncture of the testicular vein and renal vein
The increased renal vein pressure due to its compression between the superior mesenteric artery and the aorta (ie, nutcracker effect)

8. One sided varicocele can often affect the opposite testicle.

9. Varicocele Primary: Secondary: Increase in venous hyrostatic pressure
Panpiniform plexus reflux
Secondary:
Compresson or obsturction of internal spermatic vein caused by a tumor. (ie. Nutcracker)

10. Nutcracker Phenomenon is a vascular compression disorder and refers to the compression of the left renal vein between the superior mesenteric artery (SMA) and aorta.

11. Pathophysiology Intratesticular hyperthermia
Reflux of renal and adrenal metabolites
Hypoxia
Local testicular hormonal imbalance
Increased oxidative stress

12. Clinical Presentation
Patients are usually asymptomatic.
Mostly seek for evaluation for their infertility.
Scrotal discomfort and pain.
Different scrotal sizes and levels
Left predominance

13. Failure of ipsilateral testicular growth and developement.
Hypogonadism
“Bag of worms” sign.

14. Bag of Worms

15. Diagnosis
The “gold standard” way to diagnose varicoceles is by physical examination.
With a patient in a standing position, in room temperature, palpation of the scrotum by a physician can reveal a varicocele.
Exercise and prolonged standing may also demonstrate a varicocele.

17. Difficulties palpating a varicocele arise when the scrotal wall is thick or contracted. 
In addition, benign fat, termed lipoma of the cord, can feel like a variocele. 
In order to differentiate varicocele from lipome patient should be examined lying down.

18. Imaging
Venography is considered to be the best diagnostic test, but it is invasive, involving catheterization of large leg veins to access this system.
Doppler US is less invasive than, and correlates well with, venography and relies on the detection of venous flow within the varicocele.
CT.

19. Semen Analysis Most commonly Astenozoospermi(90%)
Oligozoospermi(<20M/ml) (65%)
Morphologic anomalies, immature sperms

20. Varicocele Grading Subclinical GRADE I GRADE II GRADE III
Varicocele not detected on physical exam; found by radiologic or other imaging study.
GRADE I
Varicocele only palpable during or after Valsalva maneuver on physical exam.
GRADE II
Varicocele palpable on routine physical exam without the need for Valsalva maneuver.
GRADE III
Varicocele visible to the eye and palpable on physical exam.

22. Treatment Indications
Clinical varicocele
Oligospermia
Infertility duration of ≥2 years
Otherwise unexplained infertility in couple
Varicocele treatment is recommended for adolescents with progressive failure of testicular development documented by serial clinical examination.
2014 European Association of Urology guidelines in male infertility recommend considering varicocele repair in patients with the following:

23. Treatments
Recent meta-analysis showed that semen improvement is usually observed after surgical correction. Varicocelectomy can reverse sperm DNA damage.

24. Treatments Antegrade sclerotherapy Retrograde sclerotherapy
Retrograde Embolisation
Laporoscopy
Microsurgical Inguinal or Subinguinal ligation

25. Microsurgery - Inguinal or Subinguinal Ligation
Has the lowest recurrence persistence ratio.
Basically the technique is to ligate all of the internal and external spermatic veins with preservation of spermatic arteries and lymphatics.

27. Complications
Post-op hydrocele
Atrophy
Scrotal Haematoma
Recurrence

28. Hydrocele

29. Normally fluid between visceral and parietal layers of tunica vaginalis is 1-3 ml.
Fluid secreted from parietal layer of tunica vaginalis, reabsorbed from lymphatics of parietal layer.

30. What is Hydrocele?
Hydrocele is a fluid collection within the tunica vaginalis of the scrotum or along the spermatic cord.

31. Without any other complications, hydrocele fluid is yellow and clear.
Even though hydrocele can be seen in every age, it’s seen predominantly after age 40.

33. Classification
Congenital Hydrocele: It’s related to closure of processus vaginalis early, late or incomplete.
Acquired Hydrocele: Developes after secondary pathology such as orchitis, epididimitis, tumor, trauma, raditherapy, herniotomy, varicocelectomy.

34. Congenital Hydrocele Communicating type Non- Communicating
Hydrocele of the cord
Abdomino-scrotal Hydrocele

36. Communicating Hydrocele
During intrauterine life testis placed in abdomen. Right after 14th week of gestation it descends to the scrotum through inguinal region with peritoneum.
After a while from birth, this extension of peritoneum closes. If not intraabdominal fluid accumulates in scrotum.
Bu inişte periton da skrotuma kadar testisle birlikte iner. Doğumdan bir süre sonra bu peritonun uzantısı olan kesecik kapanarak ipliksi bir yapı halini alır.
Kapanmaz ise karın içi sıvısı bu açıklıktan geçerek testis etrafında skrotumda birikir .
Eğer açıklık büyükse karın içi organlar buradan sarkarak fıtık oluşturabilir.

37. Patent Processus Vaginalis

39. Communicating type mass varies during the day.
Increase in size in the nights shows its communication with peritoneum.
Pediatric hydroceles are mostly have communication with peritoneum.
Sabahları küçük olan kitlenin gün boyunca karın içi basıncını artıran hareketler (ağlama, öksürme, beslenme, oturma, ayağa kalkma vb.) ile giderek artması .
Gece yatarken büyümüş olması peritonla ilişkinin varlığını gösterir.

40. Cryptorchidsm must be considered in a pediatric hydrocele because of the existance of patent processus vaginalis.
Communicating hydrocele can be diagnosed with physical examination and patient history.
Skrotal bası ile abdomene sıvı kacıyorsa komunikan.

41. Non-Communicating Hydrocele
Processus vaginalis obliterated.
Fluid trapped in scrotal cavity.
Bilateral and ‘giant’ size.
Mostly congenital and is spontaneously resorbed within a year.

42. In older cases with non-communicating hydrocele:
Infection
Torsion
Tumor
must be considered in differential diagnosis.

43. Hydrocele of the Cord
At times closure of processus vaginalis occurs segmentally which leads to hydrocele of the cord without communication of peritoneum.
Locates between testis and inguinal canal.

44. AbdominoScrotal Hydrocele
Has 2 big lobes and passes through inguinal ring.
Intraabdominal and inguinoscrotal segments.
When intraabdominal pressure arises, hydrocele enlarges.
In physical examination of a patient with hydrocele, presence of intraabdominal mass is typical.

45. Signs and Symptoms Swollen scrotum Stretched scrotum
Non-palpable testis
Mostly painless( if there is no inflammation)

46. Diagnosis History Physical Examination Transillumination +
Scrotal USG Definitive Diagnosis

48. DDX:
Spermatocele
Pyocele
Hematocele
Inguinal Hernia

49. Treatment Generally asymptomatic and seldomly needs treatment.
Indications:
If hydorcele is big enough to affect blood flow.
Cosmetic.
Swollen, stretched feeling and discomfort
Intercourse problems

50. Treatment - Infant
Non-communicating and communicating types are followed for a year.
If patent processus vaginalis is present, hydrocele aspiration is contraindicated.
If communicating type doesn’t close after months surgery is needed.
High ligation of patent processus vaginalis is done with inguinal incision on the level of inguinal ring.

51. Treatment – Adult Treatment is surgery.
Winkelman, Bergman and Lord techniques.
Tunica vaginalis is opened with scrotal incision, drain liquid away and enclosure of the gap.
Complications: Edema, hematoma, infection, scrotal abscess and recurrent hyrocele.

52. In conditions when surgery is risky, sclerotherapy is another method of treatment.
Drug of choice is mostly Tetracycline.
That may cause epididimal obstructions and may lead to infertility.

53. Spermatocele
Cysts derives from rete testis, ductus efferent and epididimis.
Asymptomatic.
Prevelance 1%
Physical examination: non-fixated, transillumination +
White cyst fluid
Treatment:Follow up. If uncomfortable or blocks ejaculation surgical excision.

55. Hematocele Bleeding between the layers of tunica vaginalis.
Trauma or post-op
Aggressive testicular tumors
Treatment: If cannot be resorbed, drainage should be applied.

56. Pyocele
Rare urologic emergency. Must be recognized and treated quickly to prevent testicular damage and Fournier’s gangrene.
Pyoceles are purulent collections within the potential space between the visceral and parietal tunica vaginalis.
Commonly associated with epididymo-orchitis.
USG
Edema, erythema, tenderness.
Broad spectrum antibiotics and surgical drainage.

57. THANK YOU!