1. Testis
Often difficult to differentiate a serious emergent situation from a more benign situation
Pay attention to history, clinical picture and pain expression of patient
Decide who needs tests and when
Decide who needs to go to surgery emergent and who elective

2. Scrotal Swelling Presentations
HERNIA
Hydrocele
Scrotal abscess
Varicocele
TORSION
Epididymitis

3. Hernia Bulge over inguinal canal or scrotum Changes size Reducible
Sometimes there, sometimes not
Open processus vaginalis
Often not painful
Diagnosis by exam
Aggravated by constipation
Elective surgery unless incarcerated

4. Hydrocele Bulge in scrotum or over inguinal canal
Changes size if communicating
Translucent
Diagnosis by exam
Elective surgery
..but starts screaming during exam
Not painful

5. Torsion 1 in 4000 males <25/year Bell clapper deformity
Lack of fixation
Testis freely suspended within the tunica vaginal
Extravaginal
Pre- or neonatal
Intravaginal
Older children
Peak around 13 years
Left more common
2% bilateral
Trauma as cause is rare
Only 4%-8%
Barada et al, J Urol 1989
Seng et al , J Accid Emerg 2000

6. Torsion Sudden onset of extreme pain Followed by acute swelling
Affected side elevated
Nausea and emesis
No cremasteric reflex
Can present as abdominal pain!!!
If pain gets better by itself
Not good – NECROSIS!!!
Diagnosis by exam and Doppler - Ultrasound
NO FLOW
Minevich E, emedicine Barada et al, J Urol 1989

7. Torsion - Treatment Manuel de-torsion can be attempted
But extremely painful
“Open book”
Don’t delay diagnosis
Immediate surgery
Within 6 hours
Untwist and check for viability
Remove necrotic testis
Fixate the other side
Prevent future torsion

8. Torsion- Prenatal Extravaginal torsion Presentation at birth Treatment
Non-painful
Hard
Attached to scrotal wall
Dark color shines through scrotum
Treatment
Orchiectomy
Fixate contralateral side

9. Torsion “Must not miss” diagnosis
Consider diagnosis until proven otherwise
Doppler Ultrasound
…but perform surgery even if studies are negative if clinical suspicion is high

10. Torsion Appendix testis
Painful
Swollen in upper part of testis
Blue dot sign
Difficult to differentiate from testicular torsion
Diagnosis by exam and ultrasound
Often found during exploration of testicular torsion
Surgery not necessary if clearly identified on US

11. Scrotal abscess Many possibilities Treatment Bug bite/ Rash
Orchitis/ Epididimytis
Trauma
Exotic infection
Immune disorder
Treatment
Antibiotics
Drainage
Debridment
Evaluate reason

12. Epididymitis/Orchitis
Very Painful
Onset gradually
Swollen and red
Epididymis more painful than testis
Diagnosis
Exam, Lymph nodes, US, UA
Infection
UTI (UTI pos)
Hematogenous (UA neg)
Reactive (UA neg)
Consider malformation
Ectopic ureter
Treatment
Antibiotics (E.coli –Bactrim)
Elevation
Cool
Increased flow to the epididymis

13. Varicocele
Dilation of the pampiniform venous plexus and the internal spermatic vein
Typically left
insertion of vein into renal vein
If right or no decompression on exam US recommended to rule out intra abdominal process
Usually asymptomatic and found on routine exam
Typical exam- Bag of worms
Three reasons for OR
Pain
Cosmetic
Testicular dysfunction
US to verify diagnosis and measure testis
Patient does not want to be here
Redman et al, J Urol 2001, Sheldon et al, J Urol 2001

14. Testicular Tumors 2% of all pediatric tumors
Incidence of per 100,000 children
First peak in the first 2 years of life, second in young adulthood
Adult:
mostly germ-cell tumors with malignant potential (Seminoma and Embryonal carcinoma)
Prepubertal:
yolk-sac tumors (malignant)
Teratoma benign in children
Seminomas and mixed germ-cell tumors are extremely rare
Gonadoblastoma: associated with DSD
Leukemia
Paratesticular: Rhabdomyosarcoma

15. Testicular Tumors Presentation Diagnosis Excellent survival rates
Painless scrotal swelling (85%)
Trauma, Hydrocele, Torsion 
Diagnosis
Exam
Ultrasound
aFT (yolk-sac), bHCG (Gonadoblastoma), Testosteron (Leydig- cell tumor)
Excellent survival rates
Cooper CS, Urol Oncol 2005

16. Testicular Tumors
Surgery with radical orchiectomy in 24 hours after diagnosis

17. Cryptorchidism
Testis should descend from 7 months gestation until birth
About half of UDT will drop during first year
Can be intraabdominal, in canal or ectopic

18. Cryptorchidism Exam can be difficult Often strong cremasteric reflex
Differentiate between retractile and undescended
Frogleg and try to milk testis into scrotum
Consider ectopic position
Let the parents feel the testes
Child comfortable…until exam

19. Cryptorchidism Clinical diagnosis
Consider testicular atrophy if the other testis is large
Ultrasound, MRI, CT usually not helpful…
If testis is not palpable – OR
If testes is found on imaging – OR
If testes is not found on imaging – OR
Reason for surgery
Fertility
Self- examination to detect testis tumor
Timing of surgery: after 6 month gestational age

20. Female Genitalia Labial adhesions Fusion of labia minora Not painful
No emergency
Can usually void fine
Treatment:
Lysis (NO!!)
Estrogen crème
Lysis under local or full anesthesia
Observation

21. Imperforate Hymen Normal urethral opening Bulging introitus
Can be opened in clinic
Not painful
Should be seen soon

22. Sexual abuse Detailed knowledge of the anatomy
Differentiate normal from abnormal
Suspicious behavior during examination
Immediate contact of social services

23. Syndromes Multiple syndromes impact the outer genitalia
Many detected prenatally
Should be referred for prenatal consultation
Immediate contact with center
Postnatal transfer to center
Inform parents that situation will be discussed in detail at the center

24. Syndromes - DSD DSD PAIS (46XY) CAH
Complete androgen insensitivity (CAIS)
Genetic Male DSD

25. Syndromes - Exstrophy
Bladder Exstrophy
Cloacal Exstrophy

26. Obviously there are many more problems …..