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

3. 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

4. Incidence One of the most common congenital anomalies at birth
3% of full-term male newborns
% 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

5. Epidemiology Gestational age Birth weight Prematurity
Genetic- hormonal- environmental

6. 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.

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

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

9. 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

10. 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

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

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

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

14. 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

15. Consequences of UDT
Infertility
Neoplasia
Hernia
Torsion

16. 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

17. 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?

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

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

20. 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

21. 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

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

23. 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

24. HCG treatment GnRH 14-59% success rate
10,000 IU (1500 Iu/m2 im/2 week – 4 week)
Complications:
GnRH
% 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

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

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

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

35. Acute scrotum Acute scrotal pain – tenderness or swelling
Diff diagnosis

36. 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)

37. 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%

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

39. 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)