Testicular Torsion ,Hydrocele & Fournier Gangrene

8/13/2019 Testicular Torsion ,Hydrocele & Fournier Gangrene

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TESTICULAR TORSION& HYDROCELE

Presented

Nur Insyira

K4/20th Oc



ANATOMY



Spermatic cord consists of: 1) testicular arte

deferens artery, 3)cremasteric artery , 4) ge

genitofemoral nerve, 5) autonomic nerve , 6

7) pampiniform (venous) plexus, 8) ductus



The internal spermatic, or testicular, artery arises from the aorta. The testiculchief source of blood to the testis. The artery of the ductus deferens (deferenemerges from the inferior vesicular artery. The external spermatic, or cremas

from the inferior epigastric artery.



TESTICULAR TORSI



INTRODUCTION

Testicular torsion refers to the torsionof the spermatic cord structures andsubsequent loss of the blood supplyto the ipsilateral testicle.

This is a urological emergency; earlydiagnosis and treatment are vital to

saving the testicle and preservingfuture fertility.It can occur at any age, but accountsfor 90 per cent of acute testicularpain in adolescent males betweenthe ages of 13 and 21.



PATHOPHYSIOLOGY

Torsion occurs when an excessively mobile testrotates on its cord structures, impairing venousreturn, which leads to venous congestion andoedema.

This results in reduced arterial blood inflow, withsubsequent ischaemia and infarction of the testileft uncorrected



TYPES OF TESTICULARTORSION

Divided into 2 main types(depending on the the anatomicaldetails of the axis of torsion.

1) Intravaginal torsion

The most frequent in adolescent boys, occurs when

the axis of rotation is within the tunica vaginalis.

2) Extravaginal torsion

Occurs due to the tunica vaginalis having anabnormally long attachment to the testis. Thus therotation is external to the tunica vaginalis, which

itself is also torted. This variety of testicular torsionoccurs mainly in children.



Males with a horizontal lie to theirtestes, the so-called ‘bell-clapperdeformity’ are more prone todeveloping testicular torsion. This

anatomical variant arises as a resultof the manner in which the tunicavaginalis is reflected on the testisand is bilateral in nature, thusexplaining the risk of subsequentcontralateral torsion in patients who

have experienced a testiculartorsion.

Suffering from intermittenttesticular torsion. These patientstypically present to primary carecomplaining of acute, severe

unilateral testicular pain, whicht icall resolves itself within



CLINICAL MANIFESTATIONS

Acute, severe unilateral scrotal pain, pain duratless than 24 hours

Pain radiating to lower abdomen

Nausea and vomiting Absence of infective symptoms and signs such dysuria,frequency ,pyrexia



PHYSICAL EXAMINATION Scrotal erythema, edema, and testicular

swellingTestis may also high riding position

Testis may lie horizontally

Tenderness of the testis

Elevation of testis when patient in supineposition may worsen the pain (Prehn’s sign). This may be a useful sign todifferentiate the diagnosis from epididymo-orchitis, in which the pain gets better withelevation

Absent of cremasteric reflex (if

absent,99% TT)



INVESTIGATION

Dipstix urinalysis (the only mandatory test intesticular torsion and usually is negative)

Other tests eg FBC time consuming and unrelia

Doppler ultrasound



DIFFERENTIAL DIAGNOSIS

Epididymitis

Orchitis

Epididymo-orchitis

Testicular appendages torsion

Trauma

Hernia



MANAGEMENT

1. Manual detorsion (no longer done and it is paido)

Most torsions twist inward and toward the midline; thus, manual detorsion of thtwisting outward and laterally. Only 1/3 of testicular torsion that twist outward.

Torsion of the right testicle:

- Physician is positioned in front of the standing or su

-Holds the patient's right testicle with the left thumforefinger.

-Rotates the right testicle outward 180° in a medial-to-late

Torsion of left testicle:

-uses the right thumb and forefinger rotates the patient's lef°



CONT.

Rotation of the testicle may need to be repeated 2-3 times for completdetorsion. Pain relief serves as a guide to successful detorsion, butrestoration of blood flow must be confirmed following the maneu

Other signs suggestive of successful manual detorsion include resoluthe transverse lie of the testis to a longitudinal orientation, lowerposition of the testis in the scrotum, and return of normal arteriapulsations detected with a Doppler stethoscope

Subsequent elective orchiopexy is recommended, to prevent recurtorsion



2. SURGERY FORTESTICULAR TORSION

(ORCHIOPEXY)1) Incision : Either a midline raphe incision or bilateral transverse scroincisions

2) Enter the ipsilateral scrotal compartment, incise the tunica vaginalisthen deliver the testicle for examination.

- The spermatic cord is then untwisted.

- Evaluate the testis for viability.

- If viability is in question, place the testicle in warm sponges and reevafter several minutes.

- If the testis is necrotic, perform an orchiectomy to avoid prolonged,debilitating pain and tenderness.



3) To prevent subsequent torsion:

- Fix viable gonads to the scrotal wall with 3-4 nonabsorbable sutures

- A dartos pouch can be made, into which the testicle is placed.

Always perform contralateral orchiopexy when testicular torsion isconfirmed intraoperatively, in order to prevent future torsion of that tes

* Signs of a viable testis after detorsion include a return of color , retuDoppler flow, and arterial bleeding after incision of the tunicaalbuginea.

If < than 6 H from the onset if we detorse it, the salvage rate > than 90

If we detorse it > 24 H, the testis unlikely to survive almost 0 %



3.TESTICULAR PROSTHESISREPLACEMENT

Patients requiring an orchiectomybecause of a nonviable testis maybenefit from the placement of atesticular prosthesis.

Delay this placement, usually for 6months, until healing is complete andinflammatory changes resolve.

Perform the prosthetic placement

through an inguinal incision



HYDROCELE



INTRODUCTION

Hydrocele comes from the Greek hydros (water(mass).

Defined as a collection within the tunica vaginalitestis



ETIOLOGY

A hydrocele can be produced in 4 different ways:

1. by excessive production of fluid within the sac (e.g: secondary hydr

2.by defective absorption of fluid ( for most primary hydrocele)

3. by interference with lymphatic drainage of scrotal structure

4. by connection with the peritoneal cavity via a patent processus vag(congenital)



CLASSIFICATION

1. Congenital

2. Primary

3. Secondary



CONGENITAL

Due to patent processus vaginalis

1. Communicating hydrocele

2. Vaginal hydrocele

3. infantile hydrocele4. Hydrocele of the cord



1.CONGENITAL/COMMUNICATG HYDROCELEThe processus vaginalis is patent and connect with the peritoneal cav

The communication is too small to allow herniation of abdominal conte

Diagnosis present since birth,when patient liss it will disappear, in ereposture appear again



2. VAGINAL HYDROCELE

Processus vaginalis patent up to the top of the testis, where it is shut the tunica vaginalis

Swelling in the inguinal region rather than scrotal

Testis can be felt

Swelling reduced when lies down



3. INFANTILE HYDROCELE

Opposite to the vaginal hydrocele- the processus vaginalis shut off froperitoneal cavity at the deep inguinal ring

Seen in infant and adult

Cystic swelling

4 HYDROCELE OF THE



4. HYDROCELE OF THECORD/ ENCYSTEDHYDROCELECentral portion of processus vaginalis remain patent- upper and lowerobliterated

Oval cystic swelling in relation to spermatic cord

Testis felt separate



PRIMARY AND SECONDARYHYRDOCELE



TRANSILLUMINATION TEST

DIFFERENTIATION BETWEE



DIFFERENTIATION BETWEEHYDROCELE AND INGUINALHERNIA

Hydrocele Inguinal hernia

Palpate cord above the mass Yes No

Translucent Yes No

Fluctuate Yes No

Fluid thrill Yes No

Testis palpable No Yes

Reducible No Yes

Bowel sound No Yes

Cough impulse No Yes



IMAGING

Inguinal-scrotal imaging ultrasound

This study is indicated to confirm the diagnosis.

May be useful to identify abnormalities in the testis, complex cystic matumors, appendages, spermatocele, or associated hernia.



MANAGEMENT

A hydrocele that occurs during infancy mayspontaneously resolve with the closure of theprocessus vaginalis and, therefore, surgicaltreatment should be withheld until after the first y

of life. Treatment may be necessary for a very laor enlarging hydrocele or for an associated indirhernia.



CONT.

Adults do not require therapy for hydrocele unlecomplications are present, such as discomfort adisability from the bulky mass or a tense hydrocthat cause pain and may diminish circulation and

lead to atrophy.



JABOULAY/WINKLEMANPROCEDURE

Opening and eversion of tunica sac

Most commonly performed

Results are good

It is believed that the secretorysurface which face outwards after

surgery, secretes fluid that isabsorbed by the scrotal lymphaticsand passes to the inguinal channels,providing an alternate route fordrainage.



LORD PROCEDURE

Plication of the sac

Use for small hydrocele with a thinsmall sac



THAN

K

YOU



Varicocele?

Testicular cancer? u/s detect 99% of testicular malignancy,

We cannot do FNAC in malignancy becoz there will be tumour seedlinalong the needle tract. Then what u need to do? Surgical exploration, high ligation up to

Testicular Torsion ,Hydrocele & Fournier Gangrene

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