Testicular and Scrotal Anomalies

TESTICULAR & SCROTAL ANOMALIES
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Torsio testis
Hydrocele
Varicocele
Epididimytis
Orchitis
Tumor
Cryptorchidismus
TORSIO TESTIS
 Torsion of spermatic cord structures
 Rotate between 90 – 180 degree
 Subsequent loss of blood supply to ipsilateral testicle

 Urologic emergency
 Early diagnosis and treatment are vital to saving the testicle and preserving future fertility
ETIOLOGI
 Perubahan suhu yang mendadak

 Ketakutan
 Latihan yang berlebihan
 Memakai celana ketat
 Defekasi
 Saat tidur karena spasme m. cremasterica
 Trauma scrotum
PATOFISIOLOGI
 Intravaginal (Bell Clapper Deformity)

 Sering terjadi pada remaja
 Tunica vaginalis mengelilingi semua bagian testis → Insersi epididymis ke scrotum terhambat → Bergerak bebas
 Ekstravaginal
 Sering terjadi pada fetus dan neonates
 Tunica vaginalis belum terfiksasi sempurna → Testis, epididymis, dan tunica vaginalis bergerak bebas
 Menyebabkan obstruksi aliran darah sehingga testis mengalami hipoksia, edema, dan ischemia
CLINICAL MANIFESTATIONS
 Sudden onset of severe unilateral scrotal pain
 Inguinal and or scrotal swelling
 Nausea, vomiting
 Derming sign : High position of affected testis
 Angle sign : Abnormal horizontal (transverse) lie
 Absence of cremasteric reflex on affected side
 Negative Phren sign : Not relieved by testicle elevation
 Doppler ultrasound : Decreased or absent testis blood flow
TERAPI
 Detorsi manual
 Memutar testis berlawanan dengan arah torsio
 Torsio biasanya ke medial → Memutar ke arah lateral
 Operasi harus tetap dilakukan meskipun sudah berhasil
 Operasi
 Berfungsi untuk reposisi testis dan menilai viabilitas
 Jika masih viable, maka dilakukan orchidopeksi ke tunica dartos dan orchidopeksi kontralateral
 Jika sudah necrosis, maka dilakukan orchidektomi dan orchidopeksi kontralateral
TESTICULAR SALVAGE RATES
 < 6 hours : 90 – 100%

 12 – 24 hours : 20 – 50%
 > 24 hours : 0 – 10%
EPIDIDIMITIS
 Inflammation, pain, swelling of epididymis
 Acute : Lasting for < 6 weeks
 Chronic : Lasting > 6 weeks
 Most common urologic diagnosis in aged 18 – 50 years

 Etiology
 Port de entry : Ascending, urine reflux via ejaculatory ducts, hematogenous, direct inoculation
 Sexually active : Chlamydia, N. gonorrhoeae
 Children and elder : E. coli
 Other : Mumps, M. tuberculosis, trauma, drugs
 Gradual onset of scrotal pain and swelling
 Usually unilateral
 Dysuria, frequency, or urgency
 Fever and chills, no nausea or vomiting
 Urethral discharge
 Elevation of affected hemiscrotum
 Normal cremasteric reflex and Phren sign
 Doppler ultrasound : Increased testis blood flow
LABORATORY EVALUATION
 Urinalysis : Pyuria or bacteriuria

 Urine culture is indicated for prepubertal and elderly
 Leukocytosis
 Urethral discharge examination
 Gram staining
 Culture
 PCR to detect Neisseria gonorrhea or Chlamydia
TERAPI
 Amoksisilin + probenesid atau ceftriakson IV kemudian

 Doksisiklin atau eritromisin per oral selama 10 hari
 Mengobati pasangan seksual
 Terapi simptomatik
 Menggunakan celana ketat sehingga testis terangkat
 Mengurangi aktivitas
 Kompres es
 NSAIDs
ORCHITIS
 Inflammation or infection of testicles
 May be related to epididymitis
 Extension to testes
 Etiology
 Port de entry : Ascending, blood, lymphatics
 14 – 35 years : Neisseria gonorrhea
 < 14 and > 35 years : E. coli
 Other : Autoimmune, mumps, syphilis
 Mild to severe testicular pain and swelling

 Systemic symptoms : Fever, fatigue, malaise, nausea
 Tender, erythematous, and edematous scrotal skin
 Mumps orchitis occur 4 – 7 days after parotitis
TREATMENT
 No medications for viral orchitis

 Bacterial orchitis in < 35 years old
 Antibiotic for sexually transmitted pathogens
 Ceftriaxone, doxycycline, or azytromisin
 Bacterial orchitis in > 35 years old

 Additional antibiotic for other Gram-negative bacteria
 Fluoroquinolone or TMP – SMX
 Supportive care
 Bed rest
 Analgesia : Hot or cold packs, scrotal elevation
HYDROCELE
 Cavum vaginale testis berisi cairan yang berlebihan
 Terjadi pada 6% neonates dan bersifat kongenital
 Biasanya sembuh sendiri setelah

umur 1 tahun
ETIOLOGI DAN PATOGENESIS
 Neonatus
 Processus vaginalis belum menutup sempurna → Terjadi aliran cairan peritoneum
 Perkembangan systema lymphatica pada scrotum belum sempurna → Gangguan reabsorpsi cairan
 Dewasa
 Primer : Idiopatik
 Sekunder : Tumor, infeksi terutama oleh Wuchereria bancrofti, trauma
KLASIFIKASI
 Hydrocele testis : Mengelilingi testis → Testis tidak teraba

 Ukuran hydrocele tidak berubah sepanjang hari
 Hydrocele funiculus : Terletak di funiculus spermaticus pada bagian cranial testis → Testis teraba di luar
 Ukuran hydrocele tidak berubah sepanjang hari
 Hydrocele comunicans : Processus vaginalis berhubungan dengan cavitas peritonealis

 Kantong hydrocele terpisah dari testis dan dapat dimasukkan ke cavum abdomen
 Ukuran hydrocele dapat berubah terutama saat menangis
CLINICAL PRESENTATION
 Soft non tender fullness within the hemiscrotum

 Testis is generally palpable along the posterior aspect
 Positive transillumination
 Homogenous glow withoug internal shadows
 Consider ultrasound due to possibility of neoplasm

TERAPI
 Ditunggu sampai umur 1 tahun

 Aspirasi cairan
 Tidak disarankan karena angka kekambuhannya tinggi dan sering menyebabkan infeksi
 Operasi
 Hydrocele yang besar → Menekan pembuluh darah
 Indikasi kosmetik
 Hydrocel permagna yang terlalu berat dan dapat menganggu aktivitas sehari – hari
VARICOCELE
 Abnormal dilation of pampiniform venous plexus
 Classically described as a bag of worms
 Most occur on the left side
 If on the right side consider

compression or obstruction of
inferior vena cava
 May be painful or tender
 Most often after puberty
ETIOLOGY
 Incompetent or congenitally absent valves in testicular vein

 More common in the left testicle because
 The perpendicular angle at which the left testicular vein enters the left renal vein
 The lack of effective antireflux valves at the juncture of testicular vein and renal vein
 The increased renal vein pressure due to its compression between superior mesenteric artery and aorta
 Dapat menyebabkan gangguan spermatogenesis karena
 Terjadi stagnasi aliran darah balik sehingga testis mengalami hipoksia
 Reflux hasil metabolit ginjal dan adrenal melalui v. testicularis ke testis
 Peningkatan suhu testis
 Anastomosis plexus pampiniformis dextra et sinistra → Aliran metabolit ke testis kanan → Gangguan spermatogenesis →
Infertilitas
 Asymptomatic and often seeks an evaluation for infertility

 Scrotal pain or heaviness
 Physical examination : Feeling like a bag of worm
 Classification
 Large : Easily identified by inspection alone
 Moderate : Identified by palpation without bearing down
 Small : Identified only by bearing down which increase intraabdominal pressure, thus impending drainage
 Doppler ultrasound : Increased blood flow in pampiniform vein plexus

TERAPI
 Indikasi : Gangguan fertilitas

 Ligasi v. testicularis melalui operasi terbuka atau laparoskopi
 Varicocelectomy
 Memasukkan bahan sclerosing ke dalam v. testicularis secara per kutan
CRYPTORCHIDISMUS
 Cryptorchidismus is condition of testicular
maldescent
 Abdominal
 Inguinal
 Upper scrotal
 Ectopic testis has strayed from normal pathway of
descent
 Can lead to infertility
ETIOLOGI DAN PATOGENESIS
 Etiologi
 Kelainan pada gubernaculum testis
 Kelainan intrinsic pada testis
 Defisiensi hormone gonadotropin yang merangsang descencus testiculorum
 Suhu abdomen 10C lebih tinggi → Suhu testis abdominal juga lebih tinggi → Merusak epitel germinativum →
Atrofi
 Sel Leydig tidak rusak → Potensi seksual tidak terganggu
 Akibat : Infertilitas, torsio testis, trauma, kanker
GEJALA KLINIS
 Tidak ditemukan testis di scrotum

 Belum memiliki anak setelah beberapa tahun
 Benjolan di perut bagian bawah
 Hipoplasia kulit scrotum
 USG, CT scan, dan MRI tidak terlalu membantu
DIAGNOSIS BANDING
 Anorchismus bilateral
 Pemeriksaan kadar testosterone awal → Injeksi HCG selama 4 hari → Kadar testosterone tidak meningkat
 Cryprorchidismus fisiologis (testis retractile)

 Testis terletak di region inguinal dan dapat kembali ke tempat awal
 Disebabkan oleh reflex m. cremasterica yang terlalu kuat saat cuaca dingin atau setelah aktivitas fisik
TERAPI
 Sebaiknya dilakukan pada umur 1 tahun

 Medikamentosa : HCG intranasal
 Operasi
 Mempertahankan fertilitas
 Mencegah munculnya degenerasi maligna
 Melakukan koreksi hernia
 Aspek psikologis
 Dilakukan dengan orchidopexy ke tunica dartos
TERIMA KASIH

Testicular and Scrotal Anomalies

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Testicular and Scrotal Anomalies

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TESTICULAR & SCROTAL ANOMALIES

Click icon to add picture

 Subsequent loss of blood supply to ipsilateral testicle

 Perubahan suhu yang mendadak

 Intravaginal (Bell Clapper Deformity)

 < 6 hours : 90 – 100%

 Most common urologic diagnosis in aged 18 – 50 years

 Urinalysis : Pyuria or bacteriuria

 Amoksisilin + probenesid atau ceftriakson IV kemudian

 Mild to severe testicular pain and swelling

 No medications for viral orchitis

 Bacterial orchitis in > 35 years old

 Biasanya sembuh sendiri setelah

 Hydrocele testis : Mengelilingi testis → Testis tidak teraba

 Hydrocele comunicans : Processus vaginalis berhubungan dengan cavitas peritonealis

 Soft non tender fullness within the hemiscrotum

 Consider ultrasound due to possibility of neoplasm

 Ditunggu sampai umur 1 tahun

 If on the right side consider

 Incompetent or congenitally absent valves in testicular vein

 Asymptomatic and often seeks an evaluation for infertility

 Doppler ultrasound : Increased blood flow in pampiniform vein plexus

 Indikasi : Gangguan fertilitas

 Tidak ditemukan testis di scrotum

 Cryprorchidismus fisiologis (testis retractile)

 Sebaiknya dilakukan pada umur 1 tahun

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