15- Scrotal content

Diseases of Scrotal Content

• Varicocele, Hydrocele, Spermatocele are diseases of the scrotum.
• Cevdet Kaya, MD, Professor of Urology, Medical School, Istinye University is the presenter.

Learning Outcomes

• Students will be able to describe the scrotum's anatomy and the organs within.
• Students will be able to define varicocele, hydrocele, and spermatocele.
• Students will be able to evaluate a patient with varicocele.
• Students will be able to determine normal semen analysis values.
• Students will be able to assess treatment options for hydrocele and spermatocele.

Varicocele

• Affects 15% of the normal male population and 1 out of 3 with infertility.
• Dilated veins in the pampiniform plexus of the spermatic cord cause varicocele.
• Testicular temperature elevation and venous reflux are also factors.
• Common cause of male infertility.
• Adolescent varicocele is important for testicular growth.
• Semen quality is abnormal.
• Decreased testicular volume is a symptom.
• Decreased leydig cell function.
• May cause hormonal issues.
• Possible oxidative pathogenesis.

Evaluation

• Medical and reproductive history.
• Physical examination (both recumbent and upright).
• At least two semen analyses.
• Palpable varicocele feels like a "bag of worms".
• Valsalva maneuver is performed in a standing position.
• Palpable varicoceles are often associated with infertility.
• Scrotal ultrasonography is frequently useful when a physical exam is inconclusive.

Treatment Indications

• Varicocele treatment is considered if several conditions are met:

  • The varicocele is palpable.
  • The couple has known infertility.
  • The female partner has normal fertility or potentially treatable infertility.
  • The male partner has abnormal semen parameters or test results.

• Treatment is not indicated in patients with normal semen quality or subclinical varicocele.

• Adult men with palpable varicocele and abnormal semen analysis, but who aren't trying to conceive, should still have varicocele repair.

• Adolescents with varicocele and reduced ipsilateral testicular size should be offered varicocele repair.

• Adolescents with varicocele and normal contralateral testicular size are followed up.

Treatment Indications - Additional information

• Testicular dysfunction and negative impact on spermatogenesis
  • Increased scrotal temperature.
  • Reduced blood flow and increased pressure due to venous stasis and small vascular occlusion (due to hypoxia).
  • Sertoli and germinal cell dysfunction.
  • Decreased androgen secretion.
  • Increase in catecholamines in the spermatic vein.
  • Reflux of renal and perirenal metabolites.
  • Increased NO levels in the spermatic vein and increased reactive oxygen metabolites.

Grading

• Subclinical varicocele is detected on Doppler US but isn't palpable.
• Grade 1: Palpable only during Valsalva.
• Grade 2: Palpable at rest but not visible.
• Grade 3: Visible/palpable at rest.

Treatment

• Varicocelectomy (Microsurgical Subinguinal Varicocele Repair):

  • Microscopical and subinguinal approaches.
  • Images (A-E) show the surgical steps.

• Percutaneous embolization.

  • Image of the procedure.

Hydrocele

• Collection of fluid between the tunica vaginalis layers.
  • Increased secretion or decreased absorption cause build-up.
• Primary hydrocele (patent processus vaginalis):
  • Commonly seen in newborns.
  • Persists in 20% of adults.
• Secondary hydrocele (closed processus vaginalis):
  • Other conditions can cause a hydrocele.

Hydrocele - Other causes

• Communicating hydrocele (mostly pediatric).
• Congenital hydrocele (associated with indirect hernia).
• Secondary hydrocele (adolescent/adult):
  • Infection (epididimitis-orchitis).
  • Trauma.
  • Linked to neoplasia.
  • Testicular torsion.
  • Varicocele complication

Hydrocele - Presentation

• Scrotal pain/feeling of weight.
• Cosmetic causes.
• Cancer anxiety.
• Treatment is hydrocelectomy.

Spermatocele or Epididymis Cyst

• Asymptomatic benign cystic dilatation in epididymal tubules.
• Does not cause obstruction.
• Rarely requires surgery.

This quiz covers the diseases of the scrotum, focusing on varicocele, hydrocele, and spermatocele. Students will learn about the anatomy of the scrotum and evaluate patient conditions and treatment options. Additionally, the quiz highlights the importance of these conditions in male infertility.