CHILD WITH AN EMPTY SCROTUM

A PROBLEM ORIENTED APPROACH

CHILD WITH AN EMPTY SCROTUM

Dr.B.SELVARAJ MS;Mch;FICS;

NEONATAL & PEDIATRIC SURGEON

MELAKA MANIPAL MEDICAL COLLEGE

MELAKA– 75150 MALAYSIA

A PROBLEM ORIENTED APPROACH

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CHILD WITH AN EMPTY SCROTUM

Recognise various conditions

Clinch correct diagnosis

Appropriate investigations

Timely surgical referral

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A PROBLEM ORIENTED APPROACH

OBJECTIVES

CHILD WITH AN EMPTY SCROTUM

UNDESCENDED TESTIS

ECTOPIC TESTIS

RETRACTILE TESTIS

POST-TORSION ATROPHY

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CAUSES

Embryology Of Testicular Descend

Primitive gonad in urogenital ridge turns into testis by gene in short arm of Y chromosome; Early Testis�3 hormones

Testosterone�From Leydig cells CSL regression

Mullerian inhibiting substance from Sertolli cells� Mullerian duct regression

Insulin- like3 hormone �Thickening of caudal gubernaculum� holds testis close to inguinal abdominal wall � Relative descend of testis

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8 to 15 Wks of Gestation- Transabdominal Phase

Embryology Of Testicular Descend

At 25 Wks Processus vaginalis elongates into gubernaculum

Distal end of gubernaculum elongates and reach scrotum between 30- 35 wks

Then testis descend through patent processus vaginalis

Testosterone� GFN� CGRP� Migration of gubernaculum along with testis to scrotum

28 to 35 Wks of Gestation- Inguinoscrotal Phase

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Various Stages Of

Testicular Descend

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Classification Of Cryptorchidism

(Hidden Testis)

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UNDESCENDED TESTIS

ETIOLOGY

Anatomical

Endocrine

Iatrogenic

• Short spermatic

artery

•Retroperitoneal

Adhesion

•Malfunctioning

Gubernaculum

•Narrow inguinal

ring/ canal

• Pituitary

deficiency

•Testosterone

deficiency

•Post Herniotomy

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UNDESCENDED TESTIS

Testicular descend� is arrested in it’s normal path

Rt side�60%; Lt side�30%;Bilateral�10%

Premies�30%; Full term Neonates� 4to5%; 3Month infant�1to2%; 1Yr olds�0.3%

Empty & poorly developed Scrotum

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UNDESCENDED TESTIS

Always associated with patent processus vaginalis� Inguinal Hernia

If testis is palpable in groin do Milking Manuver to R/O Retractile testis

Palpate perineum & upper thigh to R/O Ectopic Testis

If testis is impalpable� needs further workup to localise the testis

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UNDESCENDED TESTIS

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UNDESCENDED TESTIS

Milking Manuver

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UNDESCENDED TESTIS

Complications

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TRAUMA

TORSION

TESTICULAR

MALIGNANCY INFERTILITY

PSYCHOLOGICAL PROBLEMS

UNDESCENDED TESTIS

Postnatal Germ Cell Development

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UNDESCENDED TESTIS

Infertility & Cancer

Scrotum 4*c < than core body temperature� Ideal for spermatogenesis

Transformation of Neonatal gonocyte to type A Spermatogonium is impaired

This transformation occurs at 3to 6 months of age

Dysplastic gonocyte is the cause for malignant transformation in early adulthood & for infertility

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UNDESCENDED TESTIS

Workup

In Bilateral Impalpable Testis: HCG stimulation test to confirm presence of testis

To localise testis the Gold standard is Laparoscopy� Diagnostic & Therapeutic

USG of Groin & Abdomen

CT Scan Groin & Abdomen

MRI of Abdomen

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UNDESCENDED TESTIS

Management

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UNDESCENDED TESTIS

INGUINAL ORCHIDOPEXY

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UNDESCENDED TESTIS

INGUINAL ORCHIDOPEXY

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Algorithm for Impalpable Testis

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UNDESCENDED TESTIS

DIAGNOSTIC LAPAROSCOPY

Vas and Testicular vessels entering the internal inguinal ring

Canalicular UDT

Blind ending Vas and Testicular vessels

Anorchia (Vanishing Testis)

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UNDESCENDED TESTIS

Laparoscopic Fowler Stephens

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UNDESCENDED TESTIS

Laparoscopic Fowler Stephens

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Prentiss Maneuver

UNDESCENDED TESTIS

Complications of Orchidopexy

Damage to Testicular vessels� Testicular Atrophy

Damage to Vas Deferens� Infertility

Retraction of Testis out of Scrotum

Hemorrhage

Wound infection

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ECTOPIC TESTIS

� Testis after coming out of external inguinal ring

has migrated into an abnormal location

� Sites of ectopic testis are

- Superficial inguinal pouch

- Perineum

- Pre penile

- Opposite side scrotum- crossed ectopic

- Femoral triangle

� Diagnosis is obvious & Orchidopexy is easy

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Sites of UDT & Ectopic Testis

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ECTOPIC TESTIS- Perineal

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RETRACTILE TESTIS

Testis can be manipulated into scrotum

Testis is pulled and held high by overactive cremastric muscle

Descends into scrotum whenever child is relaxed/ sleeping

By puberty testis grow in size & remain in scrotum

No intervention is needed

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CHILD WITH AN EMPTY SCROTUM

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CHILD WITH AN EMPTY SCROTUM

TAKE HOME MESSAGE

Child should be operated between 6months to 1year

Undue delay in surgery carries the risk of infertility and malignancy in adult life

Hormone therapy may be tried between 3to 6 months

Retractile testis should not be operated

Intra abdominal testis is best managed with Laparoscopy

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