Inguino scrotal swelling neo

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Inguino scrotal swelling

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  • 1. Inguino-Scrotal Lumps Marty Smith Saturday 30th July 2010 Western Hospital

2. Inguino-Scrotal Lumps Why? Because theyre common. Because theyre really common. Because the anatomy is fun to quiz people on. Because theyre common. Account for up to 20% of General surgical referrals. 3. Pathologies Inguinal Sebaceous Cysts/Lipomas Inguinal Lymphadenopathy Saphenous Varix Femoral Artery aneurysm Psoas Abscess Undescended testes. Inguinal Hernia Femoral Hernia Scrotal Testicular tumor Epididymal cyst Spermatocoele Hydatid of Morgagni Varicocoele Hydrocoele Inguino-scrotal Hernia 4. Assessment-History Lump When was it first noticed? How was it noticed? Precipitant activity Recent illnesses What symptoms are present? ?pain, functional impairment GI/GU disturbance. Systemic symptoms-fevers, night sweats etc. Is the lump changing? Does the lump come and go How or when? 5. Assessment-Exam Lump Position, Shape and size Surface Skin Mass surface Temperature Tenderness Composition-Solid/Fluid/Gas Consistency Fluctuation/Fluid thrills/Resonance Translucency Pulsatility Reducibility/Cough impulse Relations to surrounding structures Regional Lymph nodes 6. Assessment-Exam Both sides Hernia Tests Standing and lying ?Get above it Cough Impulse Reducibility and control Associated structures Pulses, testes, Lymph nodes. Special tests Transillumination 7. Assessment Investigation Occasional use only Ultrasound/duplex For early hernias-not so reliable. Useful for testes/vascular assessment CT More for assessing deeper anatomy Herniagram Laparoscopy 8. Assessment How Not to Kill people, Dont miss tumors Exclude Malignancy Lymphadenopathy-Generalized, unexplained or persistent BIOPSY! Discrete Scrotal Lumps or unexaminable testes Ultrasound and/or Refer No Part time Vascular Surgery 9. Anatomy Inguinal region Inguinal Canal Spermatic Cord Femoral Canal and Ring Scrotum/testes 10. Anatomy Inguinal region Includes Lower abdominal wall Femoral Triangle Sartorius/Add Longus/ Inguinal Lig Contains Femoral Pedicle Lymph Nodes Skin/fat/muscle 11. Anatomy Inguinal Canal An oblique series of defects in the layers of the abdominal wall. Site of Inguinal Herniae Transmits the Spermatic cord/Round ligament. Round ligament Runs from Uterine fundus via canal to Labia. 12. Anatomy Inguinal Canal Floor Inguinal Ligament and Lacunar ligament Roof Arching fibres of Int Obl & Trans abdominis and Conjoint tendon Anterior Wall External Oblique aponeurosis Superficial Ring Post Wall Conjoint tendon medially, Transversalis fascia laterally Deep ring 13. Anatomy Femoral Canal Beneath the inguinal ligament Iliacus muscle Femoral Nerve Femoral Sheath containing Femoral vessels Femoral Canal Femoral Canal Space for venous expansion Lymphatics. Upper end defined by femoral ring. 14. Anatomy Femoral Canal Beneath the inguinal ligament Iliacus muscle Femoral Nerve Femoral Sheath containing Femoral vessels Femoral Canal Femoral Canal Space for venous expansion Lymphatics. Upper end defined by femoral ring. Femoral Ring Site of Femoral Herniae 15. Anatomy Eponyms Hesselbachs Triangle Lateral border of rectus muscle Inguinal Ligament Inferior epigastric vessels (med border of deep ring) Fruchauds Myopectineal Orofice Hesselbachs triangle Deep ring Femoral sheath/canal. 16. Anatomy Spermatic cord Pedicle of the testes Made up of 12 things 17. Anatomy Spermatic cord Pedicle of the testes Made up of 12 things Youre not getting away with that! 18. Anatomy 3 Arteries 3 Nerves 3 Important structures 3 Coverings 19. Anatomy 3 Arteries Testicular Artery to the Vas Deferens Cremasteric 3 Nerves Sympathetic branches Ilio-inguinal (on cord) Genital Br of Genito-femoral nerve. 3 Important structures Vas Deferens Pampiniform Plexus Processus Vaginalis 3 Coverings External Spermatic Fascia Cremasteric Muscle Internal Spermatic Fascia 20. Anatomy Spermatic cord Only truly forms at the superficial ring. Passes through the superficial ring above and medial to the pubic tubercle. Descends through S/C fat into the scrotum. 21. Anatomy Testes Suspended on spermatic cord, Enveloped within Tunica vaginalis Drain via epididymis to Vas Deferens Made up of Germinal elements-Seminiferous tubules Non-Germinal elements-Stroma, Leydig cells 22. Pathologies Inguinal Sebaceous Cysts/Lipomas Inguinal Lymphadenopathy Saphenous Varix Femoral Artery aneurysm Psoas Abscess Undescended testes Inguinal Hernia Femoral Hernia Scrotal Testicular tumor Epididymal cyst Spermatocoele Hydatid of Morgagni Varicocoele Hydrocoele Inguino-scrotal Hernia 23. Skin stuff Sebaceous cysts Retention cysts of sebaceous glands Fixed to skin-dimple if squeezed Can become infected-abscess. Incise and drain Management excise when non-inflammed. 24. Skin stuff Lipomas Benign Fatty lumps Clinically fixed (skin and fat) soft lumps, usually longstanding and asymptomatic. Management excise surgically 25. Inguinal Lymphadenopathy Causes Primary Lymphatic disease-Lymphoma Secondary Lymphadenopathy Malignant disease Benign Physiological reaction to inflammatory state Management Exclude Inflammatory causes Examine, Observe, Antibiotics etc. Exclude obvious malignancy Biopsy-FNA/Open 26. Saphenous Varix Prominent Varicosity of Upper Long Saphenous Vein. Typical Patient Middle aged and older F>M Usual Risk Factors Pregnancy, Pelvic Mass Clinically Dragging lump over upper thigh, disappears when lying Cough impulse + Thrill down vein when percussing. Management-surgical ligation. 27. Femoral Artery Aneurysm. True aneurysms Pulsatile lump in groin Associated with other aneurysmal disease Mx-Vascular surgical repair if >2-3cm False aneurysm Secondary to puncture Dx on duplex Mx-Call a vascular surgeon- thrombose or repair. 28. Psoas Abscess Abscess within Psoas fascia that tracks to groin and presents as a lump. Associated with Retroperitoneal infection/inflammation Post Surgical eg. Nephrectomy Colonic Pancreatitis Spinal TB Management Drain and treat underlying cause 29. Undescended Testes Rare in adults Usually Dx and treated as children In adults usually present as infertility Alt painless lump in Inguinal canal Prone to infertility and testicular cancer. Managemant Refer to Urologist. 30. Scrotal Lumps Assessment Hx/Ex as previous If not obvious Hernia/Varicocoele/ Hydrocoele and normal testes Ultrasound Lump origin Solid vs cystic etc. If still in doubt-Call a Urologist. Surgical exploration 31. Scrotal Lumps Solid lumps. Testicular origin mostly malignant Paratesticular origin mostly benign Cystadenoma, Adenomatoid tumor (epididymis) Inflammatory pseudotumor Cystic lumps Usually benign Epididymal cyst, Spermatocoele, Hydatid of Morgagni 32. Testicular Lumps Testicular tumors Usually painless lumps in 2nd to 4th decades Germinal-95% Seminoma/Embryonal Cell/ChorioCa/Teratoma Non-Germinal Stromal-Leydig Cell Tumor; Gonadoblastoma Management Call a Urologist Usually multimodal Therapy 33. Hydrocoele Collections of fluid in Tunica Vaginalis Typically >40yrs except infantile. Classes Congenital-communicating Reactive-tumor/trauma/infection Idiopathic. Clinically Usually dragging scrotal mass, Can get above them, fluctuant, transilluminate well Must exclude malignancy Clinically normal testes or ultrasound Treatment Aspirate-tend to recur Surgery-Jaboulet procedure. 34. Hydrocoele 35. Varicocoele Dilatation of the Pampiniform Plexus Usually affects 20 to 50 yos L>R due to venous anatomy. Acute varicocoele-exclude RP infiltration May cause infertility Painless lump Bag of worms Cough impulse +ve May reduce on lying down Treatment Ligation at deep ring or excision. 36. Other Scrotal Lumps Epididymal cyst Cyst arising from epididymis Spermatocoele Sperm filled cyst arising from the testes. Hydatid of Morgagni Small mobile cyst from top of testes Embryological remnant of Mullerian duct. Subject to torsion Management Exclude testicular Mass-Ultrasound Surgery if large/symptomatic. 37. Hernias 38. Inguinal herniae Hernia Numbers 25% of males (2% F) will develop a groin hernia 65% Indirect Inguinal herniae 55% on the right 31% Direct Inguinal Herniae Although represent 80% of bilateral herniae 4% Femoral Herniae More common in women 20 % of all groin herniae c/w 2% male. Causes Congenital Chronic Stress to area Metabolic-Collagen-vasc Ds, Smoking 39. Hernia types Inguinal Direct Indirect Pantaloon Femoral Also Sliding herniae 40. Sliding Hernia A Hernia in which the peritoneal wall that forms part of the sac has an organ naturally adherent to it. Eg. If an extraperitoneal organ (usually Bladder or colon) slides out with its adherent peritoneum through the hernia defect the organ itself becomes part of the wall of the sac. Must look out for this at the time of surgery because the organ is easily injured upon opening the sac. Can be direct or indirect. Sliding hernia Non sliding hernia 41. Inguinal herniae Clinically Groin pain/discomfort Dragging, worse during the day Lump Asymmetry-inguino-scrotal swelling GI/GU obstruction Incarceration/Irreducibility 42. Hernia examination 43. Direct vs indirect Direct Diffuse bulge Rarely into scrotum Controlled only at superficial ring Indirect Usually more defined May extend into scrotum Herniation/reduction more prominent Controlled at deep ring. 44. Femoral vs inguinal Inguinal Lie in/above groin crease Appear above and medial to pubic tubercle. Extend into scrotum Femoral Lie below crease Appear below and lateral to tubercle Extend into