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Case Presentation

Case Presentation. Basic Information. Name: xx Chart No.: xx Gender: Male Birth date: 2012-07-09. Chief Complaint. No testis found since birth. Present Illness. He received hormone injection therapy once in ~~hospital at 4~5 m/o but no improvement. Physical Examination.

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Case Presentation

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  1. Case Presentation

  2. Basic Information • Name: xx • Chart No.: xx • Gender: Male • Birth date: 2012-07-09

  3. Chief Complaint • No testis found since birth.

  4. Present Illness • He received hormone injection therapy once in ~~hospital at 4~5 m/o but no improvement.

  5. Physical Examination • Left inguinal area: testis<1cm, • Right inguinal area: no testis palpable • Flat scrotum

  6. What’s your diagnosis? • Bilateral Cryptorchidism

  7. Cryptorchidism - - What Is It? • An undescended testicle, also called cryptorchidism, is one or both testicles that have not moved down into the scrotum.

  8. Early in pregnancy, the testicles begin developing deep within the abdomen. At 32 to 36 weeks' gestation, the testicles begin to descend into the scrotum. • In 30% of premature and approximately 3% of full-term male infants, one or both of the testicles have not completed their descent at the time of birth. • Most of these will then descend spontaneously during the first three to six months of life. By 6 months of age, less than 1% of babies still have the problem.

  9. The types are classified on whether the testis is located in the normal descent pathway (true) or in an abnormal location (ectopic) and then by the anatomical position of the testis. A, Ectopic testes. The testis fails to descend into the scrotum & is deviated from its normal path of descent. B, Undescended testes. Percentages of testes arrested at different stages of normal descent

  10. An undescended testis may be found in the abdomen, in the inguinal canal, or high in the scrotum. Percent figures indicate the proportion of cases at each location. Thomas H. McConnell, The Nature Of Disease Pathology for the Health Professions, Philadelphia: Lippincott Williams & Wilkins, 2007

  11. Undescended testis – Symptoms and Signs • Symptoms : Underdeveloped scrotum; Indirect inguinal hernia • Signs: Empty scrotum • There is usually only one sign that a boy has an undescended testicle. The scrotum appears underdeveloped or smaller. • In rare cases, the undescended testicle can become twisted (testicular torsion), causing severe groin pain. If this happens, seek medical attention immediately.

  12. Importance of scrotal descent • Undescended testes leads to an increased incidence in testicular cancer. • 15-fold increase in unilateral crytporchidism • 30-fold increase in bilateral cryptorchidism • Descent is essential for normal fertility as spermatogenesis can be greatly affected.

  13. Undescended testis: management • Watchful waiting • Hormone therapy • Surgical treatment: • Orchidopexy • Orchidectomy • Laparoscopic surgery • Therefore, surgery remains the gold standard for the management of undescended testes.

  14. Standard Orchiopexy. • The key steps in this procedure are --- • complete mobilization of the testis and spermatic cord, (2) repair of the patent processus vaginalis by high ligation of the hernia sac, (3) skeletonization of the spermatic cord without sacrificing vascular integrity to achieve tension-free placement of the testis, (4) creation of a superficial pouch within the hemiscrotum to receive the testis.

  15. A transverse skin incision is made in an inguinal skin crease

  16. A,The external ring is opened. B, Cremasteric fibers are dissected from the cord

  17. A, High ligation of the processus vaginalis at the internal inguinal ring. B, The ligated processus and the cord structures

  18. Separation of the internal spermatic fascia from the cord structures after ligation of the processus vaginalis

  19. Formation of a dartos pouch

  20. A, Formation of a passage to the scrotum. B and C, Passage of the testis into the scrotal pouch

  21. Complications of Orchiopexy • Testicular retraction, • Hematoma formation, • Ilioinguinal nerve injury, • Postoperative torsion (either iatrogenic or spontaneous), • Damage to the vas deferens, • Testicular atrophy

  22. Quiz • The appropriate age of orchiopexy for undescended testis in a medical center is: a) 6 months to 1 year b) 1 year to 2 years c) 3 - 4 years d) 5 - 6 years

  23. The appropriate method of diagnostic procedure after failure of finding a testis in PE for a patient alleged to have cryptorchidism: a) ultrasound b) CT c) laparotomy d) laparoscopic examination

  24. The indications of orchiopexy include: a) concomitant inguinal hernia b) prevention of testicular malignacy c) avoidance of testicular torsion d) all of above

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