TESTICULAR PATHOLOGY 1.

Introduction embryological In humans, the gonads only acquire male and female morphological characters in t he seventh week of gestation. From the proliferation of coelomic epithelium and condensation of mesenchyme underlying form folds or genitals, or gonadal ridges. Germ cells appear only in the genital folds after the sixth week and appear bet ween the yolk sac endodermal cells and migrate along the dorsal mesentery, reach ing the primitive gonads, medial to the mesonephros. At the beginning of the fif th week and the sixth, invade the genital folds. It is thus indifferent or bipot ential gonad, in which the coelomic epithelium of the genital fold epithelial ce lls proliferate and penetrate the underlying mesenchyme, forming the primary sex cords. In week seven gonadal differentiation occurs from the effects of HY anti gen, which together with other factors conducive to synthesis of testosterone. I n the 8th week as testosterone and Sertoli cells will produce the Anti-Müllerian factor. From the 2nd month, the testicle descends on the growth of the embryo, because the testicle is attached to the inguinal region, which is more caudal. L ater as the ligament gobernaculum testi, which is fixed to the scrotum, pulling down the testicle. By the 5-7th month, the testicle passes through the inguinal ring, by shortening the gobernaculum testis, so that the 9th month, both testicl es should be within the scrotum. 2. Cryptorchidism It refers to no testicular descent, is the lack of full descent of the testis, e ither unilateral or bilateral, so that the gonad is located outside the scrotum. The term includes any location of the testis along the usual route, both inguin al and abdominal as abnormal or ectopic locations. Virtually includes cryptorchi dism, absence of palpable testis, the inability to descend into the scrotum manu ally, and the situation in which, once decreased by appropriate maneuvers, the testicle becomes to its original positio n outside the scrotum. - Epidemiologically, noted that it is the most common con genital malformation affecting the external genitalia of the man. At the time of birth is found in 3-4% of boys born at term and in more than 30% of premature b abies. In more than 80% of cases the undescended testicle is in the inguinal can al, and only 5% are actual absences. After the first year of life, the proportio n of children with cryptorchidism varies between 0.8-2%. It appears that you hav e a component of familial aggregation. 2 / 3 correspond to criporquídicos unilat eral testes, with 70% in the right side. The bilateral general problems associat ed with genetic, endocrinological ... Retractable Testicle-Classification (lift) , rises from the scrotum by a hyperactive cremaster muscle and because it fails to complete fixing the lower pole of the testis into the scrotum by gobernaculum testis. Usually bilateral. Criporquidia true: it is usually unilateral (and bil ateral associated with malformation syndromes and genetic abnormalities). 20% ar e not palpable (usually abdominal), 80% is in the scrotal area and so high that it is palpable. Everyone has a certain degree of dysgenesis, greater at the high er location ectopic testis, declining by the external inguinal ring, but away fr om the scrotum to his thigh, at the suprapubic or to the perineum. It is as if t he gubernaculum tes that "guide" to the testis and continues to do so badly wron g direction. Obviously, all these problems can cause infertility because the con ditions are not appropriate in the testis (there is a thermal deregulation and w ith undescended testes, have some level of dysgenesis also favored on the other hand the development of testicular tumors) "Exploration is essential to give a name to the syndrome of the empty scrotum. T here are some important general requirements: proper temperature (cold stimulate s the cremasteric reflex), child calm and relaxed (the fear and pain also stimul ate), the physician's hands should be warm, gel or soap in the pads help locate the testicle. We must value and describe: Location and characteristics of the te stis. It will begin exploring the inguinal canal at the top, descending slowly t o the external inguinal ring. In the case of not feeling the exploration test wa

s repeated with a squat and standing Valsalva maneuver, to try to detect intra-a bdominal testes. If palpable,€see how far down manually, the journey continues a nd the characteristics of the testis. If the physical examination detected a tes ticle outside the scrotum, but fail to descend to the bottom of the scrotum and stays there without tension, this is a retractable testicle, if the testicle can only be carried to the top of the scrotum, should be handled as a true cryptorc hidism and inguinal spermatic cord. Sometimes there is an obvious associated ing uinal hernia, which indicates the presence of testes below the internal inguinal ring. But more common is the existence of a peritoneal pouch or a ductus vagina lis without intestinal content, which may manifest clinically as a hernia or a h ydrocele. May be associated abnormalities of the vas deferens and epididymis: el ongated, atretic or completely separated from the testicle. Hemiscroto Developme nt. The retractable testicle is usually well developed, while in the cryptorchid ism often exists a greater or lesser degree of hypoplasia. Cremasteric reflex. I t explores the boy squatting by the rubbing of the inner thigh. Retractile teste s ascend ago, descended again spontaneously in many cases. Penis size and positi on of the meatus. Often the association of bilateral cryptorchidism with hypospa dias, hypoplastic penis or other malformations. General physical examination. To rule out the case of a cryptorchidism symptomat ic of a more complex syndrome (with morbid obesity, impaired growth, mental reta rdation, etc.).. In unilateral cryptorchidism is rare chromosomal alterations as sociated. After physical examination, we come to one of the following conclusion s a) palpable undescended testis, b) unilateral nonpalpable testis, or c) bilate rally nonpalpable testis. In the first case, further studies are needed, and pro ceed to the therapeutic decision it deems appropriate. In the following cases wi ll have to establish the differential diagnosis and anorchia monorquia respectiv ely. We speak of empty scrotum syndrome when notes the absence of testes in the scrotum. After physical examination, we fit the clinical picture in one of the f ollowing situations. "Diagnosis is made by physical examination and laboratory investigations, especi ally in cases where the testes are not palpable. The most commonly used compleme ntary investigations are ultrasound. Useful when the testicle is housed in the i nguinal canal and there are difficulties for identification in this situation th e diagnostic accuracy is very high, reducing intra-abdominal testes. Very few fa lse positives but not false negatives. TAC. Identify small testes, both intra-and extra-abdominal reports on the anatom ical characteristics of the testicle and cord and helps to plan surgery by ident ifying the exact position of intraabdominal testis. It has the disadvantages of reduced reliability in thin patients who need sedation in very young children an d the bowel loops can lead to confusion. Actually this was the only one who said in class. MR. It is more accurate in older children, adolescents and adults. It has the advantage of not radiate. Laparoscopy, laparotomy. If the technique is available, laparoscopy is preferred for the detection of intraabdominal testis, complemented by laparoscopic orchiopexy or orchiectomy as the finder - Treatment : prepubertal patients in which we did not find the testicle in the scrotum, we make a study hormone HCG (human chorionic gonadotropin), FSH and LH. This study serves to stimulate hormonal pituitary (hypothalamic-pituitary-gonadal), if one or both testicles will see significant increases in testosterone levels, if any, the same level will not rise. The hormonal study has a threefold purpose - to a ssess the proper functioning of the hypothalamic-pituitary-gonadal, 2 - to asses s the existence of hidden testicle and 3 - for medical and / or preoperative man agement. It is usually not the final solution the use of hormones in cryptorchid ism, but is useful in the preoperative management. The problem of hormones in ca ses of monorquidia is that there is a precocious virilization (there is a penis in accordance with the biological age ... had a child in the images of four year s and I think the lad sailor cloth). So important, should not be given hormones in children under 1 year. Another thing, it chorionic gonadotropin, is indicated

in the testis and in the so-called retractable lift,€cryptorchidism not for rea l ... Summary of this medical treatment, not given as such in class, I think it interesting, there are more hormonal treatments, but the only thing that was men tioned was HCG Since during the first year of life produces a significant percentage of spontan eous declines, that decline is virtually nonexistent after this age and histolog ical alterations in the germ line are already the second year of life, there is sufficient agreement in that age optimal for treatment is between 12 and 24 months of age. This also avoids the possible psyc hological problems at school age and the testicle is accessible to palpation for early diagnosis of possible malignancies. HCG Hormone Therapy Treatment Treatme nt is based on its stimulating effect Leidyg cell, resulting in a transient incr ease in testosterone levels. There have been highly variable success rates rangi ng from 14 to 99%, depending on the different dosing regimens, treatment interva ls, age at application and, above all, the initial position of the undescended t esticle. The testes of children with bilateral cryptorchidism are more responsiv e than unilateral. There are relapses in 10-20% of cases, requiring repeat treat ment or orquiopexia4. It is unclear the effect of HCG treatment on final testicu lar volume on the testicular histology and fertility. Side effects of treatment with HCG dependent on the dose. At high doses has been observed premature closur e of epiphyses, development of secondary sexual characteristics (pubic hair, enl argement of genitalia, hyperpigmentation of the scrotum), irritability, and chan ges in histology testicular1. Even small doses has been observed enlarged testic le, scrotum and erecciones4 erythema. Most of these effects disappear after disc ontinuation of treatment. There is a side effect but an inconvenient fact of int ramuscular administration, especially when taking into account the age at which it is administered. The correct treatment for cryptorchidism should be performed between 2-4 years a nd never before the first year. Surgical treatment of entry will be shown when t he child is older than 8 years (2-4 depending on the teacher), if there is conco mitant inguinal hernia, if it is suspected intraabdominal testis (whether it has been successfully traced by imaging techniques or not). Finally, when you have not obtained sufficient response to hormonal treatment You must try the descent of the testis into the scrotum and fixing the same (orc hiopexy). The removal of the testicle or orchiectomy is indicated with severe te sticular atrophy, testicular dysgenetic and often at a postpubertal cryptorchidi sm. Therefore, if during surgery is a test morphologically acceptable, it tries to descend to the scrotum. Otherwise, orchiectomy is done and place a vulcanized silicone prosthesis (immediate or deferred until it is completed pubertal devel opment). It is recommended transescrotal contralateral testicular fixation. If t he testicle is not also place a prosthesis. Is not justified preventive orchiect omy in childhood. Surgical technique The surgical technique aimed at transferrin g the testis into the scrotum is called orchiopexy. Usually under general anesth esia, the incision is made in the groin exposing the testis, its annexes and the spermatic cord. This allows the inspection and check for abnormalities that cou ld indicate orchiectomy. Sometimes there is an accompanying hernia sac, which mu st be reintroduced into the peritoneal cavity. Then proceed to the "Funiculolysi s" (release of the spermatic cord), resulting in increased mobility and getting sufficient length to bring the testicle to the inside of the scrotum. After prac ticing a subcutaneous tunnel, through which the testicle and cord are taken to t he scrotal cavity, fixing the testicle to the scrotal wall. The success rate is approximately 70%. 3. Germ cell tumors The percentage of testicular tumors in those individuals in their testicles have not been externalized, is 25% higher than the general population. The later age is more atrophic. That will have to be removed testicle, the risk of malignancy

, is useless, even as stated in class could "tease" the other that would be fine . Especially if you are older than 20 years and the testicle is in the area in traabdominal surgery. 95% of tumors are germ derived from primordial germ cells. €Seminoma is the most common germ cell tumor and less malignant, each of the four basic types, seminoma, embryonal carcinoma, ter atoma and choriocarcinoma may have varieties and occur in various combinations w ith different types. Is there any other kind that nothing was said as yolk sac t umor, cell-syncytiotrophoblasts ... staging of tumors I. II. III. IV. There is n o evidence that is out of the testis infradiaphragmatic IIa lymph node) node <2c m IIb) 25cm and IIc lymph) node> 5cm above and infradiaphragmatic lymph node met astases Then as we did last year, I will put tumors that are named in class but not expl ain a lot ... and that was very quick and just explain anything. Seminoma: corre sponds to half of all testicular germ cell tumors, germ cell tumor is the most c ommon and least malignant. There are three degrees of differentiation: well diff erentiated type 1 (10%), moderately differentiated or type II, more frequently ( 60%) and poorly differentiated type III or atypical seminoma (28%). It is highly radiosensitive and chemosensitive. Survival at 5 years is very high, for type I 100%, 95% for group II and 90% for III. Up to 40% of pure seminomas may have re gional lymph node metastases at the time of consultation. In just over 20% is a rise in the blood of the beta subunit of human chorionic gonadotropin, which can be very useful and important to monitor patients and to evaluate the therapeuti c outcome. Embryonal carcinoma: corresponds to 25% of testicular germ cell tumor s. The tumor is composed of epithelial and mesenchymal elements immature embryo. Any of these components may predominate in a given tumor. 75% of embryonal carc inomas produce alpha-feto-protein (not found in either pure seminoma or chorioca rcinoma. 80% betaHCG also occur. Approximately 60% of these carcinomas presented regional lymph node metastases at the time of diagnosis. it will give us ultrasound almost always. If there were no metastases, surgery would be done thr ough the groin, through an incision in this region as a high stand, clamping the spermatic cord lymphatic spread the risk and / or hematogenous. Teratoma: 8% of the tumors derived from germ cells. It consists of components derived from all three germ layers, endoderm, mesoderm and ectodermo.Puede be composed of mature tissues and differentiated (mature teratomas) or in a more embryonic or less dif ferentiated (immature teratoma). They are producers of alpha-fetoprotein and bHC G in 40 and 25% of cases respectively. The prognosis is good if it is a mature t eratoma, malignant variety is highly malignant teratocarcinoma like the followin g that we describe, choriocarcinoma. Choriocarcinoma: it is rare, representing o nly 2% of the tumors derived from germ cells. It is small and bleeding, consisti ng of two components of the trophoblast. It has a large bHCG producing activity. Metastases occur very rapidly through the blood reaching the lungs, where it sp reads from them for the rest of the body. Testicular tumor is the worst prognosi s, with a mortality of 100% at 5 years. Combined forms: among these forms, it is often the combination of teratoma with embryonal carcinoma. Summary of germ cel l tumors: often mixed, which are among young people (20-30 years). 95-99% cure b ecause they respond very well to radio and chemotherapy. Seminoma is half of ger m cell tumors of the testis, is the most common and least malignant. The markers that many of these tumors produce germ allow us to assess the existence of resi dual tumors after surgery and / or tumor metastases. The hematogenous route is m ost used for dissemination, except seminoma which mainly uses the lymphatic path way. The supraclavicular lymph node affected is a sign of malignancy, which is v ery important exploration. ----------------------------- Embryonal carcinoma Yolk sac tumor Choriocarcinoma Teratoma Seminoma Alfa-feto-protein

betaHCG + + + + + Gonadal stromal tumors are very rare, with a frequency of about 3% of testicular germ cell tumors are usually silent and asymptomatic. Discover what is normal b y palpation, noticing a hard mass, painless attached to the testicle (as a bean or pea was said in class.) ECO gives almost always the diagnosis.€It is useful t o analyze these markers that we have been quoting. The TAC will be critical to a ssess the presence of metastases. -Surgical treatment. Orchiectomy involves the partial or total removal of the testis, total will be removed if the epididymis and testicular cord part if part will be removed only functional part of the tes ticle, leaving the remaining structures (subcapsular orchiectomy) is indicated i n those processes interested in which cause a decrease in testosterone levels in blood, as in prostate carcinomas. This operation is performed on both testes, r egional anesthesia, local or complete, the incision is made in the scrotal skin. The total is indicated for tumors, infections that destroyed the testis and in cases of testicular atrophy. Will be reflected under local anesthesia, regional or total but will be at the groin incision. In the case of germ cell tumors, as I said also before, we will make an incision in the groin area for a radical orc hiectomy. Binds the spermatic cord and testicular contents emptied. The postoper ative period is usually short of 1 to 3 days and can then follow one outpatient. Then one is usually placed testicular prosthesis. Secondary testicular tumors: metastasis through hematogenous route, usually do well if it is the primary tumo r. Those who said in class are testicular lymphoma (adult), lymphoblastic leukem ia (children, which is treated with chemotherapy) and myeloma (adults). Testicular torsion got here .... I'm remembering the poor Albelda. Well I'll put what little they said in class. The happy torsion usually occurs in puberty mor e often than 14-20 years. One is quiet and suddenly held a shooting pain with a swollen testicle. The testicle has turned on its axis, cutting off blood flow. T he rotation can be 90 º, 180 º or 360 º. Most were small twists that can be remo ved without too many problems in emergencies, if you are more than eight hours w ith this twist appears ischemia leading to atrophy. If the torque does not disap pear in a few hours, the testicle may atrophy, fill with blood and must be surgi cally removed from the scrotum. Thus we see that it is a urological emergency, o ne of the few that there was said. We need to open the scrotum and detorsion man ually. The picture is diagnosed by the clinic, by palpation (attached testicle, but not take it, he elevates the pain never stops) and a box confirming ECO. The n they will see it as hot water and gradually acquires its natural color. 4. Varicocele - Introduction It is a dilation pampiniform plexus above the testicle, the more frequent on the left side and secondary valvular incompetence of the spermatic v ein in question. Appears with a frequency of 10% in young men, with up to 25% in patients consulting for infertility. It occurs when valves in the veins along t he spermatic cord do not function properly, preventing normal blood flow and cau se blood to be retained, leading to expansion or enlargement of the veins, usual ly congenital. Generally develop slowly and may be asymptomatic. The sudden appe arance in an elderly person may be the result of a renal tumor that has affected the renal vein and altered blood flow through the spermatic vein. From the anat omical point of view to remember that, the left vein drains into the renal vein (here produce 99% of varicoceles) and right vein drains into the vena cava (less chance of varicoceles because of the larger diameter and flow vena cava). - Clinic clinic not usually given unless very large, giving a slight discomfort. What occurs if visible, enlarged, twisted veins in the scrotum may cause infert

ility as we said. - Diagnosis can be made to the naked eye with the patient stan ding if the varicocele is large, if not, are performed Valsalva maneuvers to mak e that clear. Used manual palpation in both supine bidepestación. The Doppler ul trasound of the spermatic cord is also necessary and is very useful and importan t for definitive diagnosis and to the objectification and staging of it. Varicoc eles in the right side, we have to make differential diagnosis with other pathol ogies, especially since we know that tumors in the right side is very rare. - Th e clinical grade down are: Grade 0: subclinical€asymptomatic and not on the ex ploration Grade 1: bidepestación shown in the Valsalva maneuver, here are smal l veins Grade 2: palpable dilated plexus bidepestación pampiniform without man euvers and efforts Grade 3: be seen to scrotal mass naked eye while standing a nd without tenderness. - Treatment (commission last year) is used in open surger y (ligation of the spermatic veins) or transfemoral percutaneous sclerosis using occlusive catheters or sclerosing agents. The treatment is preventive, to avoid potential testicular involvement, infertility and pain. No one knows the reason s why the germinal epithelium is affected in varicocele, although it is believed that deregulation strongly influences heat a nd hypoxia, the accumulation of toxic metabolites ... Varicoceles can be managed with the use of a scrotal support. However, if pain continues or causes inferti lity or testicular atrophy may be needed further treatment, which may include su rgical removal, laparoscopic removal and catheter embolization. Both open and la paroscopic varicocelectomy was performed on an outpatient basis. The incision is usually above the inguinal ring. Binds cremasteric vein above the ring so that the circulation of venous return venous networks will explore why the drain, the y should keep ice packs in the area during the first 24 hours after surgery to r educe swelling. Catheter ablation is also performed as an outpatient procedure i s done with a small incision in the inguinal fold. Ice and is recommended to wea r a scrotal support for some time after surgery. Possible complications of this operation are: hematoma, infection or tissue damage or structure of the scrotum. In addition, there may be injury to the artery supplying the testis. Surgery is indicated in those young boys with a varicocele postpubertal manifest, to avoid problems of fertilization, in adults with children do not usually operate unles s disturbed. 5. Orchitis Orchitis is inflammation of the testicle. The most common cause of orchitis is m umps, mostly in adults Orchitis may also occur after a prostate infection or epi didymitis. Many less common diseases may have a orchitis among its manifestation s. If it affects the parenchyma, germs in the blood will complicated the process . Signs and symptoms are: • • • • Pain in the scrotum. Swelling, usually on only one side of the scrotum. Feeling of heaviness in the scrotum. Fever 40 º Carefully palpate the scrotum inflamed. Because the symptoms of orchitis are sim ilar to the immune and other diseases that affect the testicles, your urine will be analyzed and perform other tests to identify possible associated infection. One problem is that is associated with an abscess Orchitis may damage one or bot h testicles, cause infertility and reduce the size of the organ. Treatment, orch itis associated with infection is treated with an antibiotic, to improve symptom s 2-3 days, even after 10 days the inflammation may have almost disappeared. For orchitis associated with viral infection (most serious and important), such as mumps, only prescribed conservative treatments such as rest and pain medication. 6. Hydrocele -Introduction is a fluid-filled sac located along the spermatic cord within the scrotum. This increased fluid appears as a testicular swelling of variable size. "Causes are common in newborn babies and fluid accumulation may occur in one or

both sides of the scrotum. During normal development, the testicles descend dow n a tract from the abdomen into the scrotum. Hydroceles result when this tube fa ils to close or tract and the liquid drains from the abdomen through the open tu be. The fluid accumulates in the scrotum, where it becomes trapped which increas es in size. Usually resolve a few months after birth, can sometimes be associate d with an inguinal hernia. You can easily display these hydrocele by shining a f lashlight through the enlarged portion of the scrotum, to be filled with clear f luid, the scrotum will light by transillumination, whereas the inguinal hernia w ould give an image of a heterogeneous appearance due to different densities of t he herniated material. Hydroceles may have another cause,€that appears in all ages and is by inflammati on or trauma of the testicle or epididymis, or by fluid or blood blockage within the spermatic cord. This type is more common in older men. -Clinic The main sym ptom is a painless testicular swelling in one or both sides. During a physical e xam, the doctor an enlarged scrotum that is not normally sensitive. Often, the t esticle can not be felt because of the surrounding fluid. The size of fluid-fill ed sack can sometimes be increased or decreased by pressure to the abdomen or sc rotum. If the size of the fluid collection varies, it is more likely to be assoc iated with an inguinal hernia. "Diagnosis is made by clinical examination, trans illumination, the echo-Doppler ultrasound and, if necessary. The most common dif ferential diagnosis is with inguinal hernias, we use transillumination and ultra sound - Treatment of) Medical Usually, a simple hydrocele goes away without interventi on by the doctor. Where surgery is necessary, the results are generally excellen t. Normally, hydroceles are not dangerous and only treated when they cause the p atient discomfort, he might be embarrassed or they reach a considerable size to threaten the testicle's blood supply. One option is to remove the fluid in the s crotum with a needle (aspiration is done), what happens is that you can cause an infection with this method is common above the liquid building up again. Theref ore, aspiration is not a routine procedure and surgery is usually preferred. Yes aspiration to be used when the patient, this surgical risks. If it is ultimatel y done with the needle puncture, we inject sclerosing medications such as tetracycline, sodium tetradecyl sulfate or urea, to close the opening made through the scrotum and thus help prevent re -accumulation of fluid. Possible complications after this procedure are mainly, fibrosis, infection, pain in the scrotal area and recurrence of hydrocele b) Sur gical = hydrocelectomy is a minor surgical procedure performed on an outpatient basis under general or spinal anesthesia. An incision in the scrotum or lower ab domen. May be required a scrotal drainage tube and bulky dressing on the scrotal area. We recommend applying ice packs to the affected area for at least 24 hour s after surgery and using a scrotal. The possible complications that will appear include the formation of a blood clot or hematoma, infection, injury to the scr otal tissue or structures. Finally almost two main points. 1. Hydrocele associat ed with inguinal hernia should be repaired surgically as quickly as possible 2. Hydroceles that do not resolve spontaneously over a period of months should be a ssessed to perform Another possible surgery pathology just mentioned, which are sebaceous cysts of the scrotum, the testicles usually appear as multiple cysts a nd have a yellowish appearance. Without much room for a multiple dedication last year as I say goodbye for this year of the commissions. I hope my work has been helpful and beneficial. With th is intention I have dedicated much of my time on these classes that sometimes th ere is no where to pluck them, so thank all the other brokers do the task. Good chi @ s another year ... it is already running out in the end I will miss you an d everything haha. Ale, q year we are coming. A hug to everyone. Good night and good luck ☺ Julián Barceló Martínez