Empty scrotum

Supervised by Dr.Saber M. Waheeb

Definition

Cryptochidism is the absence of one or both testes from the scrotum

Normal fetal testicular development and descent

The testes begin as an immigration of primordial germ cells into testicular cords along the genital ridge in the abdomen of the early embryo .

 The testes remain high in the abdomen until the 7th month of gestation, when they move from the abdomen through the inguinal canals into the two sides of the scrotum. It has been proposed that movement occurs in two phases, under control of somewhat different factors

 The first phase movement across the abdomen to the entrance of the inguinal canal appears controlled (or at least greatly influenced) by anti-mllerian hormone (AMH.)

 The second phase, in which the testes move through the inguinal canal into the scrotum, is dependent on androgens ( most importantly testosterone .)

 In many infants with inguinal testes, further descent of the testes into the scrotum occurs in the first 6 months of life. This is attributed to the postnatal surge of gonadotropins and testosterone that normally occurs between the first and fourth months of life.

 The tissue in undescended testes becomes more markedly abnormal ("degenerates") in microscopic appearance between 2 and 4 years after birth . There is some evidence that early orchiopexy reduces this degeneration.

Epidemiology
The most common congenital anomaly of the male genitalia. There is a higher incidence in premature babies (up to .)30% It affects almost 1% of all full-term male infants at the age of 1 year. Unilateral cryptorchidism is four times more likely than bilateral

1* Prematurity 2* Low birth weight 3* environmental chemical

4* Environmental risk factors 5* Familial 6* Genetic 7* Iatrogenic

Causes:

1-Arrested testis:

1-abdominal : *lumber fossa *iliac fossa 2-extraabdominal : *inguinal canal (commonest) *near pubic tubercle

2-ectopic testis:

LOCKWOOD theory

Sites of ectopic testis: *superficial inguinal pouch( commonest ) *femoral *penile *perineal

3-asending testis:

4-Atrophied testis:

*history of normal descend . *unilateral hidden impalpable testis. *contra lateral oversized testis *equal well developed scroutum halves.

5-testicular agenesis :

rare

6-Associated with other abnormalities:

Prune belly syndrome

* HISTORY

Physical examination

* Examination should take place while the child

is supine and in a cross-legged position, and cover the following steps:

* Imaging

or ultrasound ..

* Abdominal and pelvic ultrasonography may be required if intersexuality is suspected. * US and CT scan are much less accurate in showing intra-abdominal testes.and..does not add any benefit to differentiating between palpable and non-palpable testes.

* Diagnostic laparoscopy :
is the only way to confirm or rule out an intra-abdominal, inguinal or absent/vanishing testis (non-palpable testis). *A

karyotype

can confirm or exclude forms of dysgenetic primary hypogonadism,

such as Klinefelter syndrome or mixed gonadal dysgenesis. .*.Hormone

levels {human chorionic gonadotropin}

The main goals of hormonal or surgical treatment are : 1- to allow for a normal anatomic position of the testicle 2- the preservation of fertility 3- hormonal production and the diagnosis of potential testicular malignancies. 4- correction of associated hernias 5- prevention of testicular torsion. Orchiopexy should be considered after 4 months of life, as the rate of descent diminishes considerably after this point.

In patients who are not candidates for surgical intervention. hCG or LH-releasing hormones (LHRH) are mainly used.

The approach chosen is determined by the position of the testis and the surgeon's expertise. The palpable testis can be approached from a scrotal, sub-inguinal, inguinal, or supra-inguinal approach. The non-palpable testis can be approached using an inguinal, supra-inguinal, or laparoscopic approach.

1. Look for the testis 2. Divide all attachments, including the gubernaculum, the cremasteric fibers, and the lateral spermatic fascia. 3. Identify the patent processus vaginalis and separate it from the cord structures, and perform a high ligation; be careful not to trap the vas or vessels. 4. Place the testis in a subdartos pouch.

1. Look for the testis 2. Divide all attachments, including the gubernaculum, the cremasteric fibers, and the lateral spermatic fascia. 3. Identify the patent processus vaginalis and separate it from the cord structures, and perform a high ligation; be careful not to trap the vas or vessels. 4. Place the testis in a subdartos pouch.

Diagnostic laparoscopy versus inguinal exploration.

The Fowler-Stephens principle involves dividing the testicular vessels to allow the blood supply to the vas deferens to keep the undescended testis viable. The testicular vessels should be divided away from the testis. Testicular auto-transplantation can be performed by transecting the testicular vessels and by performing a micro-vascular anastomosis to the inferior epigastric vessels

An undescended testicle isn't in a cooler environment. This might increase the risk of complications later in life. These complications include:

Fertility problems

Testicular cancer

Other complications related to the abnormal location of the undescended testicle include:

1. Trauma

If a testicle is located in the groin, it may be damaged from pressure against the pubic bone.

2. Inguinal hernia

Inguinal hernia

3. Testicular torsion