Methodological Instructions to Lesson 17 for Students
Theme: Acute diseases of scrotum organs.
Aim: To study symptoms, signs, principals of treatment of the patients with acute diseases
of scrotum.
Professional Motivation:
As to B. S. Hetman, 78 % of the patients with acute diseases of scrotum organs are young
men at the age from 20 to 25. It is known that in some cases acute epididimitis is complicated by
orchitis that can lead a man to infertility
Basic Level:
1. Anatomy and physiology of scrotum organs.
2. Laboratory and physical methods of examination, diaphanoscopy in diagnosis of
scrotum diseases.
3. Conservative measures of etiologic, pathogenetic and symptomatic treatment
physiotherapeutic and surgical therapy.
Students' Independent Study Program.
I. Objectives for Students' Independent Studies.
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. Etiology and pathogenesis of acute epididimitis and acute orchitis. There are 3 common
causes of epididimitis: 1) preexisting prostatitis, or prostatic infection introduced by an internal
or indwelling urethral catheter; 2) prostatectomy, particularly the transurethral type, where the
ejaculatoty ducts are laid open in prostatic fossa; the hyarostatic pressure with voiding or with
physical strain may force urine (which may contain bacteria for 8-12 weeks after the operation)
dawn the was; 3) reflux of sterile urine down the vas deferens will lead to a chemical
epididymitis. In its early stages, epididymitis a cellular inflammation, it starts in the vas deferens
and descends to the lower pole of the epididymis; in the acute stage epididymitis is swaollen and
indurated, the infection spreads from the lower to the upper pole. Microscopically changes grade
from edema and infiltration with leucocytes, plasma cells, and lymphocytes to actual abscess
formation. The testis may become inflamed from; a hematogenous source. Orchitis may occur
with any infectious disease (coxsackievirus infection, dengue). Patients with mumps parotitis
excrete the virus in the urine. Therefore, it would appear that a complicating mumps epididymoorchitis may also be a descending infection. The edema which develops probably leads to death
of the spermatogenic cells from ischerraia. Primary infection of an epididymis may involve its
testis by direct extension. Grossly, in nonspecific orchitis, the testis are much enlarged,
congected and tense. On section, small abscesses may be noted. Microscopically, there is edema
of the connective tissue with diffuse neutrophilic infiltration. The seminiferous tubules also show
involvement; necrosis is present In the healed stage, the seminiferous tubules are embedded in
fibrous tissue. Histologic study shows considerable atrophy. The interstitial cells are usually
present. Mumps is the most common cases of inflammation of the testis, which occurs only after
puberty. It is usually unilateral but may be bilateral. On section because of the interstitial
reaction and edema, the tubules do not extrude. Microscopically, edema and dilatation of blood
vessels are noted.
Neutrophils, lymphocytes, and macrophages are abundant. Tubular cells show varying
degrees of degeneration. In the healed stage, the testis are small and flabby. Microscopic study in
this instance shows marked tubular atrophy, although the Leudig cells are usually normal in
appearance. The epididymis usually shows similar changes.
2. General clinical symptoms,acute diseases of scrotum organs.
Epididymitis often follows severe physical strain such as lifting a heavy object. It may
develop after considerable sexual excitement. Pain develops rather suddenly in the scrotum, it
may radiate along the spermatic cord and even reach the flank; the pain is generally quite severe
and the epididymis exquisitely sensitive. Swelling is rapid and may cause the organ to become
twice the of normal in the course of 3 or 4 hours. The temperature may reach 40°C. Urethral
discharge may be noted. Symptoms of cystitis with cloudy urine may accompony the painful
swelling. Clinical symptoms of acute orchitis: onset is sudden, with pain and swelling of the
testicle. The scrotum becomes reddened and edematous. There are no urinary symptoms, as are
often seen with epididymitis. Fever may reach 40°C, and prostration may be marked. The
parotitis of mumps may be present, or evidence of other infectious disease may be found. One
ore both testis may be enlarged and very tender. The epididymis cannot be distinguished from
the testis on palpation. The scrotal skin may be reddened. An acute trans illuminating hydrocele
may develop.
3. Proving and formulation of clinica diagnosis.
In case of acute epididymitis may be tenderness over the groin (spermatic cord) or in the
lower abdominal quadrant on the affected side, the scrotum is enlarged. The overlying skin may
be reddened; if abscess is present, the skin may appear dry, flaky and thinned; it may rupture
spontaneously. Hydrocele secondary to the inflammation may develop within a few days. The
white blood count often reaches 20-30 G/liter; urinalysis may or may not reveal evidence of
infection. The white blood count is usually elevated in the patients with acute orchitis. Urinalysis
is usually normal, although some protein may be found. Abnormal renal is found in patients with
mumps. Microhematuria and proteinuria are common. The specific virus can be found in the
urine. Later, renal function and urine return to normal.
Key words and phrases: Acute epididymitis, acute orchitis, testis torsion, conservative
treatment, surgical therapy.
II. Tests and Assignments for Self-assesment:
1. In case of testis torsion is indicated:
A. Antibacterial therapy.
B. Urgent operation.
C. Non-urgent operation.
D. Block of spermatic cord.
E. Desintoxication and antimicrobal therapy.
2. In case of purative epididymitis is indicated:
A. Suspensorium wearing.
B. Urgent operation.
C. Planned operation.
D. Epididyectomy.
E. Winkelmann's operation.
Real-life situations to be solved:
A. Boy of 8 years old was brought to hospital with complaints of acute pain in right part of
scrotum that appeared urgent (after physical training lesson). On examination right orchis
enlarged on 4 cm, is very painful. What is the diagnosis? What are the tactics of treatment?
B. In patient 74 years old at the 8th day after prostatectomy appeared acute pain in left part
of scrotum, increased temperature to 39,2°C. Objective: left part of scrotum enlarged,
hyperertiic, tenderness. Palpated enlarged, very painful epididymis with orchis. For 4 days was
held antimicrobal therapy, improvement isn't preasent. Blood count: leucocyte – 18,0 G/l,
leucocyte, related to stab neutrophile – 24 %, erythrocyte sedimentation rate – 34 mm/h.
Diagnosis? What are therapuetical tactics?
1.
2.
III. Answers to the Self-assesment:
B;
D.
A. torsion of right orchis, urgent operation;
B. acute purative orcho epididymitis from the left side, hemicastration is indicated.
Task 1. Prove and formulate clinical diagnosis. Student takes complains, case and life
history of the patient, physical examination, detects main clinical signs of acute diseases of
scrotum organs (orchitis, epididymitis, orchoepidtdymitis, testis torsion), forms diagnostic
program, formulates diagnosis.
Questions for the student:
1. What are the clinical symptoms of acute epididymitis?
2. What are the clinical symptoms of acute orchitis?
3. What are the clinical signs of testis torsion?
4. What are the main methods of the patients with orchoepididymitis examination?
Task 2. To make differential diagnosis.
Student makes differentional diagnosis of orchoepididymitis, using complains, disease and
history, physical examination, laboratory and diaphanoscopy signs.
Questions for the student:
1. What diseases is it necessary to make differential diagnosis with ?
2. What is the medical tactics in patients with orchoepididymitis?
3. What is the medical tactics in patients with spermatic cord torsion?
Visual aids and material tools:
1. Medical cards of ambulatory patients.
Students Practical Activities:
Student must know:
1. Etiology and pathogenesis of acute epididymitis.
2. Symptoms and clinical course of acute epididymitis.
3. Acute epididymitis diagnosis.
4. Therapy of acute epididymitis.
5. Symptoms and clinical course of acute orchitis.
6. Diagnosis of acute orchitis.
7. Differential diagnosis of acute orchitis.
9. Treatment of acute orchitis.
10. Clinical signs of testis torsion.
11. Diagnosis of testis torsion.
12. Differential diagnostic of testis torsion.
13. Principles oftestis torsion treatment.
Students should be able to:
1. Detect from case history main clinical signs of acute diseases of scrotum organs.
2. Define necessary quantity and sequence of patients examination: physical, laboratory,
endovesical.
3. Define therapy plan for the patients with orchoepididymitis, testis torsion.
4. Use diaphanoscopy and diagnostic punction of scrotum organs in examination of
patients.