HENOCH-SCHONLEIN PURPURA (HSP) (VASCULITIS)

Henoch-Schonlein purpura (HSP) is an inflammation of the blood capillaries in the reproductive

system. It occurs more often in men and affects 2-38% of men, common in children from 2 -10
years of age, boys than in girl. It is prevalent in the spring.

Signs and symptoms

The classical triad of clinical signs and symptoms includes:

 Purpuric rash
 Abdominal cramping
 Hematuria.

Other manifestations include:

 scrotal pain
 Tenderness at the scrotum
 Scrotal edema and redness
 Nausea and vomiting
 Headaches
 Hives or angioedema

Causes

 The cause is unknown

 It is often triggered by viral infection such as cold and other upper respiratory infections
 Abnormal response of the immune system

Diagnosis

Physical examination of the scrotum and epididymis

Urinalysis
Blood test blood count
Coagulation test
Imaging studies to rule out testicular torsion

Management

 There is no specific treatment most cases resolve on its own.

 Conservative treatment with steroid (prednisolone), analgesics and antibiotics
 Non-conservative treatment: surgical exploration
Complications

Bleeding into the scrotum

VARICOCELE

Varicocele is an enlarge vein in the scrotum. Varicoceles are usually painless but can sometimes
cause testicular pain. Varicocele affects 15% to 20% of all men and can contribute to about 40%
of all cases of male infertility. This is because the temperature inside the scrotum increases due
to the buildup of blood in the veins. The higher temperature affecting both testicles may affect
sperm count or production. A varicocele is more likely to occur on the left side of the scrotum
because of the differences in how blood drains from the left testis into major veins of the body.

SIGNS AND SYMPTOMS

Swelling in the testis or scrotum

Shrinking of the testis (testicular atrophy)
Dull testicular pain or aching in the scrotum, which often gets better when lie down.
Inability to achieve pregnancy after at least a year of unprotected sexual intercourse
(infertility).
A small lump above the affected testis.

Diagnosis and Tests

Medical History about the symptoms

Physical examination with the patient standing up, taking a deep breath, holding the nose
and mouth closed and strain to push air out. This is the called vasalva maneuver.
Pelvic ultrasound to give a detail view of the veins in the testicles
Semen analysis to assess the overall health of sperm if there are concerns that a
varicocele is impacting on the patient’s fertility.

Blood test to check the hormonal levels of follicle-stimulating hormone (FSH) and
testosterone. After confirming the presence of a varicocele, its severity will be graded and
scored.

GRADES OF VARICOCELES

 Grade 0: This is the smallest type of varicocele that cannot be felt during physical
examination, but can be detected on an ultrasound.
 Grade I: At this stage, the varicocele cannot be seen but can only be felt when valsalva
maneuver is performed.
  Grade II: Varicocele can be felt with examining fingers without performing valsalva
maneuver, but not visible.
 Grade III: this is the largest varicocele, it can be seen clearly and felt.

Management and Treatment

Varicocele treatment depends on its severity:

For low-grade varicoceles, a healthcare provider at-home treatment options may be

recommended, including:
 No treatment if the varicocele presents no symptoms or cause fertility issues.
 Changes to daily routine such as avoiding certain activities that causes discomfort,
wearing of tighter-fitting underwear or a jockstrap while exercising or standing for long
periods to ease symptoms.
 Apply ice or cold packs wrapped in a towel to the scrotum for not more than 15 minutes
at a time to relieve pain and discomfort.
 Administer prescribed non-steroidal anti-inflammatory drug e.g. Ibuprofen or Naproxen.
For severe varicocele surgery (varicocelectomy) is advocated.
Varicocelectomy is a surgical procedure in which the affected veins are cut and sealed off
to treat severe varicoceles that are painful or affect fertility. This procedure redirects
blood flow to other healthy veins in the scrotum.

COMPLICATION

Low testosterone (male hypogonaldism)

Depression
Azoospermia
Infertility
Erectal dysfunction

HYDROCELE

Hydrocele is the collection of peritoneal fluid between the parietal and visceral layers of the
tunica vaginalis which directly surrounds the testes and spermatic cord. Hydrocele arises from an
imbalance of secretion and re-absorption of fluid from the tunica vaginalis. It often presents as
painless swelling in the scrotum. It is common with newborns though it can occur at any age. A
sac of fluid descends with each testis into the scrotum and it is usually seal off before birth while
the fluid absorbed into the body. When the body fails to reabsorb the fluid hydrocele ensue.
Types of HYdrocele

o Primary Hydrocele
This occurs when the distal portion of the processus vaginalis (the peritoneal tunnel
through which the testes migrate from retroperitoneum toward the scrotum during
embryological development) of the spermatic cord remain patent at term or within 1-2
years of birth, creating a potential space where fluid accumulates within it to form
hydrocele. There are four (4) types of primary hydrocele depending on the site of
obliteration of processus vaginalis:
a) Congenital hydrocele: This occurs when processus vaginalis is patent and communicates
with the peritoneal cavity. This communication allows movement of peritoneal fluid but
too small to allow the intra-abdominal contents to herniate through.
b) Infantile Hydrocele: In this case, the processus vaginalis gets destroyed at the level of
the deep inguinal ring. However the portion distal to it remains patent and allows fluid
accumulation.
c) Encysted Hydrocele of the cord: Both the proximal and the distal portions of the
processus vaginalis get obliterated while the central portion remains patent and fluid
accumulates within it.
d) Vaginal hydrocele: Processus vaginalis remains patent only around the testes and as
fluid accumulates, it renders the testes impalpable.
o Secondary Hydrocele
This usually occur as a result of an underlying condition such as infection (filariasis,
tuberculosis of the epididymis, syphilis) injury (trauma, post-herniorrhaphy hydrocele),
or malignancy. This type of hydrocele tends to be small except secondary hydrocele due
to filariasis which can be very large.

Signs and Symptoms

o Scrotal swellings
o Trans-illumination
o Fluctuation of the testes

ETIOLOGY
There are four (4) basic mechanisms by which hydrocele can develop. These are:

o Connection with the peritoneal cavity through a patent processes vaginalis (congenital
hydrocele).
o Excessive production of fluid (secondary hydrocele)
o Defective absorption of fluid.
o Interference with the lymphatic drainage of scrotal structures as in filarial hydroceles
(caused by wuchereria bancrofti) is the main cause globally, affecting 120 million people
in more than 73 countries.
o Iatrogenic causes (either trauma or post-herniorrhaphy complications).

Investigations for Hydrocele

o Physical examination to identify trans-illumination of the fluid.

o Blood test which help to rule out epididymitis/orchitis and incarcerated inguinal hernia
which can mimic hydrocele.
o Ultrasonography to give detailed testicular parenchyma, size and characterization of the
hydrocele.
o Duplex Ultrasonography: It provides information regarding testicular blood flow which
will be reduced or absent in hydroceles resulting from testicular torsion
o Plain abdominal x-ray

TREATMENT

o Surgery (Hydrocelectomy): Surgery is the treatment of choice to drain the fluid and
sew the sac closed especially when hydrocele becomes complicated or symptomatic.
There are two (2) common surgical approaches for hydrocelectomy:
a) Plication: This technique is suitable for thin-walled hydroceles. It involves minimal
dissection and therefore reduced risk of infection or hematocele.
b) Excision and Eversion: This technique is suitable for large thick-walled hydroceles. It
involves subtotal excision of the tunica vaginalis and everting the sac behind the testes
followed by placing the testes in a newly created pocket between the fascial layers of the
 scrotum (Jaboulay procedure). Particular attention is taken not to damage epididymis,
testicular vessels or vas deferens.
o Aspiration: This is especially for patient who cannot tolerate surgery. However hydrocele
fluid usually accumulates within a week. Also there is high risk for hematocele and
infection after aspiration. Aspiration followed by injection of sclerosant (tetracycline or
doxycycline) has been proven to be effective but painful.

Complication of the surgery (Hydrocelectomy)

o Reactionary hemorrhage
o Pyocele
o Infection
o Sinus formation
o Recurrent hydrocele

Complications of Hydrocele

The presence of hydrocele could indicate serious problem with the testes and potential
complications from treatment administered such as:

o Infection
o Pyocele
o Haematocele
o Atrophy of testes
o Infertility (from halt spermatogenesis due to increased pressure on the blood supply on
the testis from edema)
o Rupture
o Hernia of hydrocele (rare)

FOURNIER’S GANGRENE (FASCIITIS OF THE GENITAL AND PERINEUM)

Fournier’s gangrene is an acute necrotic infection of the scrotum, penis or perineum
characterized by scrotal pain and redness with rapid progression to gangrene and sloughing of
tissue. It is common in men and usually presents form age 50

Signs and Symptoms

 Fever
 Malaise
 Moderate to severe pain and swelling in the genital and perineum
 Rankness and smell of the affected tissues (fetid suppuration) leading to full blown
(fulminating) gangrene.
 Palpable crepitus
 Extension of necrotic tissues to the thigh through the abdominal wall and up to the chest
wall.

Causes

 The cause is unknown (idiopathic) but there are predisposing factors such as;
 Diabetes mellitus
 Profound obesity
 Cirrhosis
 Interference with the blood supply to the pelvis and various malignancies
 Bacteria, Fungus and virus. Portal of entry are colorectal (from anorectal abscesses),
urogenic (urinary tract infection), or cutaneous (surgical instrumentation) in origin.

Diagnosis

 Ultrasound evaluation for early differentiation of Fournier’s gangrene from epididymis or

orchitis and also to detect gas and fluids.
 Computed tomography to determine the portal of entry and the extension of the disease
process.
 X-ray studies to confirm location and extent of gas distribution in the wound.

Treatment

 Aggressive resuscitation and administration of broad-spectrum intravenous antibiotics as

quickly as possible.
 Urgent surgical debridement of extensive areas of necrotic tissues with repeated removal
of wound margins as necessary.
 Reconstructive surgery is undertaking once the infection is under control