The
scrotum
Prepenile
scrotum
Prepenile scrotum is an exceedingly rare
congenital condition in which the scrotum is suspended from the mons pubis in
front of the
penis.
Idiopathic scrotal oedema is described above.
Idiopathic
scrotal gangrene
Idiopathic scrotal gangrene (syn. Fournier’s
gangrene) is an uncommon and nasty condition (Fig.
68.19). It
is a vascular disaster of infective origin which is characterised by:
•
sudden appearance of scrotal inflammation;
•
rapid onset of gangrene leading to exposure of the scrotal contents;
•
absence of any obvious cause in over half the cases.
It
has been known to follow minor injuries or procedures in the perineal area, such as a bruise, scratch, urethral dilatation,
injection of haemorrhoids or opening of a periurethral abscess.
The
haemolytic streptococcus (sometimes microaerophilic) is associated with other
organisms (staphylococcus, E.
coli,
Clostridium welchii) in
a fulminating
inflammation of the subcutaneous tissues which results in an
obliterative arteritis of the arterioles to the scrotal skin (cf. gangrene of
the abdominal wall, Chapter 62).
Clinical
features
There is sudden pain in the scrotum, prostration, pallor and
pyrexia. At first
only the scrotum is involved but if unchecked, the cellulitis spreads until
the entire scrotal coverings slough leaving the testes exposed but healthy.
Treatment. Expert microbiological advice should
be obtained. The organisms are usually sensitive to gentamicin and a
cephalosporin which should be given until the bacteriological report is
available. Wide excision of the necrotic scrotal skin provides the best possible
drainage and stops the spread of the gangrene. Many patients die despite active
treatment.
Filarial
elephantiasis of the scrotum
Filarial elephantiasis of the scrotum is due to
obstruction of the pelvic lymphatics by Wuchereria bancrofti with
superadded infection and lymphangitis. In long-standing cases, the enormously
swollen scrotum may bury the penis (Fig. 68.20). There is no medical treatment
for the condition. The principle of surgical treatment
is the construction of new lymphatic pathways using plastic surgery. In very
advanced cases excision of the affected skin with implantation of the testes
into the thighs and a skin graft to the penis may be the only curative
treatment.
Nonfilarial
elephantiasis
Nonfilarial elephantiasis can result from
fibrosis of the lymphatics due to lymphogranuloma venereum.
Sebaceous
cysts
Sebaceous cysts are common in the scrotal skin.
They are usually small and multiple (Fig. 68.21).
Carcinoma
of the scrotum
In the nineteenth century squamous epithelioma
of the scrotum
was the chimney
sweep’s cancer
described by Percival Pott. With mechanisation of the cotton industry, impure
lubricating oil from the spinning machine soaking the crutch of the mule
spinners’ trousers proved even more carcinogenic than soot. Today a few cases
of scrotal cancer occur in tar and shale oil workers but the majority of cases
arises with no obvious aetiological
factor. It is remarkable that, unlike carcinoma of the penis, carcinoma of the
scrotum is almost unknown in India and Asiatic countries.
Clinical features
The growth starts as a wart or ulcer (Fig.
68.22). As it
grows it
may involve the
testis.
Treatment
The growth is excised with a margin of healthy skin. If associated
enlargement of the inguinal nodes does not subside with
antibiotics, a
bilateral block dissection should be carried out up to the external nodes.