SMALL EGG. Contents:
Comparative anatomy..... 496
Pathological anatomy...... 4 98
Methods of inspection........ 499
Small egg [testis (PNA, JNA, BNA); synonym: a seed plant, orchis] — the pair male gonad (gonad) which is developing sex cells and excreting male sex hormones in blood.
The comparative anatomy
is available For coelenterates only accumulation of sex cells. Numerous seed plants of flat worms (at their nek-ry flukes is from 30 to 200, at tape-worms — till 1000 in each joint of a body) have own channels. Seed plants of the majority of vertebrata steam rooms: at the lowest mammals they are in an abdominal cavity, at high-organized mammals are located in a sacculate outgrowth of skin — a scrotum (see) where they fall from an abdominal cavity via the pakhovy channel in development of a germ. At a number of animals (e.g., at nek-ry rodents and monkeys, and also at insectivorous and wing-handed animals) the pakhovy channel remains open, and seed plants fall to a scrotum only in a breeding season.
Laying of a small egg and its removing system is formed of two sources — the sexual roller and primary kidney. The sexual roller develops on ventromedial-ache the surfaces of primary kidney (a mesonephros, a volfov of a body) and consists of closely located cells of a mesenchyma covered with a coelomic epithelium, to-ry directly proceeds in a cover of primary kidney and a mesothelial vystilka of a coelomic cavity. In the sexual roller from a vitelline entoderm primary sex cells (gonocytes) migrate and are located in a cover epithelium. Till 6th week of embryonic development the gonad histologically is not differentiated yet, there are two couples of canals: mezonefralny (volfova) canals, to-rye in the subsequent take part in formation of an appendage and the removing system of testicles, and paramezonefral-ny (myullerova) channels — rudiments of oviducts and a uterus. Already during this period endocrine function of laying of the male gonad excreting two hormones is established: antimyuller the hormone causing regression of paramezonefralny channels, and testosterone providing development and a differentiation of mezonefral-ny channels. At the end of the 5th week of development of a germ sexual tyazh begin to form; at the same time gonocytes, actively breeding, grow in the form of tyazhy into the subject mesenchyma and are surrounded with epithelial cells. The origin of the last is disputable. One researchers consider them the cells of a coelomic epithelium plunging together with gonocytes into a mesenchyma of the sexual roller; others believe that epithelial cells come from elements of primary kidney — tubules and balls. Sexual tyazh intensively expand in length and become sharply twisting (gyrose seed tyazh, future tubules). To the middle of the pre-natal period in each epithelial tyazh the small gleam is formed, and tyazh the seed tubule turns in primary gyrose. In a wall of seed tubules epithelial cells are differentiated in sustentotsita (Sertoli's cell), and gonocytes — in a spermatogone (see the Spermatogenesis). Seed tubules separate from each other the connecting fabric which is formed of a mesenchyma. In connecting fabric vessels and nerves are located, and also large epithelial-like cells — glandulotsita (a cell of Leydiga) are differentiated. Under a cover epithelium the zone of the young connecting fabric forming then a white of a small egg forms. Broad connection of the sexual roller with primary kidney gradually is narrowed, extended and turns into the education reminding a mesentery. Tubules of primary kidney, topographical the closest to gyrose seed tubules of a small egg, are differentiated in the taking-out tubules. Together with an initial part of a volfov of a channel they form an epididymis.
On the 4th month of the pre-natal period the small egg migrates from a back wall of an abdominal cavity to a small pelvis; between the 6th and 8th month process of lowering of a small egg continues — it passes the pakhovy channel and shortly before the birth of a fruit falls to a scrotum (see), entraining layers of a front abdominal wall, to-rye create covers of a small egg. Sometimes this process comes to the end soon after the birth of the child.
Testicles are located in a scrotum. Each small egg is suspended on a seed cord (see), to-ry consists of a deferent duct, circulatory, absorbent vessels and nerves. These educations are surrounded with the covers passing into covers of a small egg (tsvetn. the tab., Art. 464, fig. 12 — 15). Length of a small egg at the adult is equal to 4 — 4,5 cm, width — 2,5 — 3,5 cm, weight — 20 — 30 g. In a small egg distinguish lateral (facies lat.) and medial (facies med.) surfaces, front and back edges (margo ant. et post.), top and bottom poles — extremitas sup. et inf. On an upper pole of a small egg non-constant club-shaped education — an appendix testis (appendix testis), representing the rest of a parameso-nefralnogo (myullerov) channel is had. To an upper pole and the rear edge of a small egg prilezhit an epididymis (epididymis), in Krom distinguish a head, a body and a tail. The head of an appendage (caput epididymidis) is spliced with an upper pole of a small egg; the body (corpus epididymidis) prilezhit to the rear edge and partly to a lateral surface of a small egg and separates from it a pocket (sinus epididymidis); the tail of an appendage (cauda epididymidis) is located on the lower pole of a small egg, being sharply bent kzad and up in relation to a head of an appendage, and connects to a small egg friable cellulose. The average weight of an appendage apprx. 3 g, its length corresponds to length of a small egg. Behind a head of an appendage in an initial part of a seed cord there is a parepididymis (paradidymis) — the rudimental organ containing the remains of tubules of a mesonephros.
The small egg and a seed cord have
7 covers: skin of a scrotum, a dartos (tunica dartos), an outside seed fascia (fascia spermatica externa), a fascia of the muscle lifting a small egg, the muscle lifting a small egg (m. cremaster), an internal seed fascia (fascia spermatica int.), vulval cover of a small egg (tunica vaginalis testis). The vulval cover forms from a vulval shoot of a peritoneum (processus vaginalis peritonei) during lowering of a small egg in a scrotum and forms the closed serous cavity limited to pristenochny and visceral plates of this cover. The visceral plate is closely connected with a white, covers a small egg and its appendage and passes into a parietal plate at the rear edge of a small egg where vessels enter it. The white (tunica albuginea) represents a connective tissue plate, edges in the field of the rear edge of a small egg gets in body and, being thickened, forms a septum of the testis, or a Highmore's body (mediastinum testis). From it connective tissue plates — partitions (septula testis) dividing a small egg into segments (lobuli testis) fan. The last have the cone-shaped form with the basis turned to the periphery of a small egg. In a small egg there are 250 — 300 segments; in each of them there are 2 — 4 gyrose seed tubules (tubuli semi-niferi contorti) anastomosing among themselves; merging, they pass into thinner direct seed tubules, and then in a septum of the testis form network (rete testis). From network of a small egg 12 — 18 short taking-out tubules (ductuli efferentes testis) falling into the twisting canal of an epididymis (ductus epididymidis) begin. The channel of an appendage passes into a deferent duct (ductus deferens), to-ry, connecting to a secretory channel of seed bubbles (ductus ekhsge-torius), forms the ejaculatory channel falling into an urethra.
Blood supply of a small egg is carried out by a yaichkovy artery (a. testicula-ris) departing from a belly part of an aorta, the artery of a deferent duct (a. ductus deferentis) which is a branch of an umbilical artery and a kremasterny artery (a. crema-sterica) departing from the lower epigastriß artery. Venous outflow is carried out in a pampiniform texture (plexus pampiniformis), and then in yaichkovy veins, from to-rykh right falls into the lower vena cava, and left — into the left renal vein. The network limf, capillaries is located in a white and a parenchyma of body. Taking away limf, vessels pass in structure of a seed cord. The lymph drainage is carried out in lumbar limf. nodes.
Nerves of a small egg form a yaichkovy texture (plexus testicularis) and a texture of a deferent duct (plexus deferentialis). Nerve fibrils branch in a parenchyma of a small egg on the course of vessels, braiding hormone-producing cells and gyrose seed tubules.
the Basic structural element of a small egg is gyrose a seed tubule. In a small egg of the adult man everyone gyrose the seed tubule has diameter of 150 — 200 microns and length from 30 to 70 cm. Its wall consists of connective tissue own cover (a boundary membrane) and one layer of epithelial cells (supporting cells of Sertoli, or sustentotsit), among to-rykh sex cells at various stages of a spermatogenesis are located. Gyrose seed tubules are separated from surrounding intersticial fabric by a narrow layer of endotheliocytes of lymphatic sinusoid.
In own cover of a gyrose seed tubule distinguish several layers. Directly to epithelial cells the basal membrane (a basal layer) of the glikoproteidny nature prilezhit, near it the fibrous layer from collagenic and elastic fibers, then the mioidny layer formed by several rows of mioidny cells — derivative fibroblasts is located. A large number of the pinotsitozny bubbles, apparently, participating in transport of substances through own cover of a tubule is connected with a membrane of mioidny cells. Sokratitelny ability of mioidny cells causes a peristaltics of gyrose seed tubules and advance on them still motionless spermatozoa to network of a small egg.
Sustentotsnshch are located on a basal membrane of a gyrose seed tubule, forming a peculiar case for the developing sex cells. The form of kernels of sustentotsit and their localization change depending on a stage of a spermatogenesis (see). The close contact of sustentotsit and the developing sex cells is characteristic. At a stage of spermatids sex cells are surrounded with high outgrowths of cytoplasm of sustentotsit, and during the next period of development up to emergence mature spermiyev heads of the ripening sex cells are deeply invaginated in sustentotsita. Together with own cover of a gyrose seed tubule of a sustentotsita form a gematotestikulyarny barrier, to-ry provides selective intake of substances in a cavity of a tubule and back.
Glandulotsita (intersticial endokrinotsita, cells of Leydiga), the main function to-rykh is secretion of testosterone, are located in intercanalicular connecting fabric. As a rule, it is the large cells of a polygonal form having the structure typical for steroidoprodutsiruyushchy cells.
In the taking-out tubules of a small egg epithelial cells have different height, higher of them are supplied with cilia. In an epididymis the epithelium of tubules is constructed as multirow (a psevdomnogo-layer epithelium): between high cylindrical cells lower, polygonal cells are wedged. On a surface of cylindrical cells bunches of the «stuck together» cilia — motionless stereocilias are located. The basal membrane of a channel of an appendage is surrounded with richly vaskulyarizovanny connecting fabric and a layer tsirkulyarno of the located smooth muscle cells (tsvetn. tab., Art. 464, fig. 16, 17).
the Small egg performs two main functions in an organism: vneshnesekretorny, consisting in development of men's sex cells — spermatozoa (see the Spermatogenesis), and intra secretory, providing synthesis of male sex hormones — androgens (see). Both functions are closely connected and interdependent. Androgens, hl. obr. testosterone (see), promote formation of men's individuals (growth and development of men's generative organs, secondary sexual characteristics), emergence and preservation of sexual desire; besides, they exert impact on processes of growth, physical development, skeleton structure, etc.
• Hormonal function of a small egg depends on its anatomic structure and a functional condition of cellular elements. Development of a spermatogenic epithelium and synthesis of androgens are carried out under control of gonadotropic hormones (see) a front share of a hypophysis (see), secretion to-rykh, in turn, is regulated by hypothalamic neurohormones (see). Disturbance of biosynthesis of gonadotropic hormones leads to change of function of a small egg. So, at the insufficient content of luteinizing hormone (see) there is an atrophy of the glandulotsit producing testosterone. It causes emergence of signs of a secondary hypogonadism (see), in particular the spermatogenesis is broken, to-ry stops at a stage of formation of spermatocytes of the I order — at patients the oligospermatism and infertility develop (see). Leads to infertility also decrease in level of follicle-stimulating hormone (see), to-ry stimulates a spermatogenesis in usual conditions.
Relationship of gonadotropic function of a hypophysis and functions of a small egg are carried out by the principle of a feed-back. So, decrease in level of testosterone in blood, napr, at a hypogonadism owing to uraemia or cirrhosis, leads to strengthening of products and release of gonadotropic hormones, at excess of testosterone this process is oppressed.
There is a close correlative connection of function of a small egg with function of other peripheral hemadens — adrenal glands, a thyroid gland.
Hormones of a thyroid gland (hl. obr. thyroxine) exchange processes in a small egg strengthen, accelerate synthesis and secretion of testosterone, however in large numbers they break these processes (see the Craw diffusion toxic). Insufficiency of function of a thyroid gland at early children's age (see Cretinism) causes a delay of sexual development. Supersecretion bark of adrenal glands of androgens leads to suppression of secretion of hormones of a small egg.
Age changes. At the newborn testicles have rather big sizes, then their growth is slowed down. In further development of testicles allocate a number of phases. In a phase of relative rest (up to 5 years) testicles change a little. In a growth phase (from 6 to 9 years) testicles increase in sizes, at the age of 7 years in gyrose seed tubules it is possible to find single spermatocytes
of the I order, to-rye, however, do not complete meiosis and degenerate. The phase of puberty (from 10 to 15 — 18 years) is characterized by the intensive growth and formation of testicles: development of sex cells happens to a stage of spermatids, also mature spermiya appear, in sizes the epididymis quickly increases. Under the influence of neuroendocrinal mechanisms, first of all hypothat-lamo-pituitary system (see), by 16 — 18 years the small egg reaches the maximum development, gaining properties of a mature gonad. At the same time men's generative organs and secondary male sexual characters finally form, the configuration of a skeleton changes, the mass of muscles increases, the definitivny spermatogenesis gradually is established. The phase of an active spermatogenesis proceeds from 15 — 18 to 55 — 60 years, then there comes the phase of involution of a small egg, during a cut activity of a spermatogenesis gradually decreases and the small egg decreases in sizes a little.
In testicles the atrophy, a hypertrophy, dystrophy, a necrosis, disturbance of blood circulation and a lymphokinesis, an inflammation can be observed.
The atrophy of a small egg is characterized by reduction of its weight at preservation of a usual form. Distinguish the pre-natal atrophy of a small egg caused by influence of adverse factors during pre-natal development and a postnatal-ny atrophy, the cut is the cornerstone impact on testicular fabric of various adverse factors. Treat such factors: the general disturbance of exchange processes (e.g., at debilitating diseases, starvation, intoxication, impact of ionizing radiation), a delay of a small egg in the inguinal channel, torsion of a seed cord, a prelum of a small egg the growing tumor, the injury of a scrotum, endocrine diseases connected with dysfunction of a thyroid gland and hypophysis, a disease of a small egg, napr, an orchitis of various etiology; diseases of other bodies (e.g., cirrhosis). At an atrophy, the obuslovlache action of factors of the general character, as a rule, both small egg are surprised; the atrophy of a small egg which resulted from action of factors of local character more often happens unilateral. The small egg at an atrophy is reduced in sizes, condensed, on a section pale gray layers of connecting fabric are visible. In gyrose seed tubules the quantity of cells of a spermatogenic epithelium considerably decreases, up to their total disappearance. Gleams of gyrose seed tubules are narrowed, are noted a hyalinosis (see) and a sclerosis (see) their connective tissue cover. At the atrophy resulting from inflammatory changes and nek-ry intoxications in an interstitium of a small egg the progressing sclerosis and a reduction a microcirculator-nogo of a bed, reduction of quantity of glandulotsit are noted. A final stage of atrophic changes of a small egg is the tubular sclerosis of gyrose seed tubules with a full obliteration of their gleam, and also an intersticial sclerosis.
The vicarious hypertrophy of a small egg is most often observed during removal of the second small egg or its atrophy. In comparison with a compensatory hypertrophy of other bodies it is expressed more weakly and caused substantially by an intracellular hyperplasia. Ability of a spermatogenic epithelium to regeneration after disturbance of blood circulation in a small egg at newborns is quite high, and at adults is expressed poorly. Regeneration of a spermatogenic epithelium at dystrophic and atrophic processes in a small egg is possible if reserve (trunk) spermatogones are kept.
Dystrophic changes of a small egg can extend as to cellular components of gyrose seed tubules, and to intersticial cellular elements — glandulotsita. At proteinaceous dystrophy (see) cells of a spermatogenic epithelium and a sustentotsita (parenchymatous disproteinoza) are surprised preferential, defeat of glandulotsit, stromas, vessels (mesenchymal disproteinoza) is less often observed. From parenchymatous disproteinoz granular dystrophy most often meets, edges develops as a result of disturbances of blood circulation, infections, intoxications, etc.; it is most expressed in sustentotsita. Also gidropichesky dystrophy of cells of a spermatogenic epithelium, sustentotsit, glandulotsit is noted. From mesenchymal disproteinoz the hyalinosis of walls of gyrose seed tubules, stromas, arterioles and capillaries of an interstitium meets more often. The amyloidosis of a small egg is observed at an amyloidosis of other bodies (see the Amyloidosis); usually it meets at secondary and hereditary forms of the general amyloidosis. Adjournment of amyloid in walls of vessels of a small egg, is more rare in a cover of seed tubules, is combined with proteinaceous and fatty dystrophy of sustentotsit (see. Fatty dystrophy). Fatty dystrophy of fabric of a small egg is most often observed at hron. alcoholism, is more rare at hron. infections, intoxications pesticides and other chemical substances. At fatty dystrophy of a small egg in cytoplasm of cells of a spermatogenic epithelium, sustentotsita, glandulo-tsita lipids in the form of drops of various size and a form collect.
To a necrosis (see) the spermatogenic epithelium of gyrose seed tubules of various sites of a small egg can selectively be exposed. Total-
the ny necrosis of a spermatogenic epithelium is observed at influence of high doses of ionizing radiation.
Disturbances of blood circulation and a lymphokinesis in a small egg are expressed by an arterial and venous plethora, a lymphostasis, hypostasis, ischemia, a heart attack, hemorrhage. At an arterial plethora the small egg does not increase in volume, however its vessels are sharply expanded, full-blooded, and in a stroma the phenomena of hypostasis develop. The congestive venous plethora can be manifestation of the general venous plethora observed at hron. to heart failure, but a thicket it is connected with disturbance of outflow of a venous blood at a varicosity of a seed cord or ?sdavleniya of veins a tumor, at the restrained inguinal hernia or torsion of a seed cord. The venous plethora causes sharp vasodilatation of microcompasses - an even bed, hypostasis of an interstitium that leads to a hypoxia of a parenchyma of a small egg. Are connected with a hypoxia a sclerosis of walls of tubules and intercanalicular - connecting fabric, the dystrophic, and also necrobiotic changes of a spermatogenic epithelium leading to braking of a spermatogenesis. At a long venous plethora in one small egg in another also find signs of disturbance of a spermatogenesis, to-rye have autoimmune character. These disturbances lead finally to infertility.
The anemia of a small egg is most often observed at hron. anemias, a cachexia, and also at a prelum and an obliteration of vessels of a seed cord. The small egg in these cases is usually reduced in volume, pale brown color on a section. Even short-term ischemia of a small egg (15 — 25 min.) leads to dystrophic and destructive changes of a spermatogenic epithelium, to-ry it is recovered in similar cases only in 2 months. At the bigger duration of ischemia there comes the irreversible destruction of a spermatogenic epithelium leading to infertility.
The heart attack of a small egg thanks to plentiful blood supply from many sources meets extremely seldom. The ischemic heart attack of a small egg is, as a rule, caused by thrombosis or an embolism of a yaichkovy artery, but can be connected with torsion of a seed cord. There are observations of a hemorrhagic heart attack of a small egg at fibrinferment of the lower vena cava.
The inflammation of a small egg, or an orchitis, can be acute or chronic, specific and nonspecific (see the Orchitis).
Methods of inspection
Inspection of the patient with pathology of a small egg includes collecting the anamnesis, survey, tool and laboratory methods of a research. During the studying of the anamnesis pay attention to the postponed injuries and diseases, disturbances of sexual function, in case of complaints to pains in a small egg (orkhialgiya) is specified by their character and intensity. During survey consider growth, physical development of the patient, expressiveness of secondary sexual characteristics, note inflammatory changes of skin of a scrotum, existence of fistulas.
At palpation of a scrotum define whether the small egg in a scrotum, its sizes and a consistence, existence of consolidations, nodes, a zybleniye in its parenchyma is located.
Use also rentgenol. methods of a research. At an injury of a scrotum make a survey X-ray analysis of area of a basin and external genitals. For studying of the course of the wound channel, and also in the presence of fistula the fistulo-grafiya is shown (see). Less often at diseases of a small egg carry out an epididimo-grafiya (see), edges it is shown preferential with the differential and diagnostic purpose (fig. 1).
Fig. 1. Epididimo-gramma at tuberculosis of an epididymis:
radiopaque substance fills a cavity of tubercular abscess (it is specified by an arrow).
A certain place in diagnosis of metastasises of malignant tumors of a small egg in limf, nodes borrow urography (see), a limfografiya (see), a kavografiya (see). For differential diagnosis of tumoral process and to the gidrotsela (see) use a diafanoskopiya (see). At recognition of different types of a cryptorchism (see) and focal patol. processes one of the most informative methods is the stsinti-grafiya of testicles with use of a 99tts-pertekhnetat. On a stsintigram-move patol. changes are shown by indistinct contours of a small egg or its certain sites, uneven accumulation and distribution of radionuclide. In comprehensive examination, especially for the purpose of differential diagnosis of a chronic orkhiepididimit (see the Orchitis, the Epididymite), to the gematotsela (see) p sometimes
the gidrotsel with new growths, the important place belongs to a computer tomography (see the Tomography computer) and to an ultrasonic method of a research (see. Ultrasonic diagnosis). The computer tomography is especially informative in the course of dynamic observation during the performing conservative treatment concerning cancer of a small egg. Ultrasonic investigation allows to differentiate accurately cystous formations of a small egg with dense, to receive the layer-by-layer image of a small egg and its appendage in any plane. For a research of androgenic activity determine the content of testosterone in blood by a radio immunological method (see), daily excretion of testosterone, other androgens or 17-ke-tosteroidov with urine, including after administration of gonadotropic hormone of a hypophysis (see Androgens, Testosterone). By means of laboratory methods investigate sperm (see). The biopsy from the suspicious sites of a parenchyma of a small egg revealed at a palpation is shown when it is not possible to gain clear idea of spermatogenic and endocrine functions of testicles on the basis of other methods of a research.
Pathology of a small egg includes malformations, damages, inflammatory and other diseases, and also tumors.
Malformations. Distinguish anomalies of quantity and anomaly of provision of testicles. Carry an anorchism (lack of both testicles), a monorchism (lack of one small egg) and a polyorchism (existence of an additional small egg) to anomalies of quantity. Inborn lack of both testicles — an anorchism, or anarchy (see), is extremely rare malformation. Clinically at the same time signs of a hypogonadism (see) and an eunuchoidism are noted (see). For specification of the diagnosis it is necessary to exclude not omission of testicles; for this purpose carry out stimulation of glandulotsit of a small egg horiogo-niny (see the Cryptorchism). Replacement hormonal therapy is shown to patients with anarchy. In some cases change of a small egg can be made (see below). Inborn lack of one small egg (monorchism) also meets seldom. Recognition of this malformation, as well as anarchy, is based hl. obr! on an exception of not descent of testis. Treatment (hormonal correction) is shown only at functional insufficiency or diseases of the available only small egg. At a polyorchism the additional small egg is usually underdeveloped, can not have a deferent duct, sometimes
has the general appendage with a normal small egg. The additional small egg quite often is exposed to a malignancy. In this regard at a polyorchism removal of an additional small egg is necessary.
Carry a cryptorchism, an ectopia and turn of a small egg to anomalies of situation. The cryptorchism making 95% and more all anomalies of a small egg arises owing to a delay of moving of a small egg to a scrotum in the pre-natal period; at the same time the small egg can be located in an abdominal cavity or in the inguinal channel. At bilateral крип^рхизме signs of hyporutting of a dizm are expressed. Treatment preferential operational also consists in bringing down of a small egg. Adult patients have a danger of a malignancy having neolet-shegosya a small egg. Therefore if the small egg does not manage to be reduced, then it is usually deleted (see the Cryptorchism).
In case of an ectopia the small egg can be located under skin of inguinal area, in the field of a pubis, on an inner surface of a hip, on a crotch or in an opposite half of a scrotum (a cross allotopia). The reasons of an ectopia of a small egg consider an underdevelopment of the corresponding half of a scrotum, or a gunterovy sheaf, existence of commissures. The malrelated small egg in connection with its possible traumatization and partly with cosmetic defect is recommended to move to a scrotum. Operation does not present difficulty since the malrelated small egg has the extended seed cord. The forecast after operation favorable.
The turn of a small egg happens most often around its vertical axis. At the same time depending on an arrangement of an epididymis distinguish antelocation (the appendage is located in front of a small egg) and horizontal, or upper (the small egg is located horizontally, an appendage over it). In most cases at this anomaly patients do not show complaints. However the wrong provision of a small egg as a result of its turn promotes development of inflammatory processes in this connection in some cases recommend carrying a suspenzoriya.
Damages. The injury of a small egg and its appendage can be closed when the integrity of a scrotum is not broken, and open. Bruises and a prelum of a small egg and its appendage are most often observed that is followed by pain, hypostasis of fabrics, hemorrhages and formation of hematomas. Between leaves of own cover of a small egg the exudate often appears (see Gidrotsele), blood is more rare (see Gematotsele). Development of a traumatic orchitis is possible (see). At the heavy closed damages of a small egg (a gap, crush) at the victim severe pain, vomiting, a fever, spasms, quite often unconscious state, shock are noted.
At the closed damages of a small egg recommend a bed rest, appoint the anesthetizing pharmaceuticals, carry out novocainic blockade of a seed cord. Bystry increase of a hematoma causes suspicion on a rupture of a small egg and serves as the indication to an operative measure, at Krom delete a hematoma, excise the dropping-out parenchyma of a small egg and take in a white. In case of partial crush of a small egg resect the damaged site of its fabric, at a separation of a small egg from a seed cord make hemicastration. The forecast of the closed damages of a small egg at timely and correct treatment favorable. In cases of a heavy bruise of a small egg its atrophy is possible.
Traumatic dislocation I. it is observed at damage of its covers and more often happens unilateral. The small egg at the same time usually moves from a scrotum under skin of a stomach or a hip. Existence of a considerable hematoma and hypostasis of fabrics of a scrotum complicates recognition of traumatic dislocation of a small egg. After a rassasyvaniye of a hematoma the diagnosis does not present difficulty. At small hypostasis and a hematoma the small egg can be set in a scrotum; more often reposition is made in the operational way. Forecast in most cases favorable.
Open damages of a small egg in peace time meet considerably less than closed. On a wedge, to manifestations they can be easy, moderately severe and heavy. Diagnosis is not difficult. Treatment, as a rule, operational. Small damages of a white take in, at loss of a parenchyma delete it, then sew up a white. Crush of one of poles of a small egg serves as the indication to its resection. Multiple ruptures of a small egg take in rare catgut seams. To points of fracture bring 1 — 2 rubber the graduate. Disturbance of blood circulation in a small egg causes frustration of a spermatogenesis, focal fibrosis.
Features of fighting damages of a small egg. Gunshot wounds of a small egg more often happen unilateral, bilateral damage meets in 6 — 8% of cases. On the nature of damage distinguish bruises, gutter, nonperforating and through wounds, a separation of a small egg from a seed cord, crush of a small egg. Among fighting damages of a small egg there are slight injuries and moderately severe injuries make 75%, severe injuries which are quite often combined with damages of other bodies (a bladder, an urethra, a rectum), pelvic bones and followed by traumatic shock, bleeding — 25%.
At bruises of a small egg in its fabrics hypostasis of various degree, hemorrhage are observed. Find defect of fabrics, hemorrhage in a zone of a gutter wound. At through wounds of a scrotum and small egg considerable damage of surrounding fabrics is noted.
Diagnosis of damages of a small egg in most cases is based on results of survey, a palpation of a scrotum and small egg, audit of a wound.
The first and pre-medical help at wound of a small egg includes imposing on a wound of an aseptic bandage, administration of the anesthetizing medicines. The first medical assistance consists in holding antishock actions, correction of a bandage, introduction with the preventive purpose of antibiotics and antitetanic anatoxin. During the rendering the qualified medical assistance carry out primary surgical treatment of a wound, put rare stitches, graduates surely leave. Delete a small egg only in case of its separation from a seed cord or crush. In specialized to lay down. establishment render medical aid in full, edges are included by treatment of an orchitis, a shouting-hiepididimita, the traumatic gematotsel and the gidrotsel, fistulas, etc.
Diseases. Nonspecific and specific inflammatory diseases of a small egg meet, gidrotset e (an edema of its covers) and torsion of a small egg. The inflammation of a small egg and its appendage (orkhiepidi-dimit) (orchitis) — the most frequent type of pathology of this body. Quite often inflammatory process passes from an appendage to a small egg, distribution of inflammatory process from a small egg on its appendage is less often observed (see the Orchitis, the Epididymite).
Tuberculosis of a small egg, as a rule, arises upon transition of process from an appendage, in rare instances at hematogenous distribution of contagiums perhaps isolated defeat of a small egg (see Tuberculosis vnelegochpy, tuberculosis of men's generative organs). Course of a disease chronic. Involvement in process of a deferent duct and a prostate is characteristic. At diagnosis pay attention to defeat of an appendage, in the area to-rogo a thicket fistulas are localized; use a tuberculinodiagnosis (see), a bacteriological research of urine and an ejaculate for the purpose of identification of mycobacteria of tuberculosis in them. Differential diagnosis is carried out with syphilis of a small egg, for to-rogo defeat of an appendage is not characteristic. Besides, at syphilis fistulas are localized usually on a front surface of a scrotum, Wassermann reaction is positive (see Wasserman reaction). In doubtful cases conduct a cytologic research of punctate or a biopsy of a small egg. Treatment specific (see. Antituberculous remedies; Tuberculosis, philosophy of treatment). In cases of extensive defeat of a small egg the orkhiektomiya is sometimes necessary. At timely begun treatment the forecast, as a rule, favorable.
Syphilis of a small egg can be inborn and acquired. Inborn syphilis of a small egg is shown right after the birth or several years later. At the same time the small egg is increased in sizes, without serious consequences, it can to be noted to a gidrotsela (see). The acquired syphilis of a small egg develops in secondary and tertiary stages of this disease and proceeds as an intersticial fibrous or gummous orchitis. In the beginning symptoms of a disease are a little expressed; pains are absent, slow increase in a small egg, a consistence its dense is noted, it can be hilly. Sometimes there is a softening of separate gummas. The centers of a softening can be opened on skin of a scrotum, forming fistulas. In an epididymis syphilitic process develops seldom. The diagnosis is based on data of the anamnesis, identification of defeat of other bodies, results of laboratory methods of a research, serological tests. The differential diagnosis is carried out with tuberculosis and a tumor of a small egg. In doubtful cases resort to a puncture of a small egg with the subsequent cytologic research of the punctate or material received at a biopsy. Treatment specific (see. Antisyphilitic means, Syphilis, treatment). The forecast at timely begun treatment is more often favorable. At fibrous intersticial syphilitic about r a hit there can come the atrophy of a small egg.
Gidrotsele — an edema of covers of a small egg, is inborn and acquired. The inborn hydrocele is connected with not fusion of a vulval shoot of a peritoneum after lowering of a small egg in a scrotum, acquired more often happens a consequence of inflammatory diseases or injuries (see Gidrotsele).
Torsion of a small egg is caused by an underdevelopment of a seed cord and the inguinal channel. It arises at a sharp overstrain of muscles of a prelum abdominale or an injury of a scrotum and leads to the expressed disturbance of blood circulation in a small egg. At full torsion of a small egg a condition of patients heavy. The sharp pain in a scrotum amplifying at a muscle tension of a prelum abdominale, the sharp movements and palpation of a small egg is characteristic, body temperature is increased, nausea, vomiting, a delay of an urination and a chair are noted. The sizes of a small egg and appendage quickly increase, there is a hydroscheocele on the party of defeat. In a small egg venous stagnation, the accruing hemorrhagic hypostasis of an interstitium, dystrophic changes and a focal necrosis of a spermatogenic epithelium develop. In 10 — 12 hours after torsion there comes the total necrosis of a small egg. At torsion of a small egg urgent operation is shown, edges consists in allocation of a small egg from surrounding fabrics and its fixing in normal situation. Orkhiektomiya is made only when the overwound small egg completely nekrotiziro-vano. The forecast at a timely operative measure favorable.
Tumors. In a small egg preferential malignant tumors are observed, from 0,5 to 3% of all malignant new growths at men fall to their share. Malignant tumors of a small egg meet at any age, but most often in 25 — 35 years. They are the main reason for death from malignant tumors of men of this age group. In rare instances malignant tumors of a small egg are observed at children under 3 years. It is established that the contributing factors to developing of tumors are a cryptorchism, an injury of a small egg, a hypoplasia or an atrophy of gyrose seed tubules, hormonal disturbances. According to E. B. Marinbakh (1972), the tumor in the neostarted-up small egg is found approximately by 65 times more often than in the small egg located in a scrotum.
According to the histologic WHO classification (1977) allocate the following groups of tumors of a small egg: The I group — the germinogenny tumors (developing from germinative cells);
The II group — tumors of a stroma of the sexual roller (the tumors developing from cells of Leydiga — so-called leydigomas, tumors developing from sustentotsit, or cells of Sulfurs-roofing felts, granulocellular tumors, etc.); The III group — tumors and the opukholepodobny defeats containing germinative cells and elements of a stroma of the sexual roller (a go-nadoblastom, etc.); The IV group — different tumors (carcinoid, etc.);
The V group — tumors of adenoid and hemopoietic tissue; The VI group — secondary (metastatic) tumors; The VII group — tumors of direct seed tubules, networks of a small egg, an epididymis, a seed cord, the capsule, rudimentary educations (mesothelioma, adenoma, etc.); The VIII group — neklassifi-tsiruyemy tumors and tumorous defeats (an epidermal cyst, etc.).
Germinogenny tumors since they make 95% of all new growths of a small egg have the greatest value. Germinogenny tumors divide into two groups: tumors
of one histologic type (seminoma, spermatocytic seminoma, embryonal cancer, tumor of a vitellicle, poliembriom, ho-rionepiteliom and teratoma); tumors more than one histologic type (a teratocarcinoma, a horionepi-telioma in combination with any other type of a tumor from germinative cells).
The seminoma (see) represents one node, several nodes consisting of the transformed germinative cells are more rare. At embryonal cancer (see) a tumor consists of undifferentiated cells of epithelial type; in metastasises in some cases along with structures of embryonal cancer there can be elements of a teratoma (see) and horionepitelioma are more rare (see. Trophoblastic disease). The tumor of a vitellicle is constructed of the undifferentiated primitive cells growing in a type of friable ferruterous and looped educations. It occurs preferential at children aged from 4 months to 3V2 years, is very rare — at adults.
Tumors of a small egg proceed in the beginning asymptomatically therefore, despite availability of a small egg to inspection, from 30 to 50% of patients come to a hospital with metastasises. Early symptoms of a tumor of a small egg is its painless increase or consolidation. In an initial stage the tumor is defined in the form of a small dense small knot at the normal sizes and a consistence of a small egg. In process of growth of a tumor the small egg becomes dense, hilly. At embryonal cancer the small egg can be moderately increased in a size, and increase happens slowly. Gradually the epididymis is involved in tumoral process. Pain usually develops at significant increase in a small egg and at spread of a tumor on a seed cord. In the latter case pains are noted in inguinal area, sometimes irradiate in a leg and lumbar area. At a horionepite-lioma, the tumor which developed from sustentotsit (Sertoli's cells), and nek-ry other tumors at patients the gynecomastia develops (see) that is caused by their hormonal activity. The leydigoma produces androgens that leads to premature puberty at boys.
Innidiation of tumors of a small egg happens on limf, to ways to retroperitoneal limf. nodes. At the same time tumors of the right small egg metastasize preferential in limf, the nodes located along the lower vena cava, left — in paraortal-ny limf. nodes. Hematogenous metastasises appear in lungs, a liver more often, is more rare in skin, bones (hl. obr. in a backbone), a brain, various departments went. - kish. path.
The clinic uses the International classification of tumors of a small egg by the TNM system: T — primary tumor; T0 — primary tumor is not defined; — the tumor does not go beyond a white and does not break a form and size of a small egg; T2 — a tumor, without going beyond a white, leads to increase and deformation of a small egg; The T3 — a tumor sprouts a white and extends to an epididymis; T4 — a tumor extends out of limits of a small egg and an appendage, sprouts a scrotum and (or) a seed cord. N — regional limf, nodes; Nx — to estimate a condition regional limf, nodes are impossible; at addition with data gistol. researches limf, nodes use the designations Nx_ — metastasises in regional limf, nodes are absent, Nx + — are available metastasises in regional limf, nodes; Nx — metastasises in regional limf, nodes are not probed, but are defined at rentgenol. a research or by means of tracer techniques of a research; N2 — metastasises in regional limf, nodes are probed. M — the remote metastasises; There is no M0 — the remote metastasises; Mkh — existence of metastasises in remote limf, nodes; Sq.m — existence of metastasises in the remote bodies; M3 — existence of metastasises in remote limf, nodes and the remote bodies. Using this classification, it is possible to reflect briefly and rather in detail by means of the specified symbols the corresponding stage of tumoral process. E.g., the tumor of a small egg, edge sprouts a white and extends to an appendage, in the presence of metastasises in regional limf, nodes and the remote bodies is designated as follows — T3Nx+M2.
Clinical classification of tumors of a small egg by stages: The I stage — a tumor of the small sizes, does not sprout a white and does not break a form of a small egg; The II stage — a tumor without metastasises, goes beyond a white, breaks a form of a small egg; The III stage — a big hilly tumor with metastasises in regional limf, nodes;
The IV stage — primary tumor, as in the I—II stages, but with metastasises in regional limf, nodes and the remote bodies.
The diagnosis is established on the basis by a wedge, pictures and the results received by means of special methods of a research (laboratory, radiological, radio isotope, ultrasonic, etc.). Horionepitelioma, embryonal cancer and teratomas with elements of these tumors often are followed by the increased content in urine of a chorionic gonadotrophin and in blood — and - the fetoprotein defined immunol. by methods. Increase in maintenance of a chorionic gonadotrophin and level and - fetoprotein, as a rule, is not noted at patients with seminomas of a small egg. The diagnosis is confirmed by means of a puncture of a small egg and the subsequent tsitol. researches of the received material. Prevalence of tumoral process limfografiya estimate by results of excretory urography (see Urography), (see), kavo-grafiya (see) and other methods rentgenol. researches of bodies, in to-rye metastasize tumors of a small egg. The differential diagnosis of a tumor of a small egg with an orchitis, tuberculosis and syphilitic defeat is based on a wedge, yielded and results of a research of the material received at a biopsy.
Treatment of malignant tumors of a small egg complex. The choice of methods of treatment and the sequence of their use depend on a stage of a disease, gistol. structures of a tumor, the general condition of the patient and sensitivity of a tumor to this or that to lay down. to influence. The first stage of treatment is the orkhifuni-kulektomiya — simultaneous removal of a small egg and seed cord (one orkhiektomiya is insufficiently radical). The plan of further treatment is made after gistol. researches of a tumor. The patient with a seminoma of I and II stages after an orkhifu-nikulektomiya conduct a preventive course of radiation therapy of zones of innidiation either courses of chemotherapy sarcolysine or Cyclophosphanum within 2 years (at one course in 3 — 4 months). At a seminoma of III and IV stages apply antineoplastic means in combination with radiation therapy more often. At single massive metastasises preference is given to radiation therapy. At patients with other germino-gene tumors of the I—III stage (first of all it concerns patients with embryonal cancer) after an orkhifunikulektomiya carry out a retroperitoneal limfadenektomiya (see Shevassyu — to Greg of macaw operation). If in removed limf, nodes at them gistol. a research metastasises are found, carry out chemotherapy. The patient with a germinogenny tumor
of the IV stage after an orkhifunikulektomiya appoint chemotherapy. With the advent of such effective himiopreparat as Cisplatinum, Bleomycinum, Rosevinum, adriamycin, Olivomycinum, Cyclophosphanum, at tumors of the I—II stage became possible to replace a limfadenektomiya with preventive courses of chemotherapy, to-rye carry out within 1 — 2 years.
The forecast depends on a stage of a tumor of a small egg and it gistol. structures, and at widespread process — from number limf, the nodes struck with metastasises, their sizes, and also existence of metastasises in lungs. At seminomas of a small egg of the I stage 5-year survival of patients makes 93,7%, the II stages — 90%, the III stages — 57,9%, the IV stages — 26%.
of Operation on a small egg of special preparation do not demand. Anesthesia — a local infiltration anesthesia or an anesthesia. On a small egg refer bringing down and fixing of a small egg at a cryptorchism to the most frequent operations, removal of one or both testicles, removal of an epididymis, operation at a hydrocele, a biopsy of a small egg and its appendage.
Bringing down of a small egg (orkhipeksiya) consists in lengthening of a seed cord due to rectification of a yaichkovy artery and moving of a small egg to a scrotum. Operation is made in one step or in two stages (see the Cryptorchism).
Removal of both testicles (an orkhiektomiya, castration) or one small egg (hemicastration) consists in crossing of a seed cord and removal of a small egg together with an appendage (see Castration, surgical castration at men). At a tubercular orchitis (orkhiepididimit) before operation and in the postoperative period appoint antituberculous remedies. Feature of an operative measure at new growths of a small egg is obligatory opening of the inguinal channel and excision of a seed cord to an internal abdominal ring — a shouting-hifunikulektomiya. Except operations for a horionepitelioma and typical seminoma, all operations at new growths of a small egg supplement with a limfadenektomiya parietal, ileal and lumbar limf, nodes if the patient has no remote metastasises in other bodies. Removal of both testicles is shown in some cases at cancer predsta-
telny gland. According to the same indications make removal of a parenchyma of testicles with preservation of their covers (enucleation).
Removal of an epididymis (epidi-dimektomiya) is made more often at a nonspecific purulent inflammation or tubercular defeat of an epididymis after unsuccessful antitubercular therapy, especially in the presence of fistulas, and also at high-quality new growths of an appendage. Access to a small egg — through pe-
Fig. 2. Diagrammatic representation of one of stages of operation of an epididimektomiya: cross and tie up a deferent duct (i); the epididymis (2) is separated in the acute way, beginning from a tail of an appendage (3).
rednebokovy surface of a scrotum. After opening of covers of a small egg its appendage is separated in the acute way, beginning from a tail to a head (fig. 2). Existence of fistula of an epididymis demands its excision together with an appendage. In a bottom corner of a wound leave the rubber graduate for one days, layer-by-layer take in a wound. Refer damage of the yaichkovy vessels which are located in the field of a head of an appendage to complications of an epididimektomiya, a cut can lead to a necrosis of a small egg or its atrophy.
The biopsy of a small egg and its appendage is made with the diagnostic purpose at infertility in case of an obliteration of deferent ducts, in need of differential diagnosis of a nonspecific and specific inflammation, a new growth, etc. Operation can be executed under local anesthesia. Capture of a piece of fabric of a small egg or appendage for gistol. researches carry out more often in the open way. Make a section of skin 1 — 1,5 cm long, in the acute way excise a piece of fabric for a biopsy, sew up a wound. At closed, to a puncture biopsy fabric from body is taken a special trocar-vykusyvate-lem or a thick needle in the aspiration way.
Change of a small egg. First attempts of change of a gonad to the person, predprinimavshiyesya at the end of 19 century, represented implantation of fabric of a seed plant of animals for the purpose of «rejuvenation», edges it was soon left. In 50 — the 60th there are 20 century A. P. Frumkin, T. E. Gnilorybov, etc. began to carry out change
of a small egg by the organ principle, recovering blood circulation by imposing of a vascular anastomosis. Operation did not gain distribution because of graft rejection owing to a tissue incompatibility.
In 1967 I. D. Kirpatovsky offered change of a small egg in the form of the uniform anatomo-physiological complex including an appendage, a seed cord and covers with use of the microsurgical equipment for formation of an arterial and venous anastomosis of yaichkovy vessels with the lower hypogastric vessels. For the purpose of the prevention of reaction of graft rejection typing of tissues of the donor and recipient and immunodepressive therapy is carried out.
In a wedge, practice carry out autotransplantation and allotransplantation of a small egg. Autotransplantation (change of own small egg) is shown at a belly form of a bilateral cryptorchism with a high arrangement of a small egg when it is impossible to make its usual bringing down in a scrotum because of a short vascular leg.
Allotransplantation of the small egg taken from the donor is made for the purpose of completion of insufficiency of sex hormones and recovery of a sexual potentiality. In particular, it can be shown at primary hypogonadism at the young age which is clinically shown androgenic insufficiency. The transplant is taken usually from a corpse, allocating it uniform anatomo-fiziolo-gicheskim with a complex together with covers of a small egg and elements of a seed cord. At change the small egg is fixed in a scrotum (ortotopiche-Skye transplantation) or out of it — on a hip, under skin of a stomach (heterotopic transplantation).
Orthotopical allotransplantation of a small egg of special preoperative preparation does not demand. Operation is performed under anesthetic or peridural anesthesia. Technology of operation is as follows: open the pakhovy channel, cut a cross fascia and allocate the lower epigastriß artery and a vein, to-rye cross at an entrance to a vagina of a direct muscle of a stomach. The central ends of the lower epigastriß artery and vein of the same name move to the pakhovy canal and there connect to a yaichkovy artery and a vein of a transplant, to-ry place in a scrotum. The deferent duct is tied up, as a rule, since the problem of operation does not include recovery of germinative function. Patomorfol. changes of a transplantirovanny small egg are caused by the ischemia developing in the moment of its withdrawal for change,
the nost of blood circulation of body after change, and also the reaction of graft rejection which is shown defeat of an intramural vascular bed at the level of a capillary network and arterioles does not suffice.
Apply the complex immunodepressive therapy including administration of Prednisolonum, a chorionic gonadotrophin and heparin to suppression of reaction of graft rejection (see. Immunodepressive substances). Duration of a course of immunodepressive therapy depends on a current of a postoperative peryod and extent of oppression reporting immunol. the reaction controlled with the help immunol. methods (see Immunity transplant, t. 9 and t. 20, additional materials). Immunodepreseiv-ny therapy considerably slows down process of destruction of the fabric of the replaced small egg connected with reaction of a tissue incompatibility.
As objective methods of assessment of results of operation use determination of content of testosterone and gonadotropic hormone in blood, scanning of the replaced small egg. At a favorable current of the postoperative period the content of testosterone in blood increases, approaching norm in 1 — 2 month after operation.
Within the first year after ortho-topical allotransplantation of a small egg positive takes are observed approximately in 80% of cases. In the subsequent perhaps gradual depression of function of a transplant. The maximum term of preservation of hormonal function of the replaced small egg and permanent recovery of a potentiality at several patients made St. 10 years.
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