Acute Scrotum
Acute ScrotumIschaemic
- Torsion of testis- Torsion of appendix appendix epididymis or
appendix testis - Testicular infarction due to vascular insult
(trauma etc)
Infection
- Epididymitis, orchitis or epididymo-orchitis - Cellulitis- Forniers Gangrene- Scrotal wall abscess
Trauma
- Testicular rupture- Testicular contusion or haematoma- Haematocele
Other
- Inguinal hernia incarceration/strangulation (call Gen Paed Surg)
- Hydrocele - Varicocele- Testicular tumour (Rapidly growing/necrotic)- Henloch-Schonlein purpura vasculitis- Referred Pain
- Urolithiasis- Retrocaecal appendix- Nerve root irritation
HistoryPain: Onset, duration, severity, radiation
Trauma/activity at time of pain
Nausea/vomiting/abdominal pain
Previous episodes
Infective symptoms: Fever, rigors, diaphoresis, malodorous urine
LUTS: Dysuria, frequency
Viral symptoms: Coryzal symptoms, runny nose, cough, rash
Past History:
- Hernias- Cryptorchidism- Previous inguinal or scrotal surgery- Ureteric calculi
Medications/Allergies
Family History
- Hernia, torsion
Social History
- Sexual transmitted disease risk
ExaminationGeneral appearance: Distressed vs comfortable
Vital signs
Scrotum
- Erythema- Swelling- Cremaster reflex
Bilateral testes
- Size- Position- Tenderness- Thickening or tenderness of cord- Blue dot sign - Translucent- Prehn’s sign: Relief of pain with elevation
of testicle (Epididymitis)
Abdominal Examination
InvestigationsUrine MCS & First catch
Bloods: UEC/FBE/CRP
Doppler US of Testes
Surgical Exploration
Testicular TorsionIntravaginal
Torsion of the spermatic cord within the tunica vaginalis
Extravaginal
In newborns the tunica vaginalis is not adherent to the dartos, therefore the spermatic cord and the tunica vaginalis can twist as a unit.
Testicular Torsion: Predisposing FactorsHistory:
12 - 18 years oldAcute onset severe testicular pain with or without swellingHistory of intermittent torsion: Acute onset of pain that spontaneously resolves
Predisposing Factors:
Cryptorchidism
Bell Clapper deformity
Testicular Torsion: PresentationPhysical Examination:
Tender, firm testisHigh riding Horizontal lieAbsent cremasteric reflexThick or knotted spermatic cordEpididymis not posterior to testis
Testicular Torsion: DiagnosisClinical suspicion
Do not delay surgical exploration to perform imaging tests
Pre operative counselling
Attempt to untort, by externally rotating testes if an operating facility is not immediately accessible.
Surgical exploration
- < 6 hours most testis remain viable- > 24 hours few remain viable- Affected testes is detorted - If not viable orchidectomy is performed- Always perform a bilateral orchidopexy as the contralateral testis may be at risk of subsequent torsion
Appendix Testis TorsionMinute sessile cyst attached to the upper pole of the testis
Tort’s around its pedicle
Remnant of the mullerian duct
Blue dot sign
May have swollen hemiscrotum if pain present for a few days
Younger age
Acute idiopathic scrotal oedema (AISE) ● a self-limiting condition characterised by marked oedema of the skin and dartos fascia without
involvement of the deeper layers, testes, or epididymis. It is an important condition to recognise in order to avoid unnecessary surgical exploration.
● it mostly occurs in children <10 years of age 3. Peak 3- 7 yrs● Swelling and erythema in the scrotal wall are characteristic, but the condition is not universally
painful. ● AISE can be unilateral or bilateral (approximately 90% of cases are unilateral 3) and extension
of erythema to the perineum or inguinal region is seen in half of cases.● The exact aetiology of AISE is unclear. It has been hypothesised that it represents a
hypersensitivity reaction related to a variant of angioneurotic oedema. It has been associated with eosinophilia, with a 66.7% incidence in one case series.
● AISE is a self-limiting condition, which tends to resolve in around 3-5 days. NSAIDs and antibiotics have been used in management.
● Ultrasound is the imaging modality of choice in the investigation of the acute scrotum. Thickening and oedema of the scrotal wall, hypervascularity of the scrotum, and normal appearance of the testes are considered specific for the condition.
● Geiger et al. have described the “fountain sign,” a novel finding on colour Doppler interrogation which is highly suggestive of the diagnosis 7. The “fountain” depicted on transverse imaging of the scrotum is due to marked increased hypervascularity in the scrotal wall which derives its blood supply from branches of the deep external pudendal and internal pudendal arteries via the anterior and posterior sacral arteries.
Epididymo-orchitisNon infectious causes
- Testicular or epididymal tumour- Autoimmune: Bahcet’s disease - Painful oral and genital ulcers, uveitis, non-mucous membrane skin lesions.
Henoch-Schonlein Purpura, Sarcoidosis- Amiodarone : Concentration of amiodarone at the head of the epididymis. Doesn’t respond to antibiotics. Resolves
with reduction of dose.
Infectious causes
- < 35 years old most commonly Neisseria gonorrhoeae and Chlamydia trachomatis - > 35 Escherichia Coli- Viral : Mumps and coxsackie- Granulomatous : Tuberculosis and BCG- Atypical: Fungal, Ureaplasma, Trichomonas
Epididymo-orchitis: PresentationHistory
Testicular pain: Gradual onset, mild to more intense. Signs and symptoms of urethritis Risk Factors for Sexually Transmitted DiseasesSymptoms of Bladder Outlet Obstruction
Physical ExaminationFeverSwelling and tenderness of the testicle,
epididymis or spermatic cordScrotal erythema and oedemaHydrocele
InvestigationsFBE, UEC, CRP
First catch urine for Chlamydia/GonorrhoeaMSU US Scrotum
Epididymo-orchitis: Treatment Sexually transmitted
- Ceftriaxone 500mg IV or IM as a single doseAND
- Doxycycline 100mg PO 12 hourly for 14 daysOR
- Azithromycin 1g PO as a single dose and repeat 1 week later
Non sexually transmitted - Trimethoprim 300mg daily OR cephalexin 500mg 6 hourly for 14 days
OR- Resistance suspected: Ciprofloxacin 500mg 12 hourly OR Norfloxacin 400mg 12 hourly for 14 days
Scrotal support, analgesia & ice pack Older men: Post void residuals and upper tract imagingYounger men: US KUB =/- voiding cystourethrogram +/- cystoscopyChase cultures to ensure appropriate therapy
Testicular Trauma: Testicular RuptureTear in the tunica albuginea resulting in extrusion of seminiferous tubules
Diagnosis is based on clinical suspicion:Mechanism of injury suspects significant testicular injury
Scrotal US: Heterogeneous testicular echotextureFracture site in tunica albuginea seen in 20%
Prompt surgical exploration: Avoid testicular loss, infection, infertility and chronic pain< 72 hours 80 - 90% of testis salvaged> 72 hours 32 - 45% of testis salvaged
Testicular Trauma: Testicular RuptureScrotum explored
Haematocele evacuated
Debridement of extruding seminiferous tubules and necrotic tissue
Tunica albuginea closed
Repair epididymal injuries
Consider a penrose drain
7 day course of broad spectrum antibiotics
Testicular Trauma: Intratesticular Haematoma without Rupture
Imaging and physical examination cannot reliably distinguish between intratesticular haematoma and rupture
Scrotal US: Hypoechoic or heterogenous area
If surgical exploration is undertaken and there is no rupture, a follow up US is recommended to ensure resolution of suspected intratesticular haematoma.
Top Related