Acute Scrotum

Management of acute scrotum

While the differential diagnosis is broad 1.An accurate history and physical examination can frequently precisely define the condition. Often, 2.Carefully chosen imaging studies can complement clinical judgment and expedite therapeutic decisions. 3.A discussion of the most important and common conditions that cause acute scrotal pain or swelling follows. .

Doughnut sign

a rim of surrounding increased activity on static images.

strangulated hernia

hernia that is constricted, cut off from circulation, and likely to become gangrenous -common in children especially infancy - present with acute irreducible scrotal swelling, irritability, and symptoms and signs of intestinal obstruction - can be sometimes seen on plain films - if they are filled with the bowel, they are easy to detect on ultrasound, but sometimes these hernias are only filled with soft tissues

Epididymitis/epididymo orchitis signs and synptoms

inflammation of the epididymis or testes or both. -occurs at any age -dysuria, frequency, urethral discharge (thick and yellow suggest N. Gonorrhea -aching pain radiating to the flank , abdomen or groin -tender along epididymis - an inflammatory hydrocele - manual elevation of testicle will decrease pain (Prehn's sign) - also tender on testicle = epididymo-orchitis. Should consider mumps

Whirl pool sign

spiral twist of the spermatic cord caused by testicular torsion.

testicular torsion

twisting of the spermatic cord causing decreased blood flow to the testis

More on testicular Torsion

•"Intermittent" testicular torsion is a well-recognized entity in which a classic torsion history is obtained, but physical examination and ultrasound findings are normal. •In such cases, it is reasonable to offer an elective bilateral scrotal orchiopexy for the possibility of intermittent symptoms becoming full-fledged torsion Torsion of the appendix testis or appendix epididymis (small polypoid appendages are often found attached to the testis or epididymis and are either Mullerian or Wolffian duct remnants.) can also present with the acute onset of scrotal pain and mass. •In most cases, the testis is palpable and has a normal lie. If encountered early, the edematous, torsed appendage can often be palpated at the upper pole of the testis. •if ecchymotic, it can usually be seen through the skin and represents the "blue-dot sign." •Doppler ultrasound will demonstrate a normally perfused testis, often with hypervascularity •The appendix testis is most commonly affected by torsion. area of the appendage. This process is often self-limited, with the infarcted appendage undergoing atrophy with time. •If exploration is pursued, the appendage is simply excised and no orchidopexy is needed. • Ultrasound is valuable here to identify normal blood flow to the testis

Management of testicular torsion

•Some patients have an inappropriately high attachment of the tunica vaginalis, such that the testicle can rotate freely on the spermatic cord within the tunica vaginalis (intravaginal testicular torsion) •This congenital anomaly, called the "bell clapper deformity," consists of a transverse as opposed to longitudinal lie of the affected testis; it can be unilateral or bilateral and is a risk factor for a torsion event. This congenital abnormality is present in approximately 12% of human males. •During testis torsion, the testicle twists spontaneously on the spermatic cord, causing venous occlusion and engorgement, with subsequent arterial ischemia and infarction. Experimental evidence indicates that 720° twist is required to compromise flow through the testicular artery and result in ischemia. •In neonates, the testicle frequently has not yet descended into the scrotum, after which it becomes attached within the tunica vaginalis. •This increased mobility of the testicle predisposes it to torsion (extravaginal testicular torsion). •Testis torsion is the most common cause of testis loss in the US. The incidence in males 12 hours; and virtually no viability if detorsion is delayed >24 hours •Testicular torsion presents with the rapid onset of severe testicular pain and swelling. •The onset of pain may be preceded trauma, physical activity, or by no activity (e.g. during sleep) •It most often occurs in children or adolescents, but this diagnosis should be considered in evaluating men with scrotal pain of any age, as it may occasionally occur in men 40-50 years old. In this age group, the diagnosis is often delayed or missed due to a low suspicion because of age. •Torsion should be in the differential for any sudden acute scrotal pain or swelling. •The classic physical examination findings with testis torsion are an exquisitely tender testicle with a high, horizontal lie. •After venous outflow is occluded, there is swelling and occlusion of arterial flow. Early on, one may be able to palpate the torsed cord and the testis below it; later in the course, however, progressive edema and inflammation ensues, such that after 12-24 hours, the entire hemiscrotum appears as a confluent mass without identifiable landmarks. •At this stage, the physical examination may be indistinguishable from that seen with epididymoorchitis) •With a high degree of suspicion, one may reasonably recommend surgical exploration without delay. •If scrotal ultrasonography is readily available, and especially if the diagnosis is questionable, this test is the single most useful adjunct to the history and physical examination in the diagnosis of torsion. •The ultra-sonographer should use 4 Doppler flow to assess arterial flow within the affected testis; if arterial flow is absent, or decreased relative to the contralateral testes torsion is highly likely. •It is helpful to compare the flow patterns between both testes to help make this diagnosis. Ultrasonography may also exclude significant testicular trauma, show a hernia extending into the scrotum, and can distinguish epididymitis from torsion by demonstrating increased flow to the epididymis and adnexal structures along with preserved testicular perfusion. Beware of the ultra-sonographer who suggests that a "complex mass" exists above the testis that might represent an inflamed epididymis; the torsed cord with edema and inflammation is difficult to distinguish from an inflamed epididymis in torsion. Remember, testicular perfusion is the key to the ultrasound diagnosis of torsion. •Tests such as nuclear testicular scans, CT or MRI, have essentially no role in the contemporary management of acute testicular processes. •When torsion is diagnosed, urgent surgical exploration and detorsion is mandated, as testicular torsion is a true vascular emergency. Testicular preservation is excellent when corrected within 4-6 hours of onset. •Beyond 12 hours, the risk of subsequent testis atrophy is significant with detorsion. Testis salvage is often still appropriate if the testicular appearance at exploration improves with observation following detorsion. •The alternative to detorsion is scrotal orchiectomy for pain relief in affected patients. After sharply entering the scrotum, the tunica vaginalis is opened. Then the testis detorsed and wrapped in a warm, moist gauze. •The contralateral side then undergoes orchidopexy to prevent torsion on that side.

Causes of referred pain

- abdominal aortic aneurysm • urolithiasis • lower lumbar or sacral nerve root compression • retrocecal appendicitis • retroperitoneal tumor • Post herniorrhaphy pain.

Fournier's gangrene

-Fournier's gangrene is a necrotizing fasciitis of the perineum caused by a mixed infection with aerobic/anaerobic bacteria, which often involves the scrotum. •Characterized by severe pain that generally starts on the anterior abdominal wall, migrates into the gluteal muscles and onto the scrotum and penis

Imaging for Testicular torsion

-If the etiology of an acute scrotal process is equivocal after history and physical examination, color Doppler ultrasonography is the diagnostic test of choice to differentiate testicular torsion from other causes, including epididymitis. - lack of immediate access to scrotal ultrasound should not delay surgical exploration.

Referred pain

-Men who have the acute onset of scrotal pain without local inflammatory signs or a scrotal mass on examination may be suffering from referred pain to the scrotum. •The diseases that may cause referred scrotal pain are diverse, reflecting the anatomy of the three somatic nerves that travel to the scrotum: the genitofemoral, ilioinguinal, and posterior scrotal nerves

Physical examination of the acute scrotum

-Position and orientation of the testes (Brunzel sign =secondary high position of testes) -Size of the testes -Cremasteric reflexes - Site of maximal tenderness - Color of the scrotum - Blue dot sign - Inguinal and abdominal examination

Treatment for testicular torsion

-Treatment for suspected testicular torsion is immediate surgical exploration with intraoperative detorsion and fixation of the testes. -Delay in detorsion of a few hours may lead to progressively higher rates of nonviability of the testis. -Manual detorsion is performed if surgical intervention is not immediately available. Surgery -Detorsion and fixation of both the involved testis and the contralateral uninvolved testis should be done since inadequate gubernacular fixation is usually a bilateral defect. - Longer periods of ischemia (>12 hours) may cause infarction of the testis with liquefaction requiring orchiectomy. Manual detorsion -If surgery is not immediately available (within two hours), it is reasonable to attempt to manually detorse the testicle -The classic teaching is that the testis usually rotates medially during torsion and can be detorsed by rotating it outward toward the thigh.

Treatment of Fournier's Gangrene

-Treatment of necrotizing fasciitis consists of early and aggressive surgical exploration and debridement of necrotic tissue, antibiotic therapy, and hemodynamic support as needed. •Antibiotic therapy alone is usually associated with a 100 percent mortality rate, highlighting the need for surgical debridement.

Management of epididymitis

-Urinalysis + urine culture Ultrasound to rule out torsion (shows increased blood flow with epididymitis) -In men above 35 give 1 gram of Azithromycin and cover for N. Gonorrhea based on local resistance patterns. -In children and men over 35, treated like an STI -NSAIDs can help reduce symptoms -If no response to treatment in 3 days require further follow up

Testicular cancer

-While most testicular tumors present as painless nodules or masses, rapidly growing germ cell tumors may cause acute scrotal pain secondary to hemorrhage and infarction. •A mass is generally palpable, and ultrasound is usually sufficient to make a diagnosis of testicular cancer.

Signs and symptoms of testicular torsion

-age typically perineal or adolescents - abdominal, flank or scrotal pain -nausea/vomiting - testicular swelling - high riding testicle

Epidydimitis and Orchitis (Epididymoorchitis)

1.Epididymitis -Epididymitis is the most common cause of scrotal pain in adults in the outpatient setting -Epididymitis is most commonly infectious in etiology, but can also be due to noninfectious causes (eg, trauma, autoimmune disease)

Others

4. Infectious conditions: Acute epididymitis Acute epididymoorchitis Acute orchitis Abscess (intratesticular, intravaginal, scrotal skin, cutaneous cysts) Gangrenous infections (Fournier's gangrene) 5. Inflammatory conditions: Henoch-Schonlein purpura (HSP) vasculitis of scrotal wall Fat necrosis 6. Scrotal wall Hernia: Incarcerated, strangulated inguinal hernia, with or without associated testicular ischemia 7. Acute on chronic events: Spermatocele, rupture or hemorrhage Hydrocele, rupture, hemorrhage or infection Testicular tumor with rupture, hemorrhage, infarction or infection Varicocele 8. Tumours: T germ cell tumours otherwise mostly painless

Fournier's gangrene signs and symptoms

A serious infection (necrotizing fasciitis) of the subcutaneous tissues of the perineum . -immunosuppressed patient: diabetic, alcoholic, liver disease - severe pain in perineum and scrotum - feeling unwell for 2-5 days prior to presentation - fever, chills, sweat - tachycardia - skin can be erythematous, edematous, blistered or gangrenous - crepitus May be present - testicles will be spared due to separate blood supply

Steps to ruling things out in acute scrotum

Acute scrotum—> history, physical exam, and urine analysis— can be of short duration with negative urine analysis Can be of long duration of symptoms and positive urine analysis. Either/or use Color Doppler ultrasound If decreased or absent blood flow then surgically explore If increased or normal blood flow then manage non operatively and observe.

Management of testicular torsion

Any suspicion at all requires a color Doppler ultrasound If torsion is obvious, attempt open book technique to distort the testicle Requires surgical management

Clinical features and diagnosis of epididymitis

Clinical features and diagnosis -In acute infectious epididymitis, palpation reveals induration and swelling of the involved epididymis with tenderness. -More advanced cases often present with testicular swelling and pain (epididymo-orchitis) with scrotal wall erythema and a reactive hydrocele. Investigations -A urinalysis and urine culture should be performed in all patients suspected of epididymitis, although urine studies are often negative in patients without urinary complaints -A urethral swab should be obtained in patients with urethral discharge and sent for culture should be performed in patients with acute onset of testicular pain to assess for testicular torsion.

Testicular Workup for Ischemia and Suspected Torsion (TWIST) score

Clinical findings Score Testicular swelling 2 Hard testis on palpation 2 Nausea or vomiting 1 High riding testis 1 Absent cremasteric reflex 1

Management for Fournier's gangrene

IV broad spectrum antibiotics CT scan Consult urology

Testicular hematoma signs and symptoms

Like rupture except swelling will be gradual and not instant

Henoch-Schonlein Purpura (HSP) signs and sumptoms

Painful scrotal edema, with purpuric rash over scrotum. May have associate vasculitic rash of buttocks and lower limb, arthritis, abdominal pain with GI bleeding and nephritis May be difficult to distinguish from testicular torsion

Trauma

Only rarely does trauma result in severe testicular injury, usually due to compression of the testis against the pubic bones from a direct blow or straddle injury. •The spectrum of traumatic complications can range from a hematocele to infection with pyocele to testicular rupture. •Testicular rupture requires surgical repair. Lesser injuries are managed according to the clinical severity and often can be treated conservatively.

Management of testicular hematoma

Pain control Elevation Ice packs

Management of testicular rupture

Pain control Ultrasound to delineate injury Consult urology, will need orchiectomy

Prehn's sign

Relief of scrotal pain by elevating testicle. NOT a reliable way to distinguish epididymitis from torsion

Testicular or epididymis rupture

Scrotal trauma eg straddle injury, bicycle, handle bars, sports injury. Delayed onset of scrotal pain and swelling Teder swollen testis, bruising, edema, hematoma or hematocele May be present

cremateric reflex

Stimulus: stroking the inner thigh of male Response: elevation of ipsilateral testicle -A normal response is cremasteric contraction with elevation of the testis. - The reflex is usually absent in patients with testicular torsion - This helps distinguish testicular torsion from epididymitis and other causes of scrotal pain, in which the reflex is typically intact.

Differential diagnosis of acute scrotum

Testicular torsion Torsion of the appendix testes Epidiymitis Orchitis Fournier's gangrene Incarcerated inguinal hernia Testicular cancer HSP (IgA Vasculitis) Mumps Referred pain (e.g. nephrolithiasis) A. Torsion of the testis (synonymous with torsion of the spermatic cord) Intravaginal; extravaginal (prenatal or neonatal) b.Appendiceal torsion, (3)Testis or epididymis Testicular infarction due to compressive hydrocele or hernia Testicular infarction due to other vascular insult (cord injury, thrombosis) (4)Trauma: Testicular rupture Intratesticular hematoma, testicular contusion Hematocele

Testicular torsion

Testicular torsion is a urologic emergency that is more common in neonates and postpubertal boys, although it can occur at any age - The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent. •Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction. •Testicular torsion may occur after an incidental event (eg, trauma) or spontaneously. •It is generally felt that the testis suffers irreversible damage after 12 hours of ischemia due to testicular torsion. •Infertility may result, even with a normal contralateral testis, because the disruption of the immunologic "blood-testis" barrier may expose antigens from germ cells and sperm to the general circulation and lead to the development of anti-sperm antibodies.

Clinical features and diagnosis

The diagnosis of testicular torsion is usually determined by acute onset of severe symptoms and characteristic physical findings, although ultrasound may be needed in equivocal cases. The onset of pain in testicular torsion is usually sudden and often occurs several hours after vigorous physical activity or minor trauma to the testicles. There may be associated nausea and vomiting. •Another typical presentation, particularly in children, is awakening with scrotal pain in the middle of the night or in the morning, •The classic finding on physical examination is an asymmetrically high-riding testis on the affected side with the long axis of the testis oriented transversely instead of longitudinally secondary to shortening of the spermatic cord from the torsion, also called the "bell clapper deformity"

Normal and surgical anatomy of the scrotum

The normal testis is oriented in the vertical axis and the epididymis is above the superior pole in the posterolateral position. (Superior Posterio lateral) Slightly Oblique Cremasteric reflex: Stroking/pinching the inner thigh should result in elevation of > 0.5 cm of the ipsilateral testicle

Treatment for epididymitis

Treatment -Acutely febrile patients with sepsis often require hospitalization for intravenous hydration and parenteral antibiotics. Ice, scrotal elevation, and nonsteroidal antiinflammatory drugs (NSAIDs) are helpful adjuncts. -Less severe cases can be treated on an outpatient basis with oral antibiotics, ice, and scrotal elevation). -Regimens that cover C. trachomatis and N. gonorrhoeae. The first-line treatment regimen includes ceftriaxone (250 mg intramuscular injection in one dose) plus doxycycline (100 mg by mouth twice a day for ten days). -Quinolones alone are no longer recommended for the treatment of epididymitis if N. gonorrhoeae is suspected (eg, in patients with acute urethritis or proctitis, high risk for sexually transmitted disease),

Henoch-Schonlein Purpura

Vasculitis due to IgA immune complex deposition; most common vasculitis in children. It's a disorder causing inflammation and bleeding in the small blood vessels.

Testicular rupture signs and symptoms

a rip or tear in the tunica albuginea resulting in extrusion of the testicular contents, including the seminiferous tubules. It is a rare complication of testicular trauma, and can result from blunt or penetrating trauma, though blunt trauma is more likely to cause rupture. -history of trauma, if not then consider cancer - immediate swelling after = rupture - on exam: tender, swollen mass, that doesn't transilluminate

Acute scrotum

scrotal pain, swelling, and redness of acute onset - may require immediate intervention - The acute scrotum in childhood or adolescence is a medical emergency. scrotal pain of acute onset that may require surgical intervention to diagnose or treat.