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.