M 1: T A S: Odule HE Cute Crotum
M 1: T A S: Odule HE Cute Crotum
LEARNING OBJECTIVES
At the end of this rotation, the student should be able to:
1. Describe six conditions that may produce acute scrotal pain or swelling.
2. Distinguish, through the history, physical examination and laboratory testing,
testicular torsion, torsion of testicular appendices, epididymitis, testicular
tumor, scrotal trauma, and hernia.
3. Appropriately order imaging studies to make the diagnosis of the acute
scrotum.
4. Determine which acute scrotal conditions require emergent surgery and which
may be handled less emergently or electively.
INTRODUCTION
The “acute scrotum” may be viewed as the urologist’s equivalent to the general
surgeon’s “acute abdomen.” Both conditions are guided by similar management
principles:
The patient history and physical examination are key to the diagnosis and often
guide decision making regarding whether or not surgical intervention is
appropriate.
Imaging studies should complement, but not replace, sound clinical judgment.
When making a decision for conservative, non-surgical care, the provider must
balance the potential morbidity of surgical exploration against the potential
cost of missing a surgical diagnosis.
A small but real, negative exploration rate is acceptable to minimize the risk of
missing a critical surgical diagnosis.
Ischemia:
Torsion of the testis (synonymous with torsion of the spermatic cord)
Intravaginal; extravaginal (prenatal or neonatal)
Appendiceal torsion, testis, or epididymis
Testicular infarction due to other vascular insult (cord injury, thrombosis,
sickle cell)
Trauma:
Testicular rupture
Intratesticular hematoma, testicular contusion
Hematocele
Infectious conditions:
Acute epididymitis
Acute epididymoorchitis
Acute orchitis
Insect bites
Abscess (intratesticular, intravaginal, scrotal cutaneous cysts)
Gangrenous infections (Fournier’s gangrene)
Inflammatory conditions:
Henoch-Schonlein purpura (HSP) vasculitis of scrotal wall
Fat necrosis, scrotal wall
Hernia:
Incarcerated, strangulated inguinal hernia, with or without associated
testicular ischemia
Acute on chronic events:
Spermatocele, rupture or hemorrhage
Hydrocele, rupture, hemorrhage, or infection
Testicular tumor with rupture, hemorrhage, infarction, or infection
Varicocele
While the differential diagnosis is broad, an accurate history and physical examination
can frequently precisely define the condition. Often, carefully chosen imaging studies
can complement clinical judgment and expedite therapeutic decisions. A discussion of
the most important and common conditions that cause acute scrotal pain or swelling
follows.
TORSION
Testicular torsion
The testicle is typically covered by the tunica vaginalis, creating a potential space
around the testis. Normally, the tunica vaginalis attaches to the posterior surface of
the testicle and allows for very little mobility of the testicle within the scrotum.
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) (Figure 1). 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 <25 years old is approximately 1:4000. Torsion more often involves the left
testicle. Among neonatal testicular torsion cases, 70% occur prenatally and 30% occur
postnatally. The testis salvage rate approaches 100% in patients who undergo
detorsion within 6 hours of the start of pain. However there is only a 20% viability rate
if detorsion occurs >12 hours; and virtually no viability if detorsion is delayed >24
hours (Figure 2).
The classic physical examination findings with testis torsion are an exquisitely tender
testicle with a high, horizontal lie. Normally the testicle has a vertical lie within the
tunica vaginalis of the scrotum – that is, the longitudinal axis of the testis is oriented
vertically. With torsion and twisting of the spermatic cord, the testis may assume an
altered lie based on the degree of twisting. 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.
Importantly, with torsion, signs of infection are usually absent: patients are usually
afebrile, free of irritative voiding symptoms such as dysuria, and harbor a normal
urinalysis and normal white blood cell count. (In later torsion, however, an elevated
WBC may be seen in response to the inflammation).
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
Doppler flow to assess arterial flow within the affected testis; if arterial flow is
absent, 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 the acute scrotum.
Small polypoid appendages are often found attached to the testis or epididymis and
are either Mullerian or Wolffian duct remnants (Figure 4). Similar to testis torsion,
torsion of the appendix testis or appendix epididymis can also present with the acute
onset of scrotal pain and mass. In most cases, however, 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 the torsed appendage is 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 in
the 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. Later in its course, it can be more
difficult to distinguish this entity from testicular torsion or epididymitis, as global
enlargement and edema of the scrotal compartment may occur. Ultrasound is
valuable here to identify normal blood flow to the testis.
TRAUMA
Penetrating and blunt testicular injury
Testicular rupture results when there is laceration of the tunica albuginea of the
testis, such that testicular parenchyma may extrude. It may occur from either blunt
or penetrating trauma. As a general principle, penetrating injuries to the scrotum
should be surgically explored. The risk of testicular injury is quite high with these
injuries. Even penetrating injuries with a tangential trajectory have a high likelihood
of injuring the testis. In cases of blunt trauma, however, the incidence of testicular
rupture varies widely, and depends on the forces exerted, the mechanism of injury,
and testis mobility. Following blunt injury, the physical examination findings may
include swelling, tenderness or ecchymosis. If one can clearly palpate the testis and it
is entirely normal to palpation, rupture is unlikely. If there is significant scrotal wall
thickening from edema or hematoma, testicular palpation may be difficult or
impossible, and scrotal ultrasonography can determine the degree of testis injury. In
addition to demonstrating a break in the continuity of the tunica albuginea or
evidence of extruded parenchyma, ultrasound evidence of a marked loss of internal
homogeneity of the testis is highly predictive of testicular rupture and warrants
surgical exploration. Blunt injury may result in testicular rupture, intratesticular
hematoma, testicular contusion (bruising) or hematocele (blood collection within the
tunica vaginalis space). Among these, only testicular rupture requires surgical repair.
Large or painful hematoceles may benefit from drainage. For intratesticular
hematoma (intact tunica albuginea, localized hematoma within an otherwise intact
testis) or local tenderness (contusion), observation, rest, cold packs and analgesics
are appropriate therapy.
Surgical exploration for trauma is performed through incisions that anticipate the
structures at risk. For penetrating trauma, a vertical incision may be easily extended
into the groin to expose the spermatic cord. For blunt trauma, a transverse incision
over the injured scrotal compartment is effective. After inspecting and draining the
tunica vaginalis space, any extruded testicular parenchyma is inspected, irrigated and
resected or retained and tunical lacerations repaired. The testicular compartment
may be drained, generally with a small Penrose drain. With trauma, most testicular
injuries are amenable to repair. Orchiectomy is indicated when there is major injury
to the spermatic cord with organ devitalization, and destruction of parenchyma is so
extensive that no significant tissue can be salvaged.
INFECTIONS
Epididymitis and epididymoorchitis
There are several features in the patient history that may indicate epididymitis, such
as a history of previous STI, recent sexual activity, irritative voiding symptoms,
BPH/incomplete emptying of the bladder, or UTI. The very sudden onset of pain and
swelling is more typical of torsion, while a more gradual, progressive onset pain
(often greater than 24 hours) suggests epididymitis. On physical examination,
epididymitis presents with tenderness posterior and lateral to the testis (the usual
location of the epididymis). Scrotal ultrasound may show an enlarged, hyper vascular
epididymis with normal or increased blood flow to the testis, which will distinguish
this condition from torsion or trauma. Abscess formation within the epididymis or in
the peri- epididymal tissues, can also be detected by ultrasound. The diagnostic
challenge occurs when trying to distinguish advanced epididymoorchitis from late
torsion. In both entities, there is typically a confluent mass in the scrotum with
edema and fixation of the overlying scrotal wall that obliterate normal anatomic
landmarks. Furthermore, advanced epididymoorchitis can result in testicular ischemia
and infarction due to compression of the testicular vasculature from epididymal
inflammation. On ultrasound, this may present in a very similar manner to testis
torsion. In either case, the lack of testis blood flow on Doppler ultrasound requires
surgical exploration which allows these conditions to be differentiated.
When diagnosed, epididymitis and orchitis are managed conservatively with
antibiotics, anti- inflammatory, analgesics, rest and scrotal elevation. If abscess
formation occurs, surgical drainage and/or orchiectomy may be necessary.
The most diagnostic is the finding of crepitus, a spongy, cracking feeling within the
skin that indicates gas-producing microorganisms underneath that can be felt in the
scrotum or perineum. When left untreated, genital gangrene will progress over hours
and result in overwhelming bacterial sepsis with an associated high mortality rate.
Therefore, broad spectrum antibiotics that cover aerobic and anaerobic organisms,
and urgent and repeated surgical drainage and debridement are required to control
the infection. At the time of surgical treatment, cystoscopy and proctoscopy may be
performed to exclude urethral and rectal abnormalities.
INGUINAL HERNIA
An acute inguinal hernia may also present as an acute scrotum. In this case, pain and
swelling involve both the scrotal contents and the groin area. Although important to
differentiate, it may be difficult to distinguish an incarcerated inguinal hernia from
other, less emergent, scrotal issues such as hydrocele, scrotal trauma, or scrotal
abscess. An incarcerated inguinal hernia involves bowel that is obstructed and is a
true surgical emergency. In selected, less acute cases, groin and scrotal ultrasound or
pelvic CT scans can clarify the diagnosis before surgical exploration. Hernia repairs
that use polypropylene mesh for correction may be associated with vas deferens
obstruction and infertility later on.
Other chronic scrotal lesions which can present acutely include hydroceles (increased
fluid within the tunical vaginalis space) and spermatoceles (cystic dilation of the fine
ducts that lead from the rete testis to the epididymal head) that hemorrhage after
trauma, or become infected. In addition, a scrotal varicocele, a condition
characterized by dilated pampiniform plexus veins and that occurs in 15% of men at
puberty, can be present for years but become acutely symptomatic. These dilated
veins surround the spermatic cord. If the varicocele has acute onset, is only right-
sided, or persists in the supine position, then inferior vena caval (IVC) obstruction
must be excluded (i.e., IVC thrombus, abdominal mass, etc.). A careful history,
physical examination and ultrasound examination is usually sufficient to diagnose
these usually benign acute on chronic events. Urgent surgical intervention is rarely
needed for drainage of a loculated infection or for a persistent hemorrhage associated
with hydroceles or spermatoceles.
SUMMARY
A full range of scrotal pathology must be considered in acute scrotum cases.
Several conditions that result in acute scrotum require surgical exploration,
making this a very time sensitive condition.
A high value is place on the history, physical examination and ultrasound
imaging for acute scrotum diagnoses.
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Lin EP et al.: Testicular torsion: twists and turns. Semin Ultrasound CT MR.
(2007)4:317-328.
Tracy CR et al.: Diagnosis and management of epididymitis. Urol Clin North Amer
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Morey AF, Brandes S, Dugi DD, 3rd, Armstrong JH, Breyer BN, Broghammer JA, et al.
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