Acute ScrotumAcute Scrotum

Acute scrotal pain, Acute scrotal pain,

tenderness, swellingtenderness, swelling

Differential Diagnosis of the Acute/Subacute ScrotumDifferential Diagnosis of the Acute/Subacute Scrotum

Torsion of the spermatic cord Torsion of the spermatic cord Torsion of the appendix testis Torsion of the appendix testis Torsion of the appendix epidibymis Torsion of the appendix epidibymis Epididymitis Epididymitis Epididymo-orchitisEpididymo-orchitisInguinal herniaInguinal herniaCommunicating hydroceleCommunicating hydroceleHydroceleHydroceleHydrocele of the cordHydrocele of the cordTrauma/insect biteTrauma/insect biteDermatologic lesions Dermatologic lesions Inflammatory vasculitis (Henoch-Schonleiin purpura)Inflammatory vasculitis (Henoch-Schonleiin purpura)Idiopathic scrotal edemaIdiopathic scrotal edemaTumor Tumor SpermatoceleSpermatoceleVaricoceleVaricoceleNonurogenital pathology (e. g., adductor tendinitis)Nonurogenital pathology (e. g., adductor tendinitis)

Torsion of the spermatic cordTorsion of the spermatic cord

- Irreversible ischemic injury may begin as soon Irreversible ischemic injury may begin as soon as 4 hrs as 4 hrs

- 50%50% of men whose testes were detorsed less of men whose testes were detorsed less than than 44 hrs had normal S/A hrs had normal S/A

- Pts younger than Pts younger than 1818 yrs were prone to testicular yrs were prone to testicular lossloss

- It is most common during adolescenceIt is most common during adolescence

(12-18yrs)(12-18yrs)- The incidence is estimated to be The incidence is estimated to be 11 in in 40004000 male male

Pts less than Pts less than 2525 yrs. yrs.

EtiologyEtiology

- Intravaginal torsion Intravaginal torsion

- Bell-clapper deformity Bell-clapper deformity

- Added weight of the testis after puberty Added weight of the testis after puberty

Testicular TorsionTesticular Torsion- TraumaTrauma

- Athletic activity Athletic activity

- Awakened from sleepAwakened from sleep

- Contraction of the cremasteric muscleContraction of the cremasteric muscle

PresentationPresentation

- Acute onset of scrotal pain Acute onset of scrotal pain - Some instance the onset appears to be more Some instance the onset appears to be more

gradualgradual- Prior episode of sever, self limited scrotal Prior episode of sever, self limited scrotal

pain and swelling pain and swelling - Nausea, vomiting Nausea, vomiting

Physical examination Physical examination

- High-riding High-riding - Transverse orientation Transverse orientation - Acute hydrocele or massive scrotal edema Acute hydrocele or massive scrotal edema - Absence of a cremasteric reflexAbsence of a cremasteric reflex (100%)(100%)- Manual detorsion may not totally correct Manual detorsion may not totally correct

the rotation the rotation

Imaging Imaging

- Color doppler U.S:Color doppler U.S: s sensitivity ensitivity 88.9%,88.9%, specificityspecificity 98.5%98.5%

- Radionuclide imaging:Radionuclide imaging: sensitivity sensitivity 90%,90%, specificityspecificity 89%89%

Treatment Treatment

- When the diagnosis of torsion of the cord When the diagnosis of torsion of the cord is suspected, prompt surgical exploration is suspected, prompt surgical exploration is warranted is warranted

- Sympathetic orchiopathy Sympathetic orchiopathy

- The contralateral testis must be fixed The contralateral testis must be fixed

Intermittent Torsion of the Intermittent Torsion of the Spermatic CordSpermatic Cord

- H/O prior episode of acute, self-limited H/O prior episode of acute, self-limited scrotal pain, intermittent scrotal pain, intermittent

- Elective scrotal explorationElective scrotal exploration

Torsion of Testicular and Epididymal AppendagesTorsion of Testicular and Epididymal Appendages

- Hormonal stimulation Hormonal stimulation

- Insidious onset, acute presentationInsidious onset, acute presentation

- Localized tendernessLocalized tenderness

- Blue dot sign Blue dot sign

- Cremastric reflex should be present Cremastric reflex should be present

- Radionuclide scan or color dopplerRadionuclide scan or color doppler (normal or(normal orincreased flow)increased flow)

Treatment Treatment

- When the diagnosis of a torsed When the diagnosis of a torsed appendage is confirmed clinically or by appendage is confirmed clinically or by imaging, non operative management is imaging, non operative management is suggested suggested

- NSAIDs NSAIDs

Acute idiopathic scrotal edema Acute idiopathic scrotal edema

- Self-limited, unknown cause Self-limited, unknown cause - Not associated with scrotal erythemaNot associated with scrotal erythema- Minimal tenderness Minimal tenderness - Pruritus Pruritus - Idiopath, allergic or chemical dermatitis, Idiopath, allergic or chemical dermatitis,

insect bites, traumainsect bites, trauma- U. S, color dopplerU. S, color doppler

Perinatal Torsion of the Perinatal Torsion of the Spermatic CordSpermatic Cord

- prenatally prenatally

- Immediate postnatallyImmediate postnatally

Prenatal torsionPrenatal torsion

- Hard, non tender testis, fixed to the overlying Hard, non tender testis, fixed to the overlying scrotal skin at delivery scrotal skin at delivery

- Discolored skin by underlying hemorrhagic Discolored skin by underlying hemorrhagic necrosisnecrosis

- Extravaginal torsion Extravaginal torsion - Blind-ending spermatic cord (vanishing testis)Blind-ending spermatic cord (vanishing testis)- Hard, non tender and fired to skin at birth don Hard, non tender and fired to skin at birth don

not merit surgical exploration, contralateral not merit surgical exploration, contralateral scrotal exploration has not been recommendedscrotal exploration has not been recommended

Postnatal torsionPostnatal torsion

- swelling, tenderness of the scrotumswelling, tenderness of the scrotum

- Extravaginal torsion, intravaginal torsionExtravaginal torsion, intravaginal torsion

- Prompt explorationPrompt exploration

- Exploration of contralateral testis Exploration of contralateral testis (17% bell (17% bell clapper deformity)clapper deformity)

Epididymitis Epididymitis

- Acute:Acute: pain, swelling and inflammation pain, swelling and inflammation less than 6 wk less than 6 wk

- Chronic Chronic

- Abscess, infraction, chronic pain, infertility Abscess, infraction, chronic pain, infertility

EtiologyEtiology

- Sterile urine refluxing into the vas while the Pt strained Sterile urine refluxing into the vas while the Pt strained

against a closed external urethral sphincteragainst a closed external urethral sphincter (10%)(10%)

STD organsm-N.gonorrhoeae, C.trachomatisSTD organsm-N.gonorrhoeae, C.trachomatis (<35yr)(<35yr)

- BacteriuriaBacteriuria (>35yr)(>35yr)

- Homosexual; coliforms, H.influenzae Homosexual; coliforms, H.influenzae

- Older men, pediatrics: bacteriuria Older men, pediatrics: bacteriuria

- Cryptorcoccus, brucellu, T. BCryptorcoccus, brucellu, T. B

- AmiodaroneAmiodarone

Diagnosis Diagnosis

- Swelling begin in the tail of the epididymis Swelling begin in the tail of the epididymis

- Indolent processIndolent process

- 50% of men with G. C epididymitis did not have 50% of men with G. C epididymitis did not have a urethral dischange a urethral dischange

- Past H/O UTI, urethritis, urethral Past H/O UTI, urethritis, urethral dischange,sexual activity, urethral cath, urinary dischange,sexual activity, urethral cath, urinary

tract surgerytract surgery

DiagnosisDiagnosis

- The cremastric reflex should be present The cremastric reflex should be present

- Pyuria, bacteriuiria or positive urine culture Pyuria, bacteriuiria or positive urine culture

- Urine culture may be sterile inUrine culture may be sterile in 40%40% toto 90%90% of of

pediatria pediatria

- Normal U/A dose not rule out epididymitis Normal U/A dose not rule out epididymitis

- Most boy with a clinical diagnosis of Most boy with a clinical diagnosis of

epididymitis have sterile urineepididymitis have sterile urine

DiagnosisDiagnosis

- Color Doppler sonographyColor Doppler sonography

- Radionuclide imaging Radionuclide imaging

Radiographic imaging Radiographic imaging

- Sterile urine:Sterile urine: U. SU. S

- Positive culture:Positive culture: U. S, VCUGU. S, VCUG

TreatmentTreatment - Bed rest for 1-3 dayBed rest for 1-3 day

- Scrotal elevationScrotal elevation

- NSAIDsNSAIDs

- STD related: ceftriaxone 250 mg IM +STD related: ceftriaxone 250 mg IM + TCN 500mgTCN 500mg

Doxycycline 100 mgDoxycycline 100 mg

- - Bacteriuria:Bacteriuria: (Levofloxacin or ofloxacin or systemic AB for 14-(Levofloxacin or ofloxacin or systemic AB for 14-

28 days)28 days)

For 14-28 days