Akute Scrotum 2

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Scrotal Pain and Swelling

Jesse Sturm, MD

December, 20, 2006


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Outline

Embryology and anatomy

Causes o Pain and Swelling

! "orsion, E#ididymitis, Orc$itis, "rauma

! %istory, P$ysical, &adiologic E'ams, (abs

Causes o Swelling

! %ydrocele, )aricocele, S#ermatocele, "umor,

*dio#at$ic


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Embryology

Descent o testes at +2-0 w.s gestation

Descends wit$in #rocesses /aginalis

! Out#ouc$ing o #eritoneal ca/ity

"unica /aginalis is #otential s#ace t$at remains

ater closure o #rocess /aginalis


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natomy

S#ermatic cord !testicular /essels, lym#$, /asdeerens! E#ididymis s#erm ormed in testicle and undergo

maturation, stored in lower #ortion

! )as Deerens ! muscular action #ro#els s#erm u# andout during e1aculation

ubernaculum ! i'ation #oint or testicle totunica /aginalis

"unica )aginalis ! #otential s#ace! Encom#asses anterior 23+4s o testicle

! "unica albuginea is inner layer o##osing testis


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natomy ! 5uts and olts

AnteriorPosterior


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Causes o Pain and Swelling

Pain! "esticular torsion! "orsion o a##endi' testis! E#ididymitis! "rauma! Orc$itis and Ot$ers

Swelling! %ydrocele

! )aricocele! S#ermatocele! "umor


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"orsion

*nade7uate i'ation o testes to tunica /agnialis

at gubernaculum

"orsion around s#ermatic cord

! )enous com#ression to edema to isc$emia


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E#idemiology

ccounts or +08 o all acute scrotal swelling

imodal ages ! neonatal 9in utero: and #ubertal

ages

! 6;8 occur in ages


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Predis#osing natomy

ellcla##er deormity

! "esticle lac.s normal

attac$ment at /aginalis

! *ncreased mobility

! "ran/erse lie o testes

! "y#ically bilateral

! Pre/alence


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"orsion? Clinical Presentation

bru#t onset o #ain ! usually testicular, can be

lower abdominal, inguinal

! Oten >


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"orsion? E'amination

Edematous, tender, swollen

Ele/ated rom s$ortened s#ermatic cord

! %oriAontal lie common 9PP) =08:

! &eacti/e $ydrocele may be #resent

Cremasteric rele' absent in nearly all

9unreliable in >+0mo old: 9PP) B;8:

Pre$n4s sign ele/ation relie/es #ain ine#ididymitis and not torsion is unreliable


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*ntermittent "orsion

*ntermittent #ain3swelling wit$ ra#id resolution

9seconds to minutes:

(ong inter/als between sym#toms

PE? testes wit$ $oriAontal lie, mobile testes,bul.iness o s#ermatic cord 9resol/ing edema:

Oten e/aluation is normal ! i sus#icious need

@ ollowu#


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Diagnosis ! "ime is "esticle

*deally #rom#t clinical diagnosis

*maging! Color do##ler ! decreased intratesticular low

alse F in large $ydrocele, $ematoma

Sens 6B


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cute torsion ( testis

Dec blood low on (

(ate torsion on &

*nc blood low around

but dec low w3in testis


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*mages "orsion

Decreased ec$ogenicity

and siAe o rig$t testicle

5uclear medicine scan

s$ows Hrim sign Ino low

to testicle and swelling


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Management

Detorsion wit$in 6$r I


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Manual Detorsion

* #resents beore swelling

##ro#riate sedation

*n 23+rdso cases testes

torses medially,


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"orsion? S#ecial Considerations

dolescents may be embarrassed and not see.care until late in course

"orsion


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5eonatal "orsion

G08 #renatal, +08 #ostnatal

Postnatal ty#ically G


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"orsion o ##endi' "estis

##endi' testis

! Small /estigial structure,

remnant o Mullerium duct

! Pedunculated, 0K+cm long

Ot$er a##endi' structures

Pre#ubertal estrogen may enlarge a##endi' and cause

torsion


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Pea. age +


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lue dot o gangrenous a##endi' testis


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Management su##orti/e

! analgesics, scrotal su##ort to relie/e swelling

Surgery or #ersistent #ain

! no need or contralateral e'#loration


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E#ididymitis

*nlammation o e#ididymis

Subacute onset #ain, swelling localiAed to

e#ididymis, duration o days

! it$ time swelling and #ain less localiAed

"estis $as normal /ertical lie

Systemic signs o inection

! inc C and C&P, e/er F in B;8 Cremasteric rele' #reser/ed

@rinary com#laints? disc$arge3dysuria PP) =08


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E#ididymitis

Scrotum $as o/erlying eryt$ema, edema in 608

5ormal /ertical

lie


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E#ididymitis

Se'ually acti/e males

! C$lamydia L 5K gonorr$ea L EK coli

(ess commonly #seudomonas 9elderly: and

tuberculosis 9renal ":

oung boys, adolescents oten #ostinectious9adeno/irus: or anatomic! &elu' o sterile urine t$roug$ /as into e#ididymis

! ;0G;8 o #re#ubertal boys $a/e anatomic cause byimaging


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Etiologies o E#ididymitis


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E#ididymitis Diagnosis

(eu.ocytosis on @ in N-08 o #atients

PC& C$lamydia F in ;08, C F in 208 o

se'ually acti/e

B;8 ebrile at #resentation

Do##ler and 5uclear imaging s$ow increased low

* $' consistent wit$ S"D, CDC recommends?

! C' o uret$ral disc$arge, PC& or C and ! @rine culture and @

! Sy#$ilis and %*) testing


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(aboratory d1uncts

Studies o acute #$ase reactants? C&P, *(


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Do##ler E#ididymitis

(et E#ididymitis

! *nc blood low in

and around let testis


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E#ididymitis "reatment

Se'ually acti/e treat wit$

Cetria'one3Do'ycycline or Olo'acin

Pre#ubertal boys

! "reat or coe'isting @"* i #resent

! Sym#tomatic t' wit$ 5S*Ds, rest

! &eerral all to @ or studies to rule out )@&,

#ost uret$ral /al/es, du#lications 5egati/e culture $as


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Orc$itis

*nlammation3inection o testicle

! Swelling #ain tenderness, eryt$ema and s$ininess to

o/erlying s.in

S#read rom e#ididymitis,

$ematogenous, #ost/iral

! )iral? Mum#s, co'sac.ie,

ec$o/irus, #ar/o/irus

! acterial? rucellosis


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Mum#s Orc$itis

E'tremely rare i /accinated

20+08 o #ts wit$ mum#s, G08 unilateral, rare

beore #uberty

Presents -6 days ater mum#s #arotitis

*m#aired ertility in


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"rauma

&esult o testicular com#ression against t$e#ubis bone, rom direct blow, or straddle in1uries

E'tent de#ends on location o ru#ture

! "unica albuginea ru#tures 9inner layer o tuncia/aginalis: allows intratesticular $ematoma to ru#tureinto $ematocele

! &u#ture o tunica /aginalis allow blood to collectunder scrotal wall causing scrotal $ematoma

Do##ler oten suicient to assess e'tent

Surgery or uncertain d', tunica albuginearu#ture, com#romised do##ler low


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"esticular %ematoma

lood as a illing

deect in testis


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Ot$er Causes o Pain

*ncarcerated inguinal $ernia %enoc$Sc$onlein Pur#ura

! )asculitis o testicular /essels

! &arely #resents wit$ only scrotal #ain

&eerred #ain! &etrocecal a##endi', urolit$iasis, lumbar3sacral ner/e in1ury

5on s#eciic scrotal #ain

! Minimal #ain, nl e'am ! return immediately or inc sym#toms


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Scrotal Swelling

%ydrocele

)aricocele

S#ermatocele "esticular Cancer


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%ydrocele

luid accumulation

in #otential s#ace o

tunica /aginalis

May be #rimary rom

#atent P) or secondary

to torsion3e#ididymitis


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%ydrocele

"ransilluminating

anterior cystic

mass


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%ydrocele

Mass increases in siAe during day or wit$ crying

and decreases at nig$t i communicating

* noncommunicating and >< yo ollow

* communicating 9enlarging:, scrotum tense9may im#air blood low: re7uires re#air

! @nli.ely to close s#ontaneously and #redis#oses to

$ernia


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)aricocele

Collection dilated /eins in

#am#iniorm #le'us

surrounding s#ermatic cord

More common on let side

! & /ein direct to *)C

! ( /ein acute angle to renal /ein

N208 o all adolescent males


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)aricocele

Oten asym#tomatic or c3o dull ac$e3ullness

u#on standing

S#ermatic cord $as bag o worms4 a##earance

t$at increased wit$ standing3/alsal/a * #re#ubertal, ra#idly enlarging, or #ersists in

su#ine #osition rule out *)C obstruction

Most management conser/ati/ely! Surgery i aected testis > unaected testis /olume


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S#ermatocele

Painless s#erm containing

cyst o testis, e#i#didymis

Distinct mass rom testis

on e'am

"ransilluminates

Do not aect ertility

Surgery or #ain relie only


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"esticular Cancer

Most common solid tumor in


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cute *dio#at$ic Scrotal Edema

Scrotal s.in red and tender

! underlying testis normal

! no $ydrocele

Eryt$ema e'tends o

scrotum onto #erineum

Em#iric t', cause un.nown

!nti$istamine, steroids

! &esol/es w3in -=G2$rs


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Conclusions

Clinical $istory and careul e'am are .ey actors in

ormulating accurate dierential

*maging and labs useul ad1uncts in unclear cases

! @3S su#erior to nuclear imaging i time essential

"*ME *S "ES"*C(E

! Early surgical inter/ention and @ in/ol/ement

Swelling wit$out #ain, usually less time sensiti/ediagnostically


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&eerences

Citci, OK Clinical Predictors or DiK Diagnosis o cute Scrotum,

Euro#ean JK o PedK SurgeryK Oct 200-K

la/is MK, Emergency E/aluation o Patients Presenting wit$ cute

Scrotum, cademy o Emergency MedicineK Jan 200

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