Acute Scrotal Pain13 Feb 2009

นพ.ประสิทธิ์ วุฒิสุทธิเมธาวี

หน่วยเวชศาสตร์ฉุกเฉิน

คณะแพทยศาสตร์

มหาวิทยาลัยสงขลานครินทร์

BackgroundNot uncommon presentation

Maybe cause from serious condition; rupture AAA,

Strangurated IIH, Fournier’s gangrene

Chalanging EP

Early diagnosis can prevent function loss

or complications

Anatomy

History & Clinical

Age (host.)

Pain characteristic

Sexual function

+/- Undescended testis

Pain Characteristic

Painless VS Painful

Sudden onset VS gradual onset

Location

Association symptoms: fever, dysuria

Age- Neonate

- Prepuberty

- Post puberty : Epididymitis

- Adult : STD

Torsion of testis

Physical ExaminationRelax

Reassure

Relate (compare) with other side

SignsScrotum

edema

erythema

size

tender

Testis

location / axis

size

tender

consistency

erythema

Transillumination testHydrocele

+/- Chronic hydrocele

Reactive hydrocele

Cremasteric ReflexPinch inner thigh, observe testis

Present : testis elevate > 0.5 cm.

Absent : testis not elevate or elevate < 0.5 cm.

Torsion of testis

Frehn’s SignScrotum elevation

Positive : pain relief

Negative : pain persist Torsion of testis

InvestigationsUrine analysis (UA.) +/- U/C

Complete blood count

Plain X-rays

Color doppler USG

Nuclear scintigraphy

Color Doppler USGNo clinical strongly of testicular torsion

No pain free intervals

No clinical diagnosis of epididymitis

Scrotal trauma

No pathognomonic findings

Color Doppler USGIncrease blood flow

Epididymitis, Torsion of appendage

Decrease blood flow

Torsion of testis

Nuclear Scintigraphy

Radioisotope (Tc99m)

Uptake at 30 min

Negative : no radioisotope uptake

(Testicular Scan)

Positive : radioisotope uptake

Nuclear ScintigraphyAvailability

Can not identify anatomy if testicular rupture

Same result in epididymitis and

torsion of testicular appendage

Limitations

Can not detect spontaneous detorsion

Common diagnosis

Differential DiagnosisEmergent

Torsion of testis Rupture of testis

Fournier’s gangrene Peritonitis

AAA

Differential DiagnosisNon-emergent

Torsion of appendage Epididymitis

Orchitis Inguinal hernia

Scrotal hematoma / abscess

Differential DiagnosisNon-emergent

Testicular neoplasm Renal colic

Hydrocele / Varicocele

Venomous insect bite

Most common diagnosisTorsion of testis

Torsion of testicular appendage

Epididymitis

Orchitis

Torsion of testis

Incidence1/4,000 annual (men < 25 years old)

Dimorphic

Neonate : < 1 year

Pre-puberty : 12-18 years old (14 yrs)

Undescended testis

Pathophysiology“Bell-Clapper” deformity

Redundant spermatic cord

Right: clockwise

Left : counterclockwise

Medial rotation (aldolescence)

Signs & SymptomsSudden scrotal pain +/- N/V, fever

High riding testis

Transverse axis of testis

Suspicion Torsion of TestisHigh riding testis

Abnormal axis (upright position)

Abnormal position of the epididymis in

scrotumAbnormal axis in contralateral testis (bell

clapper” deformity) except in 180o rotation

InvestigationsUrine analysis

Complete Blood Count

Color doppler USG: decrease blood flow

Nuclear Scintigraphy: no isotope uptake

(Duration > 12 hrs immediate Sx.)

TreatmentGeneral treatment

Pain relief

Cold application

Correct Electrolyte imbalance

Pre-operative evaluation

TreatmentSpecific treatment

Manual detorsion (temporaly)

Early Urologist (Gen Sx.) consultation

Scrotal exploration, opened

detorsion and bilateral orchiopexy

History, Physical Examination and urine analysis

Short duration of symptoms

Negative urine analysis

High probability of torsion

Long duration of symptoms

Positive urine analysis

Low probability of torsion

Surgical exploration Color doppler USG

Nuclear scintigraphy

> 6 hr< 6 hr

+ / -

Color doppler USG

Nuclear scintigraphy

Decrease or absent blood flow

Equivocal

Increase or

Normal blood flow

Surgical exploration Non-operative management

Observation

Epididymitis

InfectionBacteria

STD :

TB :

UTI

Congenital anomaly

Retained foley catheter

Chlamydia trachomatis

N. gonorrhea, Syphilis

Cold abscess

SymptomsGradual onset

Scrotal pain

Fever (95%)

Dysuria, Urethral d/c (30-50%)

Scrotal edema

SignsScrotal swelling

Scrotal erythema

Tender at scrotal and groin

Difficult to differentiate

from torsion of testis.

Torsion of testis

Sudden onset

High riding

Abnormal axis

Tender at groin

abdomen

Epididymitis

Gradual onset

Normal position / axis

Tender at superior pole

of testis

Fever, dysuria

InvestigationsUrine analysis : pyuria (50%)

Complete Blood Count: leukocytosis (30-50%)

Color doppler USG: normal/increase blood flow

Nuclear Scintigraphy: normal isotope uptake

Criteria for DiagnosisGradual onset of pain

Dysuria, Urethral d/c

History of urinary tract infection

Fever ( BT > 38.3 oc)

Tenderness at epididymis

Abnormal Urine analysis

Treatment

General treatment

Rest

Scrotal support

Analgesia (NSAIDs)

Cold application

Specific treatment

Antibiotic

STD: partner

Orchitis

PathophysiologyHighly resistance to infection

Hematologic spread

Mump

Immunocompromise

SymptomsPyogenic orchitis

Fever

Malaise

Dysuria

Viral orchitis

- Post parotitis 4-6

days

- 70 % unilateral lesion

Signs

Gradual onset

Scrotal swelling / pain / edema

Prehn’s sign: positive

Investigations

Urine analysis : pyuria

Complete Blood Count: leukocytosis

Color doppler USG: normal/increase blood flow

Nuclear Scintigraphy: normal isotope uptake

Difficult to differentiate from epididymitis

Orchitis

tender at testis

Epididymitis

tender at superior pole

of testis

TreatmentGeneral treatment

Rest

Scrotal support

Analgesia (NSAIDs)

Cold application

TreatmentSpecific treatment

Pyogenic orchitis antibiotic

Viral orchitis supportive treatment

Usually improve in 3-5 days

Torsion of testicular appendage

Background

Pre aldolescence

Age 3- 13 years old (peak 7-12 yrs)

Another diagnosis is torsion of epididymal

appendage

Pathophysiology

Unknown

Increase estrogen level increase size of

appendage strangulation

Torsion obstruct venous flow decrease

arterial flow ischemia and necrosis

SymptomsAcute onset

Scrotal pain +/- swelling

Nausea / Vomiting

Fever

Dysuria / Urethral d/c

SignsPalpate mass at superior pole of testis

Tender at testis / swelling / Blue dot sign

+/- reactive hydrocele

Transillumination test Black dot sign

Dysuria / Urethral d/c

Torsion of testis

Sudden onset

High riding

Abnormal axis

Tender through testis

Torsion of appendage

Sudden onset

Normal position / axis

Tender at superior testis

InvestigationsUrine analysis

Complete Blood Count

Color doppler USG: normal/increase blood flow

Nuclear Scintigraphy: normal isotope uptake

TreatmentGeneral treatment

Rest

Scrotal support

Analgesia (NSAIDs)

Cold application

Usually improve in 7-10 days

Conclusion

Goal

To detect and exclude “Torsion of testis“

Thank you for your attention