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39768.ppt 39768.ppt Presentation Transcript

  • Scrotal Pain and Swelling Jesse Sturm, MD December, 20, 2006
  • Outline
    • Embryology and anatomy
    • Causes of Pain and Swelling
      • Torsion, Epididymitis, Orchitis, Trauma
      • History, Physical, Radiologic Exams, Labs
    • Causes of Swelling
      • Hydrocele, Varicocele, Spermatocele, Tumor, Idiopathic
  • Embryology
    • Descent of testes at 32-40 wks gestation
    • Descends within processes vaginalis
      • Outpouching of peritoneal cavity
    • Tunica vaginalis is potential space that remains after closure of process vaginalis
  • Anatomy
    • Spermatic cord –testicular vessels, lymph, vas deferens
      • Epididymis - sperm formed in testicle and undergo maturation, stored in lower portion
      • Vas Deferens – muscular action propels sperm up and out during ejaculation
    • Gubernaculum – fixation point for testicle to tunica vaginalis
    • Tunica Vaginalis – potential space
      • Encompasses anterior 2/3’s of testicle
      • Tunica albuginea is inner layer opposing testis
  • Anatomy – Nuts and Bolts Anterior Posterior
  • Causes of Pain and Swelling
    • Pain
      • Testicular torsion
      • Torsion of appendix testis
      • Epididymitis
      • Trauma
      • Orchitis and Others
    • Swelling
      • Hydrocele
      • Varicocele
      • Spermatocele
      • Tumor
  • Torsion
    • Inadequate fixation of testes to tunica vagnialis at gubernaculum
    • Torsion around spermatic cord
      • Venous compression to edema to ischemia
  • Epidemiology
    • Accounts for 30% of all acute scrotal swelling
    • Bimodal ages – neonatal (in utero) and pubertal ages
      • 65% occur in ages 12-18yo
    • Incidence 1 in 4000 in males <25yo
    • Increased incidence in puberty due to inc weight of testes
  • Predisposing Anatomy
    • Bell-clapper deformity
      • Testicle lacks normal
      • attachment at vaginalis
      • Increased mobility
      • Tranverse lie of testes
      • Typically bilateral
      • Prevalence 1/125
  • Torsion: Clinical Presentation
    • Abrupt onset of pain – usually testicular, can be lower abdominal, inguinal
      • Often < 12 hrs duration
      • May follow exercise or minor trauma
      • May awaken from sleep
        • Cremasteric contraction with nocturnal stimulation in REM
      • Up to 8% report testicular pain in past
  • Torsion: Examination
    • Edematous, tender, swollen
    • Elevated from shortened spermatic cord
      • Horizontal lie common (PPV 80%)
      • Reactive hydrocele may be present
    • Cremasteric reflex absent in nearly all (unreliable in <30mo old) (PPV 95%)
    • Prehn’s sign elevation relieves pain in epididymitis and not torsion is unreliable
  • Intermittent Torsion
    • Intermittent pain/swelling with rapid resolution (seconds to minutes)
    • Long intervals between symptoms
    • PE: testes with horizontal lie, mobile testes, bulkiness of spermatic cord (resolving edema)
    • Often evaluation is normal – if suspicious need GU followup
  • Diagnosis – “Time is Testicle”
    • Ideally -- prompt clinical diagnosis
    • Imaging
      • Color doppler – decreased intratesticular flow
        • False + in large hydrocele, hematoma
        • Sens 69-100% and Spec 77-100%
        • Lower sensitivity in low flow pre-pubertal testes
      • Nuclear Technetium-99 radioisotope scan
        • Show testicular perfusion
        • 30 min procedure time
        • Sens and spec 97-100%
    • Acute torsion L testis
    • Dec blood flow on L
    • Late torsion on R
    • Inc blood flow around
    • but dec flow w/in testis
  • Images - Torsion
    • Decreased echogenicity
    • and size of right testicle
    • Nuclear medicine scan
    • shows &quot;rim sign“ =no flow
    • to testicle and swelling
  • Management
    • Detorsion within 6hr = 100% viability
      • Within 12-24 hrs = 20% viability
      • After 24 hrs = 0% viability
    • Surgical detorsion and orchiopexy if viable
      • Contralateral exploration and fixation if bell-clapper deformity
    • Orchiectomy if non-viable testicle
    • Never delay surgery on assumption of nonviability as prolonged symptoms can represent periods of intermittent torsion
  • Manual Detorsion
    • If presents before swelling
    • Appropriate sedation
    • In 2/3 rds of cases testes
    • torses medially, 1/3 rd lateral
    • Success if pain relief, testes
    • lowers in scrotum
    • Still need surgical fixation
  • Torsion: Special Considerations
    • Adolescents may be embarrassed and not seek care until late in course
    • Torsion 10x more likely in undescended testicle
      • Suspicious if empty scrotum, inguinal pain/swelling
    • Adult Emergency Physicians accurate in bedside US diagnoses with sens of 95% and specificity of 94% ( missed 1 epididymitis, no torsion )
    • Blavis M., Emergency Evaluation of Patients Presenting with A Cute Scrotum, Academy of Emergency Medicine. Jan 2001
  • Neonatal Torsion
    • 70% prenatal, 30% post-natal
    • Post-natal typically 7-10 days after birth
    • Unrelated to gestation age, birth weight
    • Post-natal presents in typical fashion
      • Doppler U/S and radionucleotide scans less accurate with low blood flow in neonates
      • Surgical intervention if post-natal
    • Prenatal torsion presents with painless testicular swelling, rare testicular viability
      • Rare intervention in prenatal torsion
  • Torsion of Appendix Testis
    • Appendix testis
      • Small vestigial structure,
      • remnant of Mullerium duct
      • Pedunculated, 0.3cm long
    • Other appendix structures
    • Prepubertal estrogen may
    • enlarge appendix and cause
    • torsion
  • Torsion of Appendix Testis
    • Peak age 3-13 yo (prepubertal)
    • Sudden onset, pain less severe
    • Classically, pain more often in abd or groin
    • Non-tender testicle
      • Tender mass at superior or inferior pole
    • May be gangrenous, “blue-dot” (21% of cases)
    • Normal cremasteric reflex, may have hydrocele
    • Inc or normal flow by doppler U/S
  • Torsion of Appendix Testis
    • Blue dot of gangrenous
    • appendix testis
  • Torsion of Appendix Testis
    • Management supportive
      • analgesics, scrotal support to relieve swelling
    • Surgery for persistent pain
      • no need for contralateral exploration
  • Epididymitis
    • Inflammation of epididymis
    • Subacute onset pain, swelling localized to epididymis, duration of days
      • With time swelling and pain less localized
    • Testis has normal vertical lie
    • Systemic signs of infection
      • inc WBC and CRP, fever + in 95%
    • Cremasteric reflex preserved
    • Urinary complaints: discharge/dysuria PPV 80%
  • Epididymitis
    • Scrotum has overlying erythema, edema in 60%
    • Normal vertical
    • lie
  • Epididymitis
    • Sexually active males
      • Chlamydia > N. gonorrhea > E. coli
    • Less commonly pseudomonas (elderly) and tuberculosis (renal TB)
    • Young boys, adolescents often post-infectious (adenovirus) or anatomic
      • Reflux of sterile urine through vas into epididymis
      • 50-75% of prepubertal boys have anatomic cause by imaging
  • Etiologies of Epididymitis
  • Epididymitis Diagnosis
    • Leukocytosis on UA in ~40% of patients
    • PCR Chlamydia + in 50%, GC + in 20% of sexually active
    • 95% febrile at presentation
    • Doppler and Nuclear imaging show increased flow
    • If hx consistent with STD, CDC recommends :
      • Cx of urethral discharge, PCR for C and G
      • Urine culture and UA
      • Syphilis and HIV testing
  • Laboratory Adjuncts
    • Studies of acute phase reactants: CRP, IL-1, IL-6
      • Documented epididymitis have 4 fold increase in CRP compared to testicular torsion
        • PPV 94% and NPV 94% (inc 2 fold)
        • Testicular tumor showed no increase in CRP
    Doehn C., Value of Acute Phase Proteins in the Differential Diagnosis of A Cute Scrotum, Journal of Urology. Feb 2001.
  • Doppler Epididymitis
    • Left Epididymitis
      • Inc blood flow in
      • and around left testis
  • Epididymitis Treatment
    • Sexually active treat with Ceftriaxone/Doxycycline or Ofloxacin
    • Pre-pubertal boys
      • Treat for co-existing UTI if present
      • Symptomatic tx with NASIDs, rest
      • Referral all to GU for studies to rule out VUR, post urethral valves, duplications
        • Negative culture has 100% NPV for anomaly
  • Orchitis
    • Inflammation/infection of testicle
      • Swelling pain tenderness, erythema and shininess to overlying skin
    • Spread from epididymitis,
    • hematogenous, post-viral
      • Viral: Mumps, coxsackie,
      • echovirus, parvovirus
      • Bacterial: Brucellosis
  • Mumps Orchitis
    • Extremely rare if vaccinated
    • 20-30% of pts with mumps, 70% unilateral, rare before puberty
    • Presents 4-6 days after mumps parotitis
    • Impaired fertility in 15%, inc risk if bilateral
  • Trauma
    • Result of testicular compression against the pubis bone, from direct blow, or straddle injuries
    • Extent depends on location of rupture
      • Tunica albuginea ruptures (inner layer of tuncia vaginalis) allows intratesticular hematoma to rupture into hematocele
      • Rupture of tunica vaginalis allow blood to collect under scrotal wall causing scrotal hematoma
    • Doppler often sufficient to assess extent
    • Surgery for uncertain dx, tunica albuginea rupture, compromised doppler flow
  • Testicular Hematoma
    • Blood as a filling
    • defect in testis
  • Other Causes of Pain
    • Incarcerated inguinal hernia
    • Henoch-Schonlein Purpura
      • Vasculitis of testicular vessels
      • Rarely presents with only scrotal pain
    • Referred pain
      • Retrocecal appendix, urolithiasis, lumbar/sacral nerve injury
    • Non specific scrotal pain
      • Minimal pain, nl exam – return immediately for inc symptoms
  • Scrotal Swelling
    • Hydrocele
    • Varicocele
    • Spermatocele
    • Testicular Cancer
  • Hydrocele
    • Fluid accumulation
    • in potential space of
    • tunica vaginalis
    • May be primary from
    • patent PV or secondary
    • to torsion/epididymitis
  • Hydrocele
    • Transilluminating
    • anterior cystic
    • mass
  • Hydrocele
    • Mass increases in size during day or with crying and decreases at night if communicating
    • If non-communicating and <1 yo follow
    • If communicating (enlarging), scrotum tense (may impair blood flow) requires repair
      • Unlikely to close spontaneously and predisposes to hernia
  • Varicocele
    • Collection dilated veins in
    • pampiniform plexus
    • surrounding spermatic cord
    • More common on left side
      • R vein direct to IVC
      • L vein acute angle to renal vein
    • ~20% of all adolescent males
  • Varicocele
    • Often asymptomatic or c/o dull ache/fullness upon standing
    • Spermatic cord has ‘bag of worms’ appearance that increased with standing/valsalva
    • If prepubertal, rapidly enlarging, or persists in supine position rule out IVC obstruction
    • Most management conservatively
      • Surgery if affected testis < unaffected testis volume
  • Spermatocele
    • Painless sperm containing
    • cyst of testis, epipdidymis
    • Distinct mass from testis
    • on exam
    • Transilluminates
    • Do not affect fertility
    • Surgery for pain relief only
  • Testicular Cancer
    • Most common solid tumor in 15-30 yo males
      • 20% of all cancers in this group
    • Painless mass
      • Rapidly growing germ cell tumors may cause hemorrhage and infarction
      • Present as firm mass
      • Typically do not transilluminate
    • Diagnostic imaging with U/S initially
  • Acute Idiopathic Scrotal Edema
    • Scrotal skin red and tender
      • underlying testis normal
      • no hydrocele
    • Erythema extends off
    • scrotum onto perineum
    • Empiric tx, cause unknown
      • Antihistamine, steroids
      • Resolves w/in 48-72hrs
  • Conclusions
    • Clinical history and careful exam are key factors in formulating accurate differential
    • Imaging and labs useful adjuncts in unclear cases
      • U/S superior to nuclear imaging if time essential
    • TIME IS TESTICLE
      • Early surgical intervention and GU involvement
    • Swelling without pain, usually less time sensitive diagnostically
  • References
    • Ciftci, AO. Clinical Predictors for Diff. Diagnosis of Acute Scrotum, European J. of Ped. Surgery. Oct 2004.
    • Blavis M., Emergency Evaluation of Patients Presenting with Acute Scrotum, Academy of Emergency Medicine. Jan 2001
    • Doehn C., Value of Acute Phase Proteins in the Differential Diagnosis of Acute Scrotum, Journal of Urology. Feb 2001.
    • Kaplan G., Scrotal Swelling in Children. Pediatrics in Review. Sep 2000.
    • Luzzi GA. Acute Epididymitis. BJU International. May 2001.
    • Fleisher G, Ludwig S, Henretig F. Textbook of Pediatric Emergency Medicine. 2006.