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Scrotal Pain and Swelling
Jesse Sturm, MD
December, 20, 2006
Outline
• Embryology and anatomy
• Causes of Pain and Swelling
– Torsion, Epididymitis, Orchitis, Trauma
– History, Physic...
Embryology
• Descent of testes at 32-40 wks gestation
• Descends within processes vaginalis
– Outpouching of peritoneal ca...
Anatomy
• Spermatic cord –testicular vessels, lymph, vas
deferens
– Epididymis - sperm formed in testicle and undergo
matu...
Anatomy – Nuts and Bolts
AnteriorPosterior
Causes of Pain and Swelling
• Pain
– Testicular torsion
– Torsion of appendix testis
– Epididymitis
– Trauma
– Orchitis an...
Torsion
• Inadequate fixation of testes to tunica vagnialis
at gubernaculum
• Torsion around spermatic cord
– Venous compr...
Epidemiology
• Accounts for 30% of all acute scrotal swelling
• Bimodal ages – neonatal (in utero) and pubertal
ages
– 65%...
Predisposing Anatomy
• Bell-clapper deformity
– Testicle lacks normal
attachment at vaginalis
– Increased mobility
– Tranv...
Torsion: Clinical Presentation
• Abrupt onset of pain – usually testicular, can be
lower abdominal, inguinal
– Often < 12 ...
Torsion: Examination
• Edematous, tender, swollen
• Elevated from shortened spermatic cord
– Horizontal lie common (PPV 80...
Intermittent Torsion
• Intermittent pain/swelling with rapid resolution
(seconds to minutes)
• Long intervals between symp...
Diagnosis – “Time is Testicle”
• Ideally -- prompt clinical diagnosis
• Imaging
– Color doppler – decreased intratesticula...
• 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 "rim sign“ =no flow
to ...
Management
• Detorsion within 6hr = 100% viability
– Within 12-24 hrs = 20% viability
– After 24 hrs = 0% viability
• Surg...
Manual Detorsion
• If presents before swelling
• Appropriate sedation
• In 2/3rds
of cases testes
torses medially, 1/3rd
l...
Torsion: Special Considerations
• Adolescents may be embarrassed and not seek
care until late in course
• Torsion 10x more...
Neonatal Torsion
• 70% prenatal, 30% post-natal
• Post-natal typically 7-10 days after birth
• Unrelated to gestation age,...
Torsion of Appendix Testis
• Appendix testis
– Small vestigial structure,
remnant of Mullerium duct
– Pedunculated, 0.3cm ...
Torsion of Appendix Testis
• Peak age 3-13 yo (prepubertal)
• Sudden onset, pain less severe
• Classically, pain more ofte...
Torsion of Appendix Testis
Blue dot of gangrenous
appendix testis
Torsion of Appendix Testis
• Management supportive
– analgesics, scrotal support to relieve swelling
• Surgery for persist...
Epididymitis
• Inflammation of epididymis
• Subacute onset pain, swelling localized to
epididymis, duration of days
– With...
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
tuberc...
Etiologies of Epididymitis
Epididymitis Diagnosis
• Leukocytosis on UA in ~40% of patients
• PCR Chlamydia + in 50%, GC + in 20% of
sexually active
•...
Laboratory Adjuncts
• Studies of acute phase reactants: CRP, IL-1, IL-6
– Documented epididymitis have 4 fold increase in ...
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 c...
Orchitis
• Inflammation/infection of testicle
– Swelling pain tenderness, erythema and shininess to
overlying skin
• Sprea...
Mumps Orchitis
• Extremely rare if vaccinated
• 20-30% of pts with mumps, 70% unilateral, rare
before puberty
• Presents 4...
Trauma
• Result of testicular compression against the
pubis bone, from direct blow, or straddle injuries
• Extent depends ...
Testicular Hematoma
• Blood as a filling
defect in testis
Other Causes of Pain
• Incarcerated inguinal hernia
• Henoch-Schonlein Purpura
– Vasculitis of testicular vessels
– Rarely...
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 tors...
Hydrocele
• Transilluminating
anterior cystic
mass
Hydrocele
• Mass increases in size during day or with crying
and decreases at night if communicating
• If non-communicatin...
Varicocele
• Collection dilated veins in
pampiniform plexus
surrounding spermatic cord
• More common on left side
– R vein...
Varicocele
• Often asymptomatic or c/o dull ache/fullness
upon standing
• Spermatic cord has ‘bag of worms’ appearance
tha...
Spermatocele
• Painless sperm containing
cyst of testis, epipdidymis
• Distinct mass from testis
on exam
• Transilluminate...
Testicular Cancer
• Most common solid tumor in 15-30 yo males
– 20% of all cancers in this group
• Painless mass
– Rapidly...
Acute Idiopathic Scrotal Edema
• Scrotal skin red and tender
– underlying testis normal
– no hydrocele
• Erythema extends ...
Conclusions
• Clinical history and careful exam are key factors in
formulating accurate differential
• Imaging and labs us...
References
• Ciftci, AO. Clinical Predictors for Diff. Diagnosis of Acute Scrotum,
European J. of Ped. Surgery. Oct 2004.
...
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  1. 1. Scrotal Pain and Swelling Jesse Sturm, MD December, 20, 2006
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. Anatomy – Nuts and Bolts AnteriorPosterior
  6. 6. Causes of Pain and Swelling • Pain – Testicular torsion – Torsion of appendix testis – Epididymitis – Trauma – Orchitis and Others • Swelling – Hydrocele – Varicocele – Spermatocele – Tumor
  7. 7. Torsion • Inadequate fixation of testes to tunica vagnialis at gubernaculum • Torsion around spermatic cord – Venous compression to edema to ischemia
  8. 8. 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
  9. 9. Predisposing Anatomy • Bell-clapper deformity – Testicle lacks normal attachment at vaginalis – Increased mobility – Tranverse lie of testes – Typically bilateral – Prevalence 1/125
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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%
  14. 14. • Acute torsion L testis • Dec blood flow on L • Late torsion on R • Inc blood flow around but dec flow w/in testis
  15. 15. Images - Torsion • Decreased echogenicity and size of right testicle • Nuclear medicine scan shows "rim sign“ =no flow to testicle and swelling
  16. 16. 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
  17. 17. Manual Detorsion • If presents before swelling • Appropriate sedation • In 2/3rds of cases testes torses medially, 1/3rd lateral • Success if pain relief, testes lowers in scrotum • Still need surgical fixation
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. Torsion of Appendix Testis Blue dot of gangrenous appendix testis
  23. 23. Torsion of Appendix Testis • Management supportive – analgesics, scrotal support to relieve swelling • Surgery for persistent pain – no need for contralateral exploration
  24. 24. 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%
  25. 25. Epididymitis • Scrotum has overlying erythema, edema in 60% • Normal vertical lie
  26. 26. 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
  27. 27. Etiologies of Epididymitis
  28. 28. 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
  29. 29. 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.
  30. 30. Doppler Epididymitis • Left Epididymitis – Inc blood flow in and around left testis
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. Testicular Hematoma • Blood as a filling defect in testis
  36. 36. 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
  37. 37. Scrotal Swelling • Hydrocele • Varicocele • Spermatocele • Testicular Cancer
  38. 38. Hydrocele • Fluid accumulation in potential space of tunica vaginalis • May be primary from patent PV or secondary to torsion/epididymitis
  39. 39. Hydrocele • Transilluminating anterior cystic mass
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. Spermatocele • Painless sperm containing cyst of testis, epipdidymis • Distinct mass from testis on exam • Transilluminates • Do not affect fertility • Surgery for pain relief only
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. 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.
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