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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.