นพ.ประสิทธิ์ วุฒิสุทธิเมธาวี

1. Acute Scrotal Pain
13 Feb 2009
นพ.ประสิทธิ์ วุฒิสุทธิเมธาวี
หน่วยเวชศาสตร์ฉุกเฉิน
คณะแพทยศาสตร์
มหาวิทยาลัยสงขลานครินทร์

2. Background
Not uncommon presentation
Maybe cause from serious condition; rupture AAA,
Strangurated IIH, Fournier’s gangrene
Chalanging EP
Early diagnosis can prevent function loss
or complications

3. Anatomy

4. History & Clinical
Age (host.)
Pain characteristic
Sexual function
+/- Undescended testis

5. Pain Characteristic
Painless VS Painful
Sudden onset VS gradual onset
Location
Association symptoms: fever, dysuria

6. Age
- Neonate
Torsion of testis
- Prepuberty
- Post puberty : Epididymitis
- Adult : STD

7. Physical Examination
Relax
Reassure
Relate (compare) with other
side

9. Signs
Testis
Scrotum
location / axis
edema
size
erythema
tender
size
consistency
tender
erythema

10. Transillumination test
Hydrocele
+/- Chronic hydrocele
Reactive hydrocele

12. Cremasteric Reflex
Pinch inner thigh, observe testis
Present : testis elevate > 0.5 cm.
Absent : testis not elevate or elevate < 0.5 cm.
 Torsion of testis

13. Frehn’s Sign
Scrotum elevation
Positive : pain relief
Negative : pain persist  Torsion of testis

14. Investigations
Urine analysis (UA.) +/- U/C
Complete blood count
Plain X-rays
Color doppler USG
Nuclear scintigraphy

15. Color Doppler USG
No clinical strongly of testicular torsion
No pain free intervals
No pathognomonic findings
No clinical diagnosis of epididymitis
Scrotal trauma

16. Color Doppler USG
Increase blood flow
Epididymitis, Torsion of appendage
Decrease blood flow
Torsion of testis

19. Nuclear Scintigraphy
(Testicular Scan)
Radioisotope (Tc99m)
Uptake at 30 min
Positive : radioisotope uptake
Negative : no radioisotope uptake

22. Nuclear Scintigraphy
Limitations
Availability
Can not identify anatomy if testicular rupture
Can not detect spontaneous detorsion
Same result in epididymitis and
torsion of testicular appendage

23. Common diagnosis

24. Differential Diagnosis
Emergent
Torsion of testis Rupture of testis
Fournier’s gangrene Peritonitis
AAA

26. Differential Diagnosis
Non-emergent
Torsion of appendage Epididymitis
Orchitis Inguinal hernia
Scrotal hematoma / abscess

27. Differential Diagnosis
Non-emergent
Testicular neoplasm Renal colic
Hydrocele / Varicocele
Venomous insect bite

30. Most common diagnosis
Torsion of testis
Torsion of testicular appendage
Epididymitis
Orchitis

31. Torsion of testis

32. Incidence
1/4,000 annual (men < 25 years old)
Dimorphic
Neonate : < 1 year
Pre-puberty : 12-18 years old (14 yrs)
Undescended testis

33. Pathophysiology
“Bell-Clapper” deformity
Redundant spermatic cord
Medial rotation (aldolescence)
Right: clockwise
Left : counterclockwise

37. Signs & Symptoms
Sudden scrotal pain +/- N/V, fever
High riding testis
Transverse axis of testis

38. Suspicion Torsion of Testis
High riding testis
Abnormal axis (upright position)
Abnormal position of the epididymis in
scrotum
Abnormal axis in contralateral testis (bell
clapper” deformity) except in 180o rotation

40. Investigations
Urine analysis
Complete Blood Count
Color doppler USG: decrease blood flow
Nuclear Scintigraphy: no isotope uptake
(Duration > 12 hrs immediate Sx.)

42. Treatment
General treatment
Pain relief
Cold application
Correct Electrolyte imbalance
Pre-operative evaluation

43. Treatment
Specific treatment
Manual detorsion (temporaly)
Early Urologist (Gen Sx.) consultation
Scrotal exploration, opened
detorsion and bilateral orchiopexy

45. History, Physical Examination and urine analysis
Short duration of symptoms Long duration of symptoms
Negative urine analysis Positive urine analysis
High probability of torsion Low probability of torsion
< 6 hr
> 6 hr
Surgical exploration +/- Color doppler USG
Nuclear scintigraphy

46. Color doppler USG
Nuclear scintigraphy
Decrease or absent blood flow Increase or
Equivocal Normal blood flow
Surgical exploration Non-operative management
Observation

47. Epididymitis

48. Infection
Bacteria
UTI
Congenital anomaly
Retained foley catheter
Chlamydia trachomatis
STD :
N. gonorrhea, Syphilis
TB : Cold abscess

49. Symptoms
Gradual onset
Scrotal pain
Fever (95%)
Dysuria, Urethral d/c (30-50%)
Scrotal edema

50. Signs
Scrotal swelling
Scrotal erythema
Tender at scrotal and groin

51. Difficult to differentiate
Torsion of testis Epididymitis
Sudden onset torsion Gradual onset
from of testis.
High riding Normal position / axis
Abnormal axis Tender at superior pole
Tender at groin of testis
abdomen Fever, dysuria

52. Investigations
Urine analysis : pyuria (50%)
Complete Blood Count: leukocytosis (30-50%)
Color doppler USG: normal/increase blood flow
Nuclear Scintigraphy: normal isotope uptake

54. Criteria for Diagnosis
Gradual onset of pain
Dysuria, Urethral d/c
History of urinary tract infection
Fever ( BT > 38.3 oc)
Tenderness at epididymis
Abnormal Urine analysis

55. Treatment
General treatment Specific treatment
Rest Antibiotic
Scrotal support
STD: partner
Analgesia (NSAIDs)
Cold application

56. Orchitis

58. Pathophysiology
Highly resistance to infection
Hematologic spread
Mump
Immunocompromise

59. Symptoms
Pyogenic orchitis Viral orchitis
Fever - Post parotitis 4-6
days
Malaise
- 70 % unilateral lesion
Dysuria

61. Signs
Gradual onset
Scrotal swelling / pain / edema
Prehn’s sign: positive

62. Investigations
Urine analysis : pyuria
Complete Blood Count: leukocytosis
Color doppler USG: normal/increase blood flow
Nuclear Scintigraphy: normal isotope uptake

63. Difficult to differentiate from epididymitis
Orchitis Epididymitis
tender at testis tender at superior pole
of testis

64. Treatment
General treatment
Rest
Scrotal support
Analgesia (NSAIDs)
Cold application

65. Treatment
Specific treatment
Pyogenic orchitis  antibiotic
Viral orchitis  supportive treatment
Usually improve in 3-5 days

66. Torsion of testicular appendage

67. Background
Pre aldolescence
Age 3- 13 years old (peak 7-12 yrs)
Another diagnosis is torsion of epididymal
appendage

68. Pathophysiology
Unknown
Increase estrogen level  increase size of
appendage  strangulation
Torsion  obstruct venous flow  decrease
arterial flow  ischemia and necrosis

71. Symptoms
Acute onset
Scrotal pain +/- swelling
Nausea / Vomiting
Fever
Dysuria / Urethral d/c

72. Signs
Palpate mass at superior pole of testis
Tender at testis / swelling / Blue dot sign
+/- reactive hydrocele
Transillumination test Black dot sign
Dysuria / Urethral d/c

73. Torsion of appendage Torsion of testis
Sudden onset Sudden onset
Normal position / axis High riding
Tender at superior testis Abnormal axis
Tender through testis

74. Investigations
Urine analysis
Complete Blood Count
Color doppler USG: normal/increase blood flow
Nuclear Scintigraphy: normal isotope uptake

76. Treatment
General treatment
Rest
Scrotal support
Analgesia (NSAIDs)
Cold application
Usually improve in 7-10 days

77. Conclusion

78. Goal
To detect and exclude “Torsion of testis“

79. Thank you for your attention