The document discusses acute scrotum, which refers to acute scrotal pain with or without swelling and redness. It can be caused by conditions ranging from minor issues requiring reassurance to emergencies needing immediate surgery. Common causes include testicular torsion, epididymitis, trauma, and torsion of the appendix testis. Diagnosis involves history, exam, and sometimes ultrasound or MRI. Treatment depends on the underlying cause, with epididymitis often resolving on its own but testicular torsion requiring urgent surgery to detorse the testis within 24 hours to prevent loss of the testis. Even with timely treatment, testicular atrophy can still sometimes occur from testicular torsion.

3. ACUTE SCROTUM
BY
ABDELRAHMAN ABDELKADER
ASSIUT UROLOGY AND
NERPHEROLOGY HOSPITAL
2020

4. • The term acute scrotum is defined as acute scrotal pain with or
without swelling and erythema
• Acute scrotum is a spectrum of conditions affecting scrotum
and it’s content that ranges from incidental findings that may
require patient reassurance only or acute events that may
require immediate surgical intervention

5. ACUTE SCROTUM
1. MOST COMMONLY CAUSED BY TORSION OF THE TESTIS OR APPENDIX TESTIS, OR
EPIDIDYMITIS/EPIDIDYMO-ORCHITIS
2. OTHER CAUSES OF ACUTE SCROTAL PAIN ARE IDIOPATHIC SCROTAL OEDEMA,
3. MUMPS ORCHITIS,
4. VARICOCELE,
5. SCROTAL HAEMATOMA,
6. INCARCERATED HERNIA,
7. APPENDICITIS
8. SYSTEMIC DISEASE (E.G. HENOCH-SCHÖNLEIN PURPURA) .
9. TRAUMA CAN ALSO BE A CAUSE OF ACUTE SCROTUM AS IT CAN RELATE TO POST-
TRAUMATIC HAEMATOMAS, TESTICULAR CONTUSION, RUPTURE DISLOCATION OR
TORSION
10.SCROTAL FAT NECROSIS HAS ALSO BEEN REPORTED TO BE AN UNCOMMON CAUSE
OF MILD-TO-MODERATE SCROTAL PAIN IN PRE-PUBERTAL OVERWEIGHT BOYS
AFTER EXPOSURE TO COLD .

6. Diagnostic evaluation
• In many cases, it is not easy to determine the cause of acute scrotum based on history and physical
examination alone
• The diagnosis of acute epididymitis in boys is mainly based on clinical judgment and adjunctive investigation.
• The sudden onset of invalidating pain in combination with vomiting is typical for torsion of the testis or appendix testes.
• In general, the duration of symptoms is shorter in testicular torsion and torsion of the appendix testes compared to
epididymitis In the early phase.
• Location of the pain can lead to diagnosis. Patients with acute epididymitis experience a tender epididymis, whereas patients
with testicular torsion are more likely to have a tender testicle, and patients with torsion of the appendix testis feel isolated
tenderness of the superior pole of the testis.
• An abnormal (horizontal) position of the testis is more frequent in testicular torsion than epididymitis
• Looking for absence of the cremasteric reflex is a simple method
• Elevation of the scrotum may reduce complaints in epididymitis, but not in testicular torsion.
• Fever occurs more often in epididymitis (11-19%).
• The classical sign of a “blue dot” was found only in 10-23% of patients with torsion of the appendix testis
• Doppler US is useful to evaluate acute scrotum,but it is operator-dependent and can be difficult to perform in pre-pubertal
patients . It may also show a misleading arterial flow in the early phases of torsion and in partial or intermittent torsion. Of key
importance, persistent arterial flow does not exclude testicular torsion. In a multicenter study of 208 boys with torsion of the
testis, 24% had normal or increased testicular vascularization . A comparison with the other side should always be done.
• Scintigraphy and, more recently, dynamic contrast-enhanced subtraction MRI of the scrotum also provide a comparable
sensitivity and specificity to US . These investigations may be used when diagnosis is less likely and if torsion of the testis still

9. Management
Epididymitis:
• The aetiology is usually unclear.Epididymitis is usually self-limiting and with supportive therapy, in the form of
minimal physical activity and analgesics, heals without any squeal . However, bacterial epididymitis can be
complicated by abscess or necrotic testis and surgical exploration is required .
Testicular torsion:
• Manual detorsion of the testis is done without anaesthesia.
• It should initially be done by outwards rotation of the testis unless the pain increases or if there is obvious resistance.
• Success is defined as the immediate relief of all symptoms and normal findings at physical examination (LE: 3;),
Doppler US may be used for guidance .
• Bilateral orchiopexy is still required after successful detorsion. This should not be done as an elective procedure, but
rather immediately following detorsion.
• One study reported residual torsion during exploration in 17 out of 53 patients, including eleven patients who had
reported pain relief after manual detorsion. Torsion of the appendix testis can be managed non-operatively with the
use of anti-inflammatory & analgesics (LE: 4). During the six-week follow-up, clinically and with US, no testicular
atrophy was revealed. Surgical exploration is done in equivocal cases and in patients with persistent pain.
• Urgent surgical exploration is mandatory in all cases of testicular torsion within 24 hours of symptom onset. In
patients with testicular torsion > 24 hours, semi-elective exploration is necessary (LE: 3). There is still controversy on
whether to carry out detorsion and to preserve the ipsilateral testis, or to perform an orchiectomy, in order to preserve
contralateral function and fertility after testicular torsion of long duration (> 24 hours).

10. • long-term outcome in terms of fertility is not
conclusive:
• Despite timely and adequate detorsion and fixation of the testicle, up to half of
the patients may develop testicular atrophy, even when intraoperatively
assessed as viable.
• A recent study showed a normal pregnancy rate after unilateral testicular
torsion, with no difference between the patients undergoing orchidopexy and
those after orchidectomy .
• Subfertility and infertility are consequences of direct injury to the testis after
the torsion. This is caused by the cut-off of blood supply, but also by post-
ischaemia-reperfusion injury that is caused after the detorsion when oxygen-
derived free radicals are rapidly circulated within the testicular parenchyma.
• Androgen levels Even though the levels of FSH, luteinising hormone (LH) and
testosterone are higher in patients after testicular torsion compared to normal
controls, endocrine testicular function remains in the normal range after

12. • Thank you