2. OUTLINE
• INTRODUCTION
• DEFINITION
• EPIDEMIOLOGY
• ANATOMY OF THE SCOTUM
• ETIOLOGY
• PATHOPHYSIOLOGY
• MANAGEMENT OF ACUTE SCROTUM
• COMPLICATIONS
• CONCLUSION
3. INTRODUCTION
• Acute scrotal pain is an important urological
emergency
• Rapid evaluation and treatment are necessary
due time dependency of certain morbid but
reversible conditions
• Though of low mortality but great morbidity
• The scrotum contains the testes for
procreation and normal sexual function
4. DEFINITION
• Acute scrotal pain is define as the
constellation of new onset pain, swelling and
or tenderness of intra scrotal contents.
• Pain is usually sudden in onset within minutes
or up to 1 to 2 days depending on the cause.
5. EPIDEMIOLOGY
• Male genitourinary complaints estimated to
0.5-2.5% of all emergency visits
• 1 in 4000 of patients within 25yrs of age
present with spermatic cord torsion
• Most cases of acute scrotum in children
presents with torsion of the testicular
appendix
• Epididymitis is the most common cause of
acute scrotum in adults
6. ANATOMY OF SCROTUM AND ITS
CONTENTS
SCROTUM
• A fibromuscular sac contains testes
and associated structures
• Consist of 2 layers
– Heavily pigmented skin
– muscular layer (cremasteric and dartos
muscle covered by fascia)
• Superficial dartos is devoid of fat and
is continues with scarpas and colles
fascia
• Septum divides it into 2
compartments
8. ANATOMY OF SCROTUM AND ITS
CONTENTS
TESTES
• Ovoid shaped organs 3-5cm in length and 3cm in
both width and depth
• Tunica albuginea envelopes them with continues
internal septations while tunica vaginalis
surrounds the tunica albuginea
• Posterior surface is covered by the epididymis
and vas deference arises from lower pole of the
epididymis
• The testicular appendix is a small tubular
appendage on the superior aspect of the testes
while the appendix epididymis is found on the
epididymis
9.
10. ANATOMY OF SCROTUM AND ITS
CONTENTS
• Blood supply of the testes is from testicular artery a
branch of abdominal aorta, deferential artery from
inferior vesical artery and cremasteric artery from
inferior epigastric artery
• Venous drainage is to the pampiniform plexus and
ultimately to testicular vein. Right testicular vein to
inferior vena cave while the left to left renal vein
• Lymph from skin, scrotal layers and tunica vaginalis to
superficial and deep inguinal nodes. Lymph from testes
and epididymis into retroperitoneum
• Nerve supply: iliohypogastric, ilioinguinal,
genitofemoral and pudendal nerves
13. ETIOLOGY
• Neuropathic/referred pain
– Urethral stone
– Inguinal hernia
– Aortic or common iliac artery aneurysm
– Nerve entrapment
– Diabetic neuropathy
– Sexual abuse
• Common causes are epididymitis, epididymo-
orchitis, testicular torsion, varicocele and
obstructed/strangulated hernia
14. PATHOPHYSIOLOGY
• Spermatic cord torsion may be intravaginal or
extravaginal
• Intravaginal frequently associated with bell
clapper deformity (spermatic cord twisting on
itself)
• Extravaginal seen almost exclusively in neonates.
• Most cases of spermatic cord torsion leading to
infarction are twisted to at least 720 degrees.
15.
16. PATHOPHYSIOLOGY
• Epididymitis is a genitourinary infection usually
due spread from bladder or urethra.
• In men < than 35yrs commonly associated with
sexually transmitted organisms (C.trachomatis,
N.gonorrhea)
• Older than 35yrs or not sexually active men
usually associated with gram negative organisms
(E.coli, k.pneumoniae, P.mirabils)
• Rare orgnisms suh as CMV, Mycobacterium and
fungi may also be implicated
19. MANAGEMENT OF ACUTE SCROTUM
• It involves taking a focused history and physical
examination
HISTORY
• Age of the patient,
• Onset,duration and characteristics of pain
• Heavy weight lifting, trauma
• Swelling, discharge, skin color changes
• Associated sx: fever,dysuria, hematospermia
• Sexual history and other co-morbid conditions
20. MANAGEMENT OF ACUTE SCROTUM
Examination
• GPE: painful distress, fever, hydration
• Abdominal
• Perineal:
– inspection for rashes, ulcers, abnormal asymmetry,
abnormal horizontal position
– Palpation of scrotal contents for tenderness, testicular
size, masses, hernia
• Examine bilaterally for cremasteric reflex, prehns
sign
21. MANAGEMENT OF ACUTE SCROTUM
INVESTIGATIONS
• Doppler USS most appropriate invx
• Scrotal USS
• Radionucleid scrotal imaging
• MRI
• Other invx: FBC, urinalysis, urine m/c/s,
urethral swab for culture in STI
22.
23. MANAGEMENT OF ACUTE SCROTUM
TREATMENT
• Testicular torsion
– Emergency surgical exploration detorsion and
orchidopexy within 6hrs of onset of symptom.
– Manual detorsion can be attempted.
Contraindicated in severe pain/ torsion of >6hrs
• Epididymitis: treat with antibiotics directed to
most likely causative organism
24. MANAGEMENT OF ACUTE SCROTUM
• Torsion of testicular appendix
– Bed rest
– Scrotal elevation
– analgesics
• Testicular trauma: blunt trauma from blows,
kicks or falling astride
– Minor: ice pack, analgesics
– If testes is bruised or swollen, emergency surgical
exploration.
27. conclusion
• Acute scrotal pain is a urological emergency
requiring prompt assessment
• Though has a diagnostic dilemma due to
diverse etiologies
• Early scrotal exploration based on careful
physical examination decrease the risk of
misdiagnosis of spermatic cord torsion.
