Acute scrotum

1. ACUTE SCROTUM
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

2. Moderators:
Professors:
 Prof. Dr. G. Sivasankar, M.S., M.Ch.,
 Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr. J. Sivabalan, M.S., M.Ch.,
 Dr. R. Bhargavi, M.S., M.Ch.,
 Dr. S. Raju, M.S., M.Ch.,
 Dr. K. Muthurathinam, M.S., M.Ch.,
 Dr. D. Tamilselvan, M.S., M.Ch.,
 Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC,
Chennai.
2

3. DIFFERENTIAL DIAGNOSES
 Torsion of spermatic cord
 Torsion of appendix testis/epididymis
 Epididymitis
 Epididymo-orchitis
 Trauma /insect bite
 Inguinal hernia
 Inflammatory vasculitis [HSP]
 Dermatologic conditions
 Pyocele/ Fourniers gangrene
 Testicular tumor
 Idiopathic scrotal edema
 Non urologic causes/non scrotal
3
Dept of Urology, GRH and KMC,
Chennai.

4. DIFFERENTIAL DIAGNOSES
 Childhood
 Torsion of spermatic cord
 Torsion of appendages
 Hernia
 Epididymo-orchitis
 Adolescent
 Torsion of spermatic cord
 Torsion of appendages
 Epididymo-orchitis
 Mumps orchitis
 Trauma
 Adults
 Epididymo-orchitis
 Hernia
 Pyocele
 Fournier’s gangrene
 Trauma
 Tumor
 Torsion
4
Dept of Urology, GRH and KMC,
Chennai.

5. Evaluation
 Pain – onset
 Duration
 Progress
 Aggravating/ relieving factors
 Swelling- site, extent
 Dysuria ,hematuria, urethral discharge
 Obstructive voiding
 Systemic symptoms- fever,chills
 G.I symptoms
 Trauma /Instrumentation
 Drug h/o - amiodarone, topical agents
5
Dept of Urology, GRH and KMC,
Chennai.

6. Examination
 Swelling scrotum /testis/ nodule
 U/L or B/L
 Tenderness
 Prehn’s sign- elevation of testis in supine position
relieves pain
 Erythema / cellulitis
 Lie and position of testis
 Cremasteric reflex- absence100% correlation with
torsion (Rabinowitz 1984)
 Transillumination
6
Dept of Urology, GRH and KMC,
Chennai.

7. Clinical Criteria for Acute Scrotum
 Karmazyn, et al:
 172 children with testis torsion or other diagnoses
(appendix torsion and epididymitis)
 41 with testis torsion and 131 other dx
 3 factors associated with testis torsion
 Duration < 6 hours, absent or decreased cremasteric and diffuse
testicular tenderness (score 0-3).
 Children with a score of 0: no torsion
 Children with a score of 3: 87% torsion
 Ultrasound for score 1 & 2, surgery for score 3 and send home for
score 0
B. Karmazyn, et al. Pediatr Radiol, 35: 302-310, 2005
7
Dept of Urology, GRH and KMC,
Chennai.

8. INVESTIGATIONS
 URINE R/M
 URINE C/S
 HEMOGRAM
 COLOR DOPPLER USG- Sensitivity
89%,Specificity 99%(Baker et al) for torsion testis
 Radionucleide imaging -Sensitivity 90%,Specificity
89%, PPV 75% for torsion testis; false positive due to
hyperemia of scrotal wall
8
Dept of Urology, GRH and KMC,
Chennai.

9. ULTRASONOGRAM
 Assesses blood flow of the testicular
artery
 Provides information on echotexture of
the testes and surrounding tissues
 Can find abnormalities such as
hematoma, torsed appendix and
hydrocele
 Testicular torsion causes changes in
echotexture over 24-48 hours with slow
evolution of heterogeneous echotexture
indicating necrosis.
 Operator dependence: signal can be lost
with cord compression over the pubic
tubercle with the probe
 Normal testis
9
Dept of Urology, GRH and KMC,
Chennai.

10. Scrotal US
 Patient in the supine position
 Scrotum supported by a towel placed between the thighs
 A large amount of warm gel is used to minimize pressure on
the scrotal skin.
 High-frequency linear-array transducers are recommended for
performing the study: (15–8 MHz for neonates and infants and
8–5 MHz for prepubertal and pubertal boys)
 Use the fundamental mode and scan each hemi-scrotum in the
transverse and longitudinal planes.
 Spermatic cord is an important part of the examination
 The cord is identified in the inguinal canal, and its course is
followed up to the posterosuperior border of the testis
10
Dept of Urology, GRH and KMC,
Chennai.

11. Differentiation
 Torsion testis(17%)
Adolescent age
Sudden onset pain
GI symptoms,
no urinary symptoms
Prehn’s sign absent
Cremasteric reflex –ve
High riding testis
Horizontal lie
Hx of previous episodes
 Epididymo-orchitis
Adults
Gradual onset
Fever
Urinary symptoms present
Prehn’s sign present
Cremasteric reflex positive
Swollen testis and epididymis
11
Dept of Urology, GRH and KMC,
Chennai.

12. TORSION TESTIS
12
Dept of Urology, GRH and KMC,
Chennai.

13. Etiology
 Lack of normal fixation – Bell clapper
deformity
 Added weight of testis after puberty
 Trauma(5%), Athletic activity
 Sudden contraction of Cremasteric muscle
 Venous occlusion occurs first- edema
compromises arterial inflow- ischemia-
infarction
13
Dept of Urology, GRH and KMC,
Chennai.

14. ANATOMY
 Normal Testis (A)
 Bell-Clapper
Deformity(B)
 Mesenteric attachment
between epididymis and
testis (C)
 Torsion of Spermatic Cord
(D)
 E same as C, with torsion
of mesentery
14
Dept of Urology, GRH and KMC,
Chennai.

15. Types
Extravaginal torsion
15
Dept of Urology, GRH and KMC,
Chennai.

16. Types
 Intravaginal torsion
16
Dept of Urology, GRH and KMC,
Chennai.

17. Clinical features
 Sudden onset severe scrotal pain -50%
 5% insidious onset of pain
 Past hx of self limited scrotal pain and
swelling
 Nausea, vomiting, referred pain-lower
abdomen
 Absence of urinary symptoms
17
Dept of Urology, GRH and KMC,
Chennai.

18. Clinical Examination
 High riding testis due to foreshortening of
spermatic cord – 360 degree rotation- one to
several times
 Transverse orientation – obscured in late cases
due to scrotal edema
 Absence of Cremasteric reflex – 100%
specificity
TORSION IS A CLINICAL DIAGNOSIS
18
Dept of Urology, GRH and KMC,
Chennai.

19. Mechanism of torsion and detorsion
 Anterior surface of each testis turns towards
the midline(patient’s perspective)
 Detorsion to be done in two planes –
craniocaudal and mediolateral (Kiesling et al)
 Twist or unscrew the testis outward towards
the thigh - open the book
 If unsuccessful, rotate in opposite direction
 Perform detorsion at initial examination
19
Dept of Urology, GRH and KMC,
Chennai.

20. Ultrasound Doppler
 Adjunctive investigation of choice
 To confirm the absence of torsion when
surgical intervention is unnecessary
 Sensitivity:– 85-90%, Specificity:–75-
95%(Learner et al, 1990)
20
Dept of Urology, GRH and KMC,
Chennai.

21. Doppler USG
Normal testis Torsion testis
21
Dept of Urology, GRH and KMC,
Chennai.

22. Radionuclide Imaging
 Originally the study of
choice
 Now more limited in its
application
 Evaluates only testicular
blood flow
 Limited use in children
 Time consuming,
expensive
22
Dept of Urology, GRH and KMC,
Chennai.

23. Pre operative consent
 Orchidectomy if testis unsalvageable
 B/L fixation in case of torsion
 No fixation if no torsion
 Small future risk of torsion despite fixation
 Long term risk of atrophy
 No guarantee of fertility
 Risk of hematoma,infection, orchitis
23
Dept of Urology, GRH and KMC,
Chennai.

24. Treatment
 Prompt surgical exploration within 4-6 hrs
 Midline raphe or transverse incision
 Affected side first
 Check viability of testis, place warm packs
 Dartos pouch fixation / suture fixation
 Explore contralateral hemiscrotum- 40% chance of
anatomic abnormalities
 Orchidectomy if unsalvageable
 If appendix testis found- remove to prevent future
confusion
24
Dept of Urology, GRH and KMC,
Chennai.

25. Torsion testis
25
Dept of Urology, GRH and KMC,
Chennai.

26. Outcome
 < 6 hours, 90% salvage
 > 24 hours, 100% loss and atrophy
 Only 50% men whose testis underwent detorsion
less than 4 hrs had normal semen analysis.
26
Dept of Urology, GRH and KMC,
Chennai.

27. Epididymo Orchitis
 Most common acute scrotum post-pubertal
 if presentation in prepubertal consider appendix testis
torsion vs. congenital anomalies
 In men younger than 35 years, epididymo-orchitis caused
by sexually transmitted pathogens - Chlamydia ,Neisseria
gonorrhoeae
 In men older than 35 years epididymo-orchitis caused by
non-sexually transmitted, Gram negative enteric organisms
causing urinary tract infections, e.g. E. coli, Pseudomonas
spp
 Gram-negative enteric organisms are more commonly the
cause of epididymo-orchitis if recent instrumentation or
catheterisation has occurred
27
Dept of Urology, GRH and KMC,
Chennai.

28. Etiology contd.
 Obstruction: adults older than 40 years usually have a bladder
outlet obstruction, (e.g. benign prostatic hyperplasia or urethral
stricture)
 Children may have various congenital abnormalities or
functional voiding problems.
 Trauma
 Behcet’s disease
 Amiodarone- dose-dependent and usually occurs at doses
greater than 200 mg daily
 brucellosis, coccidioidomycosis, blastomycosis,
cytomegalovirus and candidiasis usually occur in
immunocompromised hosts
28
Dept of Urology, GRH and KMC,
Chennai.

29. Diagnosis
 Gradual onset of pain,5% acute pain
 Bilateral in 10% cases
 Fever in 40% of patients
 Dysuria in 50% of patients
 Urinalysis may show pyuria in 50%
 Urethral swab and first void urine
 Midstream urine for microscopy, culture and
sensitivities.Sterile in 40-90% cases
29
Dept of Urology, GRH and KMC,
Chennai.

30. Ultrasound
Epididymitis
Doppler shows increased flow
30
Dept of Urology, GRH and KMC,
Chennai.

31. Radiological evaluation
• Anatomical abnormalities of the urinary tract are
common in the group infected with Gram negative
enteric organisms -further investigation of the urinary
tract should be considered in all such patients,
especially in those older than 40 years
• Adults usually have bladder outlet obstruction or
urethral stricture; children may have an ectopic
ureter, posterior urethral valves or VUR
• Prepubertal boys with positive cultures need USG
KUB and VCUG
31
Dept of Urology, GRH and KMC,
Chennai.

32. GENERAL ADVICE
 Bed rest1-3 days, scrotal elevation and
supportive underwear
 Ice packs
 Anti-inflammatory agents
 Analgesics
 Antibiotics
 Avoid instrumentation
32
Dept of Urology, GRH and KMC,
Chennai.

33. COMPLICATIONS
 Scrotal abscess
 Testicular infarction: cord swelling can limit testicular artery
blood flow
 Recurrence
 Chronic epididymitis
 Sterility is uncommon after acute epididymitis, although the
documented true incidence is unknown. Disturbances in the
sperm quality are usually transient.
 More important is the far less common azoospermia:
 Caused by the epididymal duct obstruction observed in untreated and
improperly treated men with epididymitis.
 The incidence of this condition is unknown
33
Dept of Urology, GRH and KMC,
Chennai.

34. TORSION OF APPENDAGES
 Appendix testis - Hydatid of Morgagni
 cranial remnant of mÜllerian system
 Most common appendage for torsion (90%)
 92% of all testes
 Appendix epididymis
 remnant of wolffian system
 23% of testes,usually projects from the head
 Appendix of the vas
 Appendix of cord
34
Dept of Urology, GRH and KMC,
Chennai.

35. APPENDIX TESTIS APPENDIX EPIDIDYMIS
35
Dept of Urology, GRH and KMC,
Chennai.

36.  Torsion of the appendix testis occurs mainly in
prepubertal boys (aged 7–14 years), is more
frequent on the left side
 incidence 46-71% -most common cause of
scrotal pain in the above age group
 Appendages are pedunculated structures,
which predisposes them to torsion
36
Dept of Urology, GRH and KMC,
Chennai.

37. Clinical presentation
 Gradual or sudden intense pain
 Localized in the upper pole of the testis
 Nodule of the upper scrotum with bluish skin
discoloration (“blue dot” sign) is
palpated(30%)-pathognomonic feature of this
entity (USG is not necessarily required for the
diagnosis when it is present )
37
Dept of Urology, GRH and KMC,
Chennai.

38. Investigations
 Ultrasound -Testicular appendage torsion appears as a
lesion of low echogenicity with a central
hypoechogenic area.
 If the edematous appendix and the head of the
epididymis are close enough, this condition will have
the "Mickey Mouse" appearance on transverse view
 Doppler shows normal blood flow to the testis, with
an occasional increase on the affected side
 Radionucleide scan- HOT DOT Sign-pathognomonic
 Positive results are seen in only 45% of patients
whose symptoms have lasted 5-24 hours
38
Dept of Urology, GRH and KMC,
Chennai.

39. Normal appendage
Torsion of appendix epididymis 39
Dept of Urology, GRH and KMC,
Chennai.

40. Torsion of appendix testis
40
Dept of Urology, GRH and KMC,
Chennai.

41. TORSION OF APPENDIX TESTIS
41
Dept of Urology, GRH and KMC,
Chennai.

42. Management
 Bed rest
 Nonsteroidal anti-inflammatory agents Within
days, the twisted appendix may calcify and
become detached, leaving a scrotal
calcification, known as a scrotolith
 If found on exploration for torsion simple
excision
42
Dept of Urology, GRH and KMC,
Chennai.

43. Testicular trauma
 75% blunt ,25% penetrating
 Penetrating trauma B/L 30% cases
 Protective mechanisms-
 Mobility of scrotum
 Contraction of cremaster
 Tough fibrous tunica albugenia
43
Dept of Urology, GRH and KMC,
Chennai.

44. Clinical features
 Swelling, ecchymosis-variable
 Degree of hematoma does not correlate with
severity of injury
 Look for urethral/femoral vessel injury
 Hematocele and Tenderness make examination
difficult.
44
Dept of Urology, GRH and KMC,
Chennai.

45. Testicular trauma-USG
hematocele
USG findings in # testis –inhomogenity of the parenchymal texture and
disruption of tunica albugenia
45
Dept of Urology, GRH and KMC,
Chennai.

46. Ultrasonogram
Doppler in testicular hematoma
Extra test. hematoma
Intra test.hematoma
46
Dept of Urology, GRH and KMC,
Chennai.

47. MANAGEMENT
 Early exploration and repair- of rupture, significant
hematomas/hematoceles
 Objectives: scrotal incision
 testis salvage
 Prevent infection
 Control bleeding
 Reduced convalescence
 Preservation of fertility and hormonal function
 Remove necrotic and extruded seminiferous tubules
 Close tunica albugenia with nonabsorbable suture
 Ligate vas and do delayed reconstruction
47
Dept of Urology, GRH and KMC,
Chennai.

48. Testicular trauma
Hematoma
Rupture testis
48
Dept of Urology, GRH and KMC,
Chennai.

49. Outcomes
 Salvage rates exceed 90% with exploration
within 3 days of injury
 Conservative management- 45% delayed
exploration rate, 20-50% orchidectomy rate,
33% salvage rates
 Penetrating trauma is associated with gonadal
salvage rates of 32-65% cases (Cline et al
1998)
49
Dept of Urology, GRH and KMC,
Chennai.

50. Results: Cass 1983
66 Blunt Testicular Ruptures
Conservative Early
# 23 43
Delayed (>4d) 11 0
Orchiectomy 5 (45%) 4 (9%)
Hospital stay 7.8 d 4.9 d
50
Dept of Urology, GRH and KMC,
Chennai.

51. Fournier’s Gangrene
 Necrotizing fasciitis of the perineum
 Older age, indolent onset,95% cases have
source
 Infection from skin,urethra,rectum
 Associated with strictures,instrumentation,
extravasation
 May ascend of fascial planes
 Colles > Dartos > Scarpas >Bucks
51
Dept of Urology, GRH and KMC,
Chennai.

52. Etiopathogenesis
 Predisposing factors
 DM
 Local trauma
 Paraphimosis
 Extravasation
 Local infections
 Surgery -circumcision,
hernia repair
 Urethrocutaneous fistula
52
Dept of Urology, GRH and KMC,
Chennai.

53. Clinical features
 Cellulitis ,tenderness
 Fever, systemic toxicity
 Crepitus with gangrene patches
 Dysuria, obstructive voiding
 Anemia ,hypoCa, hypoNa, raised S.Cr
 Biopsy –intact epidermis with dermal/sub
cutaneous necrosis,vascular thrombosis
53
Dept of Urology, GRH and KMC,
Chennai.

54. Management
 PROMPT DIAGNOSIS
 Hydration , antibiotics
 Immediate debridement till normal fascia
 Relook after 24-48 hrs
 Orchidectomy never needed
 SPC if extravasation/ urethral trauma
 Hyperbaric oxygen
 Mortality 20-50%
54
Dept of Urology, GRH and KMC,
Chennai.

55. Fournier’s Gangrene
55
Dept of Urology, GRH and KMC,
Chennai.

56. Mumps orchitis
 20-40% of postpubertal boys with mumps
 Bilateral ,gradual onset
 Systemic symptoms
 Follow parotitis by 4-7 days
 Urine analysis and urethral cultures to R/O
epididymitis
 Immunofluorescence antibody testing-confirm
mumps
 Spontaneous resolution in 3-10 days
56
Dept of Urology, GRH and KMC,
Chennai.

57. Idiopathic scrotal edema
 Difficult to distinguish from torsion/tumor
 Ages 2 to 11, allergic origin
 Sudden onset, unilateral or bilateral
 Minimal tenderness, no fever/scrotal erythema
 Pruritus significant
 Normal Urine analysis
 Normal gonads
 Self limiting process
 conservative treatment resolves in 3-4 days
57
Dept of Urology, GRH and KMC,
Chennai.

58. Imaging
 US findings, which include thickening of the
scrotal walls and hypervascularity, are
characteristic
Thickened walls
58
Dept of Urology, GRH and KMC,
Chennai.

59. Henoch-Scholein Purpura
 Diffuse vasculitis involving:
 skin, joints, GI tract and kidneys
 hematuria and proteinuria
 Etiology unknown
 complement / IgA involvement
 75% of patients < 7 years of age
 33% have scrotal / testicular involvement
 differentiate from torsion
 Observation ,steroids in some cases
59
Dept of Urology, GRH and KMC,
Chennai.

60. 60
Dept of Urology, GRH and KMC,
Chennai.

61. 61
Dept of Urology, GRH and KMC,
Chennai.