2. 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
3. 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
4. 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
6. Causes of Pain and Swelling
◦ Pain
◦ Testicular torsion
◦ Torsion of appendix testis
◦ Epididymitis
◦ Trauma
◦ Orchitis and Others
◦ Swelling
◦ Hydrocele
◦ Varicocele
◦ Spermatocele
◦ Tumor
7. Torsion
◦ Inadequate fixation of testes to tunica
vagnialis at gubernaculum
◦ Torsion around spermatic cord
◦ Venous compression to edema to ischemia
8. 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
9. Predisposing Anatomy
◦ Bell-clapper deformity
◦ Testicle lacks normal
attachment at vaginalis
◦ Increased mobility
◦ Tranverse lie of testes
◦ Typically bilateral
◦ Prevalence 1/125
10. 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
11. 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
12. 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
13. 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%
14. ◦ Acute torsion L testis
◦ Dec blood flow on L
◦ Late torsion on R
◦ Inc blood flow around
but dec flow w/in testis
15. Images - Torsion
◦ Decreased echogenicity
and size of right testicle
◦ Nuclear medicine scan
shows "rim sign“ =no flow
to testicle and swelling
16. 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
17. Manual Detorsion
◦ If presents before swelling
◦ Appropriate sedation
◦ In 2/3rds of cases testes
torses medially, 1/3rd lateral
◦ Success if pain relief, testes
lowers in scrotum
◦ Still need surgical fixation
18. 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
19. 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
20. 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
21. 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
23. Torsion of Appendix Testis
◦ Management supportive
◦ analgesics, scrotal support to relieve swelling
◦ Surgery for persistent pain
◦ no need for contralateral exploration
24. 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%
26. 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
28. 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
29. 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.
31. 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
32. 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
33. 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
34. 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
40. 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
41. 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
42. 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
43. Spermatocele
◦ Painless sperm containing
cyst of testis, epipdidymis
◦ Distinct mass from testis
on exam
◦ Transilluminates
◦ Do not affect fertility
◦ Surgery for pain relief only
44. 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
45. 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
46. 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
47. 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.
