SCROTAL SWELLING ANDPAIN IN CHILDREN Presented by Dr munir suwalem S.H.O Peadiatric surgery B.M.C Benghazi - libya
The Scrotum is a cutaneous pouch which contains the testes and parts of the spermatic cords. It is divided on its surface into two lateral portions by a ridge or raphé, which is continued forward to the under surface of the penis, and backward, along the middle line of the perineum to the anus the scrotum consists of two layers ,the outer layer is integument and the inner layer is dartos tunic, which divides the scrotal pouch into two cavities for the testes,
Vessels and Nerves.— The arteries supplying the coverings of the testes are: the superficial and deep external pudendal branches of the femoral, the superficial perineal branch of the internal pudendal, and the cremasteric branch from the inferior epigastric. The veins follow the course of the corresponding arteries. The lymphatics end in the inguinal lymph glands. The nerves are the ilioinguinal and lumboinguinal branches of the lumbar plexus, the two superficial perineal branches of the internal pudendal nerve, and the pudendal branch of the posterior femoral cutaneous nerve.
The function of the scrotum appears to be to keep the temperature of the testes slightly lower than that of the rest of the body. the temperature should be one or two degrees Celsius below body temperature (around 37 degrees Celsius or 99 degrees Fahrenheit); higher temperatures may be damaging to sperm count.
CLASSIFICATION scrotalswelling is usually classified as: Painful or painless Acute or chronic
Acute scrotal swelling with pain Torsion of spermatic cord Torsion of appendix testis Acute epididymitis-orchitis Trauma Insect bite Thrombosis of spermatic vein Fat necrosis inguinal Hernia(incarcerated) Folliculitis Henoch-Schönlein purpura
EPIDEMIOLOGY Prevalence Inguinal hernias and hydroceles are the most common causes of scrotal swelling. Testiculartorsion occurs in 1:4000 boys. Varicoceles are present in 15% of male adolescents and adults.
EPIDEMIOLOGY Age Hernias can occur at any age but are more common in premature infants. Testicular torsion most commonly occurs between the ages of 12 and 18 years. Idiopathic scrotal edema affects children < 14 years. Acute inflammation of the epididymis or testis, including mumps orchitis, can occur at any age but is uncommon before adolescence. Varicoceles are usually asymptomatic and are usually detected between 10 and 15 years of age.
MECHANISM Acute scrotal swelling with pain Torsion of the testicle Twisting of the spermatic cord, with resulting compromise of the blood supply to the testis Torsion of the appendix testis When the appendix testis torses, inflammation and swelling of the testis and epididymis ensue, causing testicular pain and scrotal erythema.
MECHANISM Acute epididymitis-orchitis usually after UTI Results from an anomaly of the urinary tract, either congenital or acquired: Renalduplications and posterior urethral valves are among the more common anomalies. Withintermittent catheterization, the condition can occur from retrograde passage of bacteria back from ejaculatory ducts at the level of the prostate to the testis and epididymis.
MECHANISM Henoch-Schönlein purpura Systemic vasculitis that can cause abdominal and joint pain , May involve the scrotal wall in a minority of cases Trauma A similar appearance can follow a difficult breech delivery Severe blunt trauma affecting the scrotal contents Scrotal skin disease Insect bites, folliculitis, and allergic dermatitis may cause erythema and edema of the scrotal wall.
MECHANISM Scrotal swelling without pain Hernias and hydroceles Most are caused by persistent patency of the processus vaginalis Layers of the processus vaginalis condense late in gestation or early postnatally. Obliteration of the processus vaginalis only around the testis leads to an indirect inguinal hernia with protrusion of fluid (or other contents) through the internal ring to the end of the pouch and potentially to the scrotum.
MECHANISM Communicating hydrocele occurs when fluid travels through a processus vaginalis into the tunica vaginalis around the testis. Scrotal hydrocele occurs after complete obliteration proximally with patency distally. Hydroceles of the cord occur when the processus vaginalis obliterates proximally and distally, leaving a patent area in the midportion with retained fluid.
MECHANISM Varicoceles A predilection for the left side exists, reflecting anatomy of the left gonadal vein entering the left renal vein at a right angle. The right gonadal vein enters the vena cava directly at an angle, precluding reflux of venous blood.
HISTORY Acute scrotal swelling with pain Torsion of the testicle Acute onset of constant, severe scrotal pain aggravated by physical activity Nausea and vomiting may occur. Possible history of incidental antecedent scrotal trauma, but pain usually occurs during rest or sleep Neonatal testicular torsion Can exhibit at delivery as a nontender hard scrotal mass
HISTORY Torsion of the appendix testis Onset of pain and swelling is commonly acute but can be progressive, usually occurring during rest. Pain can be severe, but nausea and vomiting are less common than with testicular torsion. Acute epididymitis-orchitis History can reveal acute or more protracted onset of pain. The patient may have fever or dysuria or pyuria Epididymal inflammation may arise after scrotal trauma.
HISTORY Henoch-Schönlein purpura Onset may be insidious or acute, producing a variable degree of erythema and edema. In more severe cases, the process may involve the testis and epididymis, mimicking testicular torsion. Focalfat necrosis Can exhibit with scrotal pain and swelling, usually after trauma in an obese boy
HISTORY Trauma History (eg, injury from zipper entrapment of scrotal skin) can be definitive. Mumps orchitis Rarely occurs in isolation; pain and swelling usually occur within a week after parotitis. Scrotalskin disease History may be of limited utility.
HISTORY Scrotal swelling without pain Inguinalhernias and hydroceles Hernia Swelling expands with increases in intraabdominal pressure (eg, crying, bowel movements, coughing). The parent or child often reports the swelling to be smallest in the morning and largest late in the day.
HISTORY Hydrocele Whether the hydrocele is acute or whether the scrotum has been chronically enlarged is often unclear. The patient may have a history of trauma to the scrotum that stimulates production of serous fluid. Whenthe scrotum changes size during the day, suspect a communicating hydrocele.
HISTORY Tumors Usually present as a hard, painless mass (or vague heavy feeling) in the testicle detected by the child, parent, or examining physician Spermatoceles and epididymal cysts Painless and round, they usually remain stable in size but can sometimes enlarge.
PHYSICAL EXAM Acute scrotal swelling with pain Torsion of the testicle Scrotal erythema Swelling of the involved hemiscrotum Higher-than-normal position of the testis within the scrotum Palpation may show a horizontal rather than normal vertical orientation of the testicle. Evaluation of the cremasteric reflex should begin on the contralateral side; palpate the apparently unaffected testis to confirm normal size and position. Unilateral loss of the cremasteric reflex on the side of the swelling and pain highly correlates with the presence of torsion.
PHYSICAL EXAM The testis should then be palpated. Despite the pain this maneuver may cause, it helps differentiate torsion from epididymitis. Actual point of torsion of the spermatic cord can sometimes be palpated. Associated hydrocele may be palpated and confirmed by transillumination.
PHYSICAL EXAM torsion of the appendix testis May demonstrate hemiscrotal erythema and swelling A blue-dot sign, if the necrotic appendage visible through the scrotal skin, can help make the diagnosis. A normal cremasteric reflex is present bilaterally, and the testis is normally positioned within the scrotum. Testicular discomfort, if present, is typically mild, but point tenderness may be elicited from uppermost pole of the testis near the head of the epididymis.
PHYSICAL EXAM Acute epididymitis-orchitis Scrotal erythema and swelling are present, along with an intact cremasteric reflex. Palpation during early phase of the inflammatory process demonstrates tenderness limited to the epididymis. In the later phase, tenderness and inflammation include both epididymis and testis, and the distinction between the 2 structures may be difficult to appreciate. The Prehn sign (relief of pain with testicular elevation) may be positive.
PHYSICAL EXAM Trauma Examination must include both hemiscrotums and surrounding structures (penis, perineum), assessing for swelling, ecchymosis, and bleeding. Tenderness may be limited to testis or epididymis, depending on extent of trauma. Mumps orchitis Tender testis Scrotal skin disease Redness and edema limited to scrotum, with normal testicle and spermatic cord
PHYSICAL EXAM Scrotal swelling without pain Inguinalhernias and hydroceles Feel for the testis first and keep it in mind during the rest of the examination. Avoid confusing testis with contents of an incarcerated hernia.
PHYSICAL EXAM Hernia A bulge in the inguinal region with fluid that can be gently reduced back into the abdomen is diagnostic of an inguinal hernia. In the cooperative child who can increase his intraabdominal pressure, this procedure may be repeatedly shown, particularly with the child standing. Presence of thickened spermatic cord or silk- stocking sign (the feel of the layers of the processus vaginalis being rubbed against each other) suggests patency of the processus vaginalis or a hernia.
PHYSICAL EXAM Hydrocele When fluid is limited to the testis and spermatic cord can be palpated above the fluid, a hydrocele is present. Hydrocele of the spermatic cord feels distinct from the testis and is round or ovoid, possibly mimicking the presence of an additional testis. Hydroceles (communicating, scrotal, or of the cord) are rarely associated with tenderness on palpation
PHYSICAL EXAM Tumors On palpation, mass is harder than the substance of the testis, but this distinction may be difficult to discern. Mass may bulge from surface of the testis. Spermatoceles and epididymal cysts Separate from the testis and can be transilluminated
Torsion of Sudden onset testicular Discolouration of scrotum; the testis pain and swelling; exquisitely tender testis, occasionally nausea, riding high vomiting. Note: pain may be in the iliac fossa Torsion of More gradual onset of Focal tenderness at upper(hydatid of testicular pain pole of testis; "blue dot" sign Morgagni) – necrotic appendix seen through scrotal skinEpididymo Onset may be insidious; Red, tender, swollen orchitis fever, vomiting, urinary hemiscrotum; tenderness symptoms; rare in pre- most marked posteriolateral pubertal boys, unless to testis. Pyuria may be underlying genitourinary present. anomaly, when associated with UTI.
Incarcerat History of intermittent Firm, tender, ed inguinoscrotal bulge, irreducible, inguinal with associated inguinoscrotal hernia irritability swellingIdiopathic Swelling noted but Bland violaceous scrotal child not distressed oedema of scrotum, oedema extending into perineum + penis; testes not tenderHydrocele Swollen hemiscrotum Soft, non-tender in well, settled baby swelling adjacent to testis; transilluminates
Henoch Painful scrotal oedema, may be difficult to Schonlein with purpuric rash over distinguish from testicular purpura scrotum. May have torsion in absence of other associated vasculitic features rash of buttocks and lower limbs, arthritis, abdominal pain with GI bleeding, and nephritisTesticular or Scrotal trauma eg. Tender swollen testis. epididymis straddle injury, bicycle Bruising, oedema, rupture handlebars, sports haematoma, or injury. Delayed onset of haematocele may be scrotal pain and present. swelling.
LABORATORY EVALUATION Urinalysis may help distinguish orchitis from torsion of the spermatic cord or testicular appendage when leukocytes or nitrites are present. Acute scrotal swelling with pain Torsion of the testicle Urinalysis is unremarkable. Although the leukocytes count may be mildly elevated, it is not discriminating.
LABORATORY EVALUATION Acute epididymitis-orchitis Urinalysis may prove positive for leukocytes and nitrite but is often unremarkable among adolescents. The leukocyte count is usually elevated
LABORATORY EVALUATION Scrotal swelling without pain Inguinalhernias and hydroceles Laboratory tests are useful only for incarcerated inguinal hernias, with an elevated leukocyte count and possible acidosis. Tumors Preoperative tumor markers (α- fetoprotein, β-human chorionic gonadotropin) should be measured and used for postoperative monitoring.
IMAGING Acute scrotal swelling with pain Torsionof the testicle Imaging by Doppler ultrasonography or nuclear scintigraphy should be done if the diagnosis of testicular torsion is in question. Perform imaging only when it will not delay surgical exploration if torsion exists, adding to the risk of testicular loss.
IMAGING Torsion of the appendix testis If an inflammatory process resulting from torsion of the appendage makes differentiation from true spermatic cord torsion impossible, imaging may be helpful. Scrotal Doppler ultrasonography or nuclear scintigraphy will show normal or increased flow to ipsilateral testis.
IMAGING Acute epididymitis-orchitis Ultrasonography and nuclear scintigraphy show normal symmetric blood flow or increased blood flow to an enlarged epididymis or testis. Voiding cystourethrography has been a routine part of the evaluation, but its yield is low with a normal ultrasound and a sterile urine.
IMAGING Trauma Scrotal ultrasonography can document the integrity of the testis and of the tunica albuginea and the adequacy of blood flow.
IMAGING Scrotal swelling without pain Ultrasonography can determine cystic or solid nature of a tense scrotal mass (eg, hydrocele, tumor) or spermaticoInguinal hernias and hydroceles Ultrasonography can delineate scrotal contents, especially when a large or tense hydrocele limits physical examination of mass (eg, hydrocele of the cord, paratesticular tumor).
IMAGING Tumors Scrotal ultrasonography is used to delineate the mass. Varicoceles Testicular size, most accurately assessed by ultrasonography, should be measured; significant loss of testicular volume is an indication for surgery.
TREATMENTAcute scrotal swelling with pain Torsion of the testicle Surgical intervention is indicated not only when testicular torsion is strongly suspected, but also in equivocal cases when torsion cannot be convincingly excluded. The likelihood of salvaging the testis is highest when surgery is done shortly after onset of pain.
TREATMENT With surgery, first explore the affected testis, and, when torsion is present, detorse the cord. Explore the contralateral testis (will have the same defect in anatomy) and fix it in place to avert a future torsion. If the testis can be saved, fix it in the scrotum.
TREATMENT Torsion of appendix testis Management is nonsurgical. The patient should rest and use nonsteroidal pain relievers and cold compresses for several days to reduce inflammation, swelling, and pain. Surgical intervention is indicated only when acute testicular torsion cannot be excluded. In these cases, the infarcted appendage is removed at surgical exploration.
TREATMENT Acute epididymitis-orchitis Treat with antibiotics based on the results of the urine culture and sensitivities. Anti inflammatory agents, scrotal elevation, and rest should be prescribed.
TREATMENT Trauma Testicular or spermatic cord contusions: Manage symptomatically. Testicular rupture requires surgical exploration, evacuation of the hematoma, debridement, and repair (when possible). Mumps orchitis Treatment is symptomatic.
TREATMENT Scrotal swelling without pain Inguinal hernias and hydroceles Repair on diagnosis to prevent incarceration , Perform surgery inguinally; isolate the sac from the cord structures and ligate it at the level of the internal ring. Inspect the contralateral ring using diagnostic laparoscopy through the isolated ipsilateral sac. If the internal ring is open, proceed with contralateral surgical correction. If the hydrocele is painful, then surgery should proceed sooner.
TREATMENT Tumors Perform radical orchidectomy through an inguinal approach. If the mass is not suspicious for cancer, a possible approach is to enucleate the mass and proceed with orchidectomy only if the frozen section is positive. Spermatoceles and epididymal cysts Management typically is observation. Surgerymay be indicated when pain or significant enlargement is present.
PROGNOSIS Acute scrotal swelling with pain Torsion of the testicle Spermatogenesis may be compromised after 4–6 hours of ischemia. Testicular salvage is time dependent, with universal loss of the testis after 24 hours of torsion. Neonatal testicular torsion Neonatal testicular torsion can exhibit at delivery as a nontender hard scrotal mass. Salvage in these cases is rare..
PROGNOSIS Mumps orchitis Infertility may occur when the condition results in atrophy of both testicles. Scrotal swelling without pain hydroceles Most hydroceles resolve spontaneously by 1 year and should be repaired if they persist beyond this age.