Clinical guide in making diagnosis and prompt management of acute scrotum

1. PRESENTATION BY DR: Moses Cletus G.
MODERATOR: DR. HAMZA B.K
Dept of Surgery
BDTH
Kaduna, Nigeria

2. OUTLINE
 INTRODUCTION
 NORMAL ANATOMY
 CAUSES
 CLINICAL FEATURES
 MANAGEMENT

3. Introduction
Acute scrotal conditions are important urological
emergencies;
Though of low mortality, but great morbidity
The scrotum houses the testis for procreation and
normal sexual function

4. The spectrum of conditions that affect the scrotum and
its content, leading to acute event that may require
immediate surgical intervention.
Full range of scrotal pathology must be considered in
acute scrotum cases

5. Normal anatomy
Normal testis is oriented in the vertical axis
Epididymis is above the superior pole in the
posteriolateral position
Cremasteric reflex

7. Causes of acute scrotum
 Torsion of testis and epididymis
 Acute epididymitis
 Strangulated hernia
 Trauma(hematocele)
 Tumours
 Henoch scholein purpura
 Viral inflammation
 Infected hydrocele
 Referred pain

8. Testicular torsion
 One or more vessel twist
 Ischeamic necrosis and atrophy
 Sudden pain
 80-100% survive within 6-8hours
 O% salvage in > 24hours

9.  Types; intravaginal and extravaginal
Extravagina; common in neonatal period
prenatal in the cord
high birth weight
5% of cases
2% bila

10.  Intravaginal
twist within the tunical
peak at 13yrs
bell clapper deformity anomaly
high insertion of t-v
bil in 2%

12.  Predisposing factors:
undescended testis
ectopic testis
bell clapper deformity
inverted/transverse position of testis
separation of epididymis from body of testis

14. Clinical features
 Sudden onset of pain
 Radiate to the groin/lower abd
 Maybe nausea/vomiting
 Pain may be recurrent

15.  Examination;
swollen,tender,high riding testes
maybe pale/diaphoretic
absent cremasteric reflex
positive prehn sign

16.  Investig
uss
color doppler uss
radionuclide scan

18.  Mgt
-manual detorsion(usually it twist inward medially)
-use strong analgesics or LA
-30-70% successful
Surgical: bil orchidopexy
if >24hours orchiectomy
sympathetic orchidopathia autoimmune reac

20. Epididymitis
 Most common cause in adults
 Infectious but can also be autoimmune/trauma
Features of pain,swelling,
scrotal wall erythema and reactive hydrocele
Invest;
urinalysis and culture
urethral swab, uss

21.  Rx
If sepsis:hospitalization with i.v antbx
Use of ice
Scrotal elevation
Nsaids are helpful adjuncts
Less severe cases as outpt basis

22. Fournier’s gangrene
 Necrotizing fasciitis of perineum
 Caused by mixed infection
Features
severe pain usually from ant abd wall
migrates to gluteal muscle and to scrotum/penis

24.  Rx
surgical debridement
Antibiotics
hemodynamic support

25. Other causes
 Torsion of the appendix testis
common in childhood
pain is usually gradual than T.T
Examination; classic “blue dot” sign on
careful inspection of site

28.  Mgt
Conservative;rest, ice and nsaids
Recovery is slow-weeks to months
Surgical excision for patient with persistent pain

29. trauma
 Rare
 Usually from compression against pubic bone
 Direct blow or straddle injury
Complications may range from hematocoele to pyocele
and even rupture of testis
Mgt; rupture require repair

30. tumors
 Most are painless
 Rapidly growing may cause pain
Examination palpable scrotal mass
Confirm by uss
Mgt;
Depend on type

31. Referred pain
 Scrotal pain without any scrotal findings on
examination
 Causes; AAA, urolithiasis,nerve root compression
rectocecal appendicitis,retoperitoneal tumour,
post herniorrhaphy

32. conclusion
A full range of conditions that result in acute scrotum
require surgical exploration making this a very time
sensitive condition

33. Reference
 AUA Update series; volume 36. 2017
 Principles and practice of surgery, E.A Badoe; ‘scrotum
and epididymis’
chapter 42 Pg 952- 967