acute scrotum

1. THE ACUTE
SCROTUM
ROSFI F HUZAIMA

2. THINGS YOU SHOULD KNOW
AS A JUNIOR DOCTOR
There are multiple causes
for acute scrotal pain
and it is often difficult to
differentiate them
Acute testicular torsion is a
urological emergency
Do not delay surgical
referral exploration for
unnecessary investigations

3. TOPIC OUTLINE
Causes
Ischaemia .
Infection
Trauma
Referred pain
Other

4. CAUSES
Ischaemia
Torsion of testis
Torsion of appendage
Testicular infarction
Infection
Epididymitis
Epididymo-orchitis
Orchitis
Fornier’s Gangrene
Cellulitis
Testicular
Trauma
Rupture
Contusion or Haematoma
Haematocoele
Referred
pain
Nerve root pain
Retrocaecal appendicitis
Urinary stone
Other
Varicocoele
Hydrocoele
Spermatocoele
Strangulated inguinal
hernia
Heinrech-Scholein
purpura (HSP) vasculitis
Testicular tumour (rapidly
growing/necrotic)

5. ANATOMY OF TORSION
– Types
– << Intravaginal
– twisted spermatic cord within
tunica vaginalis
– Extravaginal >>
– twisted spermatic cord AND
tunica vaginalis (in neonates)
– Structures
– Testis
– Appendix epididymis
– Appendix testis

6. RISK FACTORS
– Bell-Clapper deformity
– Undescended testis
Bell-Clapper Deformity (blue is tunica vaginalis)

7. SURGERY
Immediate
exploration
Detorsion
Fixation OR
Orchidectomy

8. TESTIS/EPIDYDIMIS
INFECTION
– Bacterial
– UTI  younger/older patients
– usually gram negative bacteria
– STD  sexually active patients
– Chlamydia trachomatis
– Neisseria gonorrhoeae
– Viral
– Mumps

9. INVESTIGATIONS
– Urine cultures
– Urinary STD screen in
sexually active
– Doppler ultrasound
– (Bloods + blood cultures)
Doppler ultrasound
Microscopy of E. coli

10. TREATMENT
– Analgaesia & scrotal support
– Urinary tract source (for 14 days) – empirical
– Trimethoprim 300mg PO daily
– OR cephalexin 500mg PO QID
– OR augmentin 1tab PO BD
– Sexually active young men – empirical
– Ceftriaxone 500mg IV
– AND Azithromycin 1g PO stat
– AND Doxycycline 100mg PO BD (14 days)
– If not improving exclude abscess
– Ensure urine clear at end of antibiotics with
U/A

11. FOURNIER’S GANGRENE
– Necrotising fasciitis of genitalia & perineum
– High mortality (30%)
– Rapidly progressing
– Risk factors – Diabetic,
Immunocompromised, Alcoholic
– Treatment
– Rapid surgical debridement
– Supportive care & broad spectrum antibiotics
– Hypobaric oxygen

12. TRAUMA
– Testicular Rupture
– Requires prompt surgical repair
– Can only be seen on US in 20% - go by clinical suspicion
– Testicular Contusion/Intratesticular Haematoma
– Hypoechoic or haetrogenous area on ultrasound
– Usually explored because rupture cannot be excluded.
– Then managed symptomatically:
– Analgaesia
– Scrotal support & elevation
– Ensure resolution on follow-up ultrasound  could be a testicular carcinoma!

13. REFERRED PAIN
– Retrocaecal
appendicitis
– Urinary stones
– Nerve root pain

14. OTHER CAUSES
– Varicocoele
– Hydrocoele
– Spermatocoele
– Strangulated inguinal hernia
– Heinrech-Scholein purpura (HSP) vasculitis
– Testicular tumour (rapidly growing/necrotic)

15. TERIMAKASIH