The acute scrotum is the painful, swollen scrotum or its contents of sudden onset. The “acute scrotum” may be viewed as the urologist’s equivalent to the general surgeon’s “acute abdomen.” Scrotal emergencies are rare but potentially life and fertility threatening. The most common causes of acute scrotal pain in adults are testicular torsion and epididymitis. Patients with scrotal pain less than the age of 16 have torsion until proven otherwise. Scrotal pain with nausea & vomiting is specific for torsion. A small but real, negative exploration rate is acceptable to minimize the risk of missing a critical surgical diagnosis. TIME IS TESTICLE

1. ACUTE SCROTAL PAIN
BY
Athanase YAMFASHIJE
MED STUDENT

2. INTRODUCTION
The acute scrotum is the painful, swollen scrotum or its
contents of sudden onset
The “acute scrotum” may be viewed as the urologist’s
equivalent to the general surgeon’s “acute abdomen.”
Scrotal emergencies are rare but potentially life and
fertility threatening

3. SCOPE
 Normal anatomy
 Differential diagnosis of ASP
 Principles of management
 Testicular torsion
 Torsion of appendix testis
 Epididymitis
 Orchitis
Trauma
Strangulated hernia
Fournier gangrene
Henoch-Schonlein Purpura
Take away
References

4. NORMALANATOMY

5. The normal testis is oriented in the vertical axis and the
epididymis is above the superior pole in the posterolateral
position.
Cremasteric reflex: Stroking/pinching the inner thigh should
result in elevation of > 0.5 cm of the ipsilateral testicle

8. DIFFERENTIAL DIAGNOSIS FOR ASP
The most common causes of acute scrotal pain in adults are
testicular torsion and epididymitis
Other conditions that may result in acute scrotal pathology include
Fournier’s gangrene, torsion of the appendix testis, trauma/surgery,
testicular cancer, strangulated inguinal hernia, Henoch-Schönlein
purpura, mumps, and referred pain

9. DISTINGUISHING CONDITIONS RESPONSIBLE FOR
ASP IN ADULT
SYMPTO
M ONSET
PAIN
LOCATION
CREMASTERIC
REFLEX
OTHER CLINICAL
FINDINGS
TESTICULA
R TORSION
Acute Testis Negative High riding testis, Bell-Cpper
deformity, Profound testicular
swelling
EPIDIDYMI
TIS
Acute or
chronic
Epididymis Positive Epididymal induration and
tenderness, positive urinalysis
or culture
FOURNIER
GANGREN
E
Acute Diffuse Positive Tense edema outside of
involved skin, blister/bulla,
crepitus, fever, rigors,
hypotension
APPENDEC
EAL
TORSION
Sub-acute Upper pole of
testis
Positive blue-dot sign, tenderness over
anterosuperior testis

10. PRINCIPLES OF MANAGEMENT
The patient history and physical examination are key to the diagnosis
Imaging studies(doppler ultrasound) should complement, but not
replace, sound clinical judgment
When making a decision for conservative, non-surgical care, the
provider must balance the potential morbidity of surgical exploration
against the potential cost of missing a surgical diagnosis
A small but real, negative exploration rate is acceptable to minimize
the risk of missing a critical surgical diagnosis

11. TESTICULAR TORSION
Occurs when an abnormally mobile testis twists on the spermatic
cord, obstructing its blood supply
 Inadequate fixation of testes to tunica vaginalis at gubernaculum
 Torsion around spermatic cord
Venous compression >>to edema >>to ischemia
Bimodal ages – neonatal (in utero) and pubertal ages/ 65% occur in
ages 12-18yo

12.  Accounts for 20% of all acute scrotum
Incidence: 1 in 4000 in males <25yo
Increased incidence in puberty due to increased weight of
testes
Testicular torsion may occur after an incidental event (eg,
trauma) or spontaneously

13. Testicular torsion can be either
Intravaginal(16% of all acute scrotum) that is most common,
peak incidence between 12-18 years of life
Extravaginal (5% of all torsions)- less common and confined
to perinatal period.
Left testis is more affected than right
Bilateral torsion :2% of all torsions

15. CLINICAL PRESENTATIONS
Edematous, tender, swollen testis of sudden onset
More likely to be associated with nausea and/or emesis
An elevated testis with a transverse lie (reactive hydrocele may be present)
Cremasteric reflex absent
Prehn’s sign :elevation relieves pain in epididymitis and not torsion/ is
unreliable
In children, there may be awakening with scrotal pain in the middle of the
night or in the morning

17. 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 urology follow
up)

18. DIAGNOSIS
Usually diagnosis is made during PE
Color Doppler U/S can be needed in equivocal cases/Confusion
The classic finding on physical examination is an
asymmetrically high-riding testis on the affected side with the
long axis of the testis oriented transversely instead of
longitudinally secondary to shortening of the spermatic cord
from the torsion, also called the “bell clapper deformity”

22. MANAGEMENT
Detorsion within 6hrs = 100% viability
 Within 12-24 hrs = 20% viability
 After 24 hrs = 0 to 10% viability
Surgical detorsion and orchiopexy if viable
 Contralateral exploration and fixation ( bell-clapper
deformity in more than 90% is bilateral)
Orchiectomy if non-viable testicle
Never delay surgery on assumption of non viability as
prolonged symptoms can represent periods of intermittent
torsion

23. 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
Infertility may result, even with a normal contralateral testis,
because the disruption of the immunologic "blood-testis" barrier
may expose antigens from germ cells and sperm to the general
circulation and lead to the development of anti-sperm
antibodies

24. 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

26. TORSION OF APPENDIX TESTIS
Peak age 3-13 yo (pre-pubertal)
Sudden onset, pain less severe
Classically, pain more often in abdomen or
groin
Non-tender testicle
Tender mass at superior
May be gangrenous, “blue-dot” (21% of
cases)
Normal cremasteric reflex, may have
hydrocele
Increased or normal flow by Doppler U/S

27. TREATMENT
Supportive management
Analgesics, scrotal support to relieve swelling
Surgery for persistent pain
No need for contralateral exploration

28. EPIDIDYMITIS
Epididymitis is the most common cause of scrotal pain in adults in
the outpatient setting
It is most commonly infectious in etiology, but can also be due to
noninfectious causes (eg, trauma, autoimmune disease)
Etiology

29. CLINICAL FEATURES
 In acute infectious epididymitis, palpation reveals
induration and swelling of the involved epididymis with
tenderness.
More advanced cases often present with testicular
swelling and pain (epididymo-orchitis) with scrotal wall
erythema and a reactive hydrocele

30. INVESTIGATIONS
A urinalysis and urine culture should be performed in all
patients suspected of epididymitis, although urine studies are
often negative in patients without urinary complaints
A urethral swab should be obtained in patients with urethral
discharge and sent for culture
U/S should be performed in patients with acute onset of pain
to R/O testicular torsion

31. TREATMENT
Sexually active treat with Ceftriaxone/Doxycycline or
Ofloxacin
Pre-pubertal boys
Treat for co-existing UTI if present
Symptomatic tx with NSAIDs, rest
urologist follow up for studies to rule out VUR, post urethral
valves, duplications

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. MUMP 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. ORCHITIS COMPLICATIONS
Focal testicular infarction can occur as a complication of
epididymitis when swelling of the epididymis is severe enough
to constrict the testicular blood supply
This appears as a hypoechoic intratesticular mass devoid of
blood flow
The complications of orchitis are abscess formation and
ischemia

35. TRAUMA

36. 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 and r/o torsion
Surgery for uncertain dx, tunica albuginea rupture,
compromised Doppler flow

37. STRANGULATED HERNIA
Strangulated Hernias in children are common especially in
infancy.
Children may present with acute irreducible scrotal swelling,
irritability and symptoms and signs of intestinal obstruction.
If they are filled with bowel, they are easy to detect on
ultrasound, but sometimes these hernias are only filled with soft
tissue .

39. FOURNIER GANGRENE
Fournier’s gangrene is a necrotizing fasciitis of the perineum
caused by a mixed infection with aerobic/anaerobic bacteria,
which often involves the scrotum
Characterized by severe pain that generally starts on the anterior
abdominal wall, migrates into the gluteal muscles and onto the
scrotum and penis

41. Clinical features:
 Tense edema outside the involved skin,
 blisters/bullae, crepitus, and subcutaneous gas,
 systemic findings, such as: fever, tachycardia, and
hypotension

42. MANAGEMENT
Fournier's gangrene is a surgical emergency,
Early aggressive drainage or debridement is essential
Affected patients may require cystectomy, colostomy,
Antibiotic treatment should be based upon Gram's stain, culture, and
sensitivity
Broader gram-negative, anaerobes antibiotic coverage should be
considered as early empirical treatment.
Hemodynamic support as needed.

43. HENOCH-SCHONLEIN PURPURA
systemic vasculitis characterized by:
 Non thrombocytopenic purpura, arthralgia, renal disease,
abdominal pain, gastrointestinal bleeding, and occasionally
scrotal pain.
Scrotal pain can be the presenting symptom, and onset may
be acute or insidious.
The diagnosis is usually made clinically,
 Ultrasound may need to be performed to distinguish
Henoch-Schönlein purpura from testicular torsion.
Treatment is supportive

45. REFFERED PAIN
Men who have the acute onset of scrotal pain without local
inflammatory signs or a scrotal mass on examination may be
suffering from referred pain to the scrotum
Referred pain can be caused by:
Abdominal aortic aneurysm
Urolithiasis
Lower lumbar or sacral nerve root compression
Retrocecal appendicitis
retroperitoneal tumor
Post herniorrhaphy pain.

46. TAKE AWAYS
Patients with scrotal pain less than the age of 16 have torsion until
proven otherwise.
 Patients greater than 18yo with testicular pain more commonly
have epididymitis
Testicular torsion tends to be acute in onset
 Scrotal pain with nausea & vomiting is specific for torsion
 Patients with epididymitis tend to be gradual in onset and
accompanied by fever

47. Beware of Uncommon Clinical Presentation of Testicular Torsion
 Slow onset of pain
 Abdominal pain (20‐30%)
 Fever (16%)
 Urinary frequency (4%)
WBC in urine (30%)
 Elevated CBC (60%)

48. Patients with clinically suspected testicular torsion need to go
directly to the OR
 DON’T rely on “physical exam findings” (prehen
sign, cremasteric reflex) to “rule out” testicular torsion
 Torsion of the testicular appendage is common and once
diagnosed can be managed conservatively

49. When the diagnosis is unclear, color doppler ultrasound is the
diagnostic test of choice
You either have a “normal” testicular ultrasound or you don’t
 “Time is testicle”

50. REFERENCE
Clinical oriented anatomy,6th edition,2010
Campbell urology textbook, 11th ed
https://www.auanet.org/education/auauniversity/for-medical-
students/medical-students-curriculum/medical-student-
curriculum/acute-scrotum
https://www.slideshare.net/jameswheeler001/acute-scrotal-pain
https://med-fom-urlgsci.sites.olt.ubc.ca/files/2014/08/Scrotal-
Masses-and-Testis-Tumours-Med-Yr-3-2014-2015-full.ppt