Acute scrotal pain can be caused by many conditions, but the most common are testicular torsion and epididymitis. A thorough clinical examination is important to distinguish between these and other causes like trauma. Testicular torsion is a urological emergency requiring urgent surgical intervention, as delayed treatment can result in loss of the testis. Epididymitis is usually treated with antibiotics as an outpatient. Ultrasound is useful to confirm diagnoses and determine if surgical intervention is needed.

1. ACUTE
SCROTAL
PAIN
M I C H A E L C O N N E L LY

2. INTRODUCTION
The spectrum of conditions that affect the
scrotum and its contents ranges from
incidental findings, which may require
patient reassurance only to acute events
that may require surgical intervention

3. WERE GOING TO HAVE A BALL
• Normal Anatomy
• Testicular Torsion
• Epididymitis /
Epididymo-orchitis
• Testis Appendix
• Referred pain
• Fournier’s gangrene

5. THE NUMBER OF CAUSES ARE NUTS
• Most Common; Testicular torsion and epididymitis
• Torsion of appendix testis
• Trauma/Surgery
• Testicular cancer
• Strangulated inguinal hernia
• Henoch-Schonlein purpura
• Mumps
• Referred pain

6. TESTICULAR TORSION
•Urological emergency
•More common in neonates and post-pubertal
boys
•Although can occur at any age
•25-50% of admitted scrotal pain
•Who?

7. • Results form inadequate fixation of the testis to the tunica
vaginalis
• Ischaemia from reduced arterial inflow and venous outflow
obstruction
• Following trauma or spontaneous
• Generally considered irreversible damage after 12hrs
• Even with a normal contralateral testis, infertility may result;
– Disruption of the immunologic blood-testis barrier
– Exposes antigens from germ cells to the general circulation
– Anti-sperm antibodies

8. CLINICAL FEATURES
• Diagnosis determined by acute onset of severe symptoms,
with classic examination findings
• USS/Doppler is the gold standard
• Sudden
• Often occurs several hours following minor trauma
• May be nausea and vomiting
• Another classic finding in boys is awakening with scrotal
pain

11. THE CREMASTERIC REFLEX
•Normal response is cremasteric contraction with
elevation of the testis
•Usually absent in patients with testicular torsion
•Used to distinguish between torsion from
epidimytis and other causes of pain
•Prehn’s sign; Relief of scrotal pain by testicle
elevation in torsion; NOT RELIABLE

13. A TEST-IS OF TIME
•De-torsion and fixation of the involved and
uninvolved testis
•Inadequate gubernacular fixation is usually a
bilateral defect
•>12hrs may require orchidectomy due to
infarction with liquefaction!!

16. MANUAL DE-TORSION
• ONLY if surgery not immediately available within
2hrs
• Usually rotates medially; detorted by rotating
outward towards the thigh
• HOWEVER; Retrospective analysis of 200 males
–Age 18 months - 20 years
–Lateral rotation in one third of patients!!

17. SUCCESS
•Relief of pain
•Transverse > Longitudinal
•Lower
•Return of arterial pulsations; colour doppler
study
•Surgery always required; even following manual
as orchidopexy must be performed

18. EPIDIDYMITIS
• Most common cause scrotal pain in adults in
outpatient setting
• Most commonly infectious;
– CT, NG, <35
– Proteus, E.coli >35
• Can be non-infectious;
– Trauma
– Autoimmune disease
• Palpation reveals induration, swelling and
tenderness of epididymis
• More advanced;
– Testicular swelling
– Pain (epididymo-orchitis)
– Scrotal wall oedema and reactive hydrocele

19. INVESTIGATIONS
•Urinalysis and culture;
–Often negative if no urinary symptoms
•Urethral swab
•USS/Doppler

21. TREATMENT
• Febrile patients with sepsis; IV hydration and IV
antibiotics
• Ice, scrotal elevation and NSAIDS can be helpful
• Less severe can be treated as an outpatient
• Cefriaxone 500mg in 2ml 1% lignocaine IM, plus
doxycycline 100mg PO BD 14/7
• OR…Azithromycin 1g PO stat, and repeat after 1/52

22. PRIMARY ORCHITIS
• Mumps is the most common cause of
orchitis without accompanying
epididymitis
• Bilateral 14-35% cases
• Enlarged and decreased echogenicity
• Intra-testicular venous flow is difficult to
detect in normal testes;
–Therefore easily detected venous
flow greatly suggests orchitis

25. FOURNIER’S GANGRENE
• Necrotising fasciitis of the perineum
• Mixed infection with aerobic & anaerobic bacteria, involving
scrotum
• Severe pain, usually starts anterior abdominal wall; migrates
to gluteal muscles then scrotum and penis
• Early and aggressive surgical exploration and debridement of
necrotic tissue
• Plus haemodynamic support as required
• Antibiotic therapy alone is associated with 100% mortality

26. TORSION OF THE APPENDIX TESTIS

28. MANAGEMENT
• Usually conservative;
–Rest
–Ice
–NSAIDS
• Recovery is usually slow with this approach; pain may
last for weeks to months
• Surgical excision is reserved for persistent pain

29. TESTICULAR TRAUMA

30. TESTICULAR CANCER
• Can cause pain!
• Most are painless nodules
• Rapidly growing stem cell tumours can cause acute pain
secondary to haemorrhage or infarction
• Generally mass is palpable; USS is usually sufficient to
diagnose CA

31. REFERRED PAIN
• THREE SOMATIC NERVES;
–Genitofemoral
–Ilioinguinal
–Posterior scrotal
• AAA
• Renal stones
• Lower lumbar pain
• Retrocecal appendicitis
• Retroperitoneal tumour

32. ITS IN THE BAG (SUMMARY)
• Clinical examination important
• Is this time critical?
• USS
• Seek advice if in doubt
• Have the deepest of sympathy for anyone attending
ED with testicular trauma and consider admitting them
to hospital for as long as they want