This document provides an overview of acute scrotum conditions, including testicular torsion, epididymo-orchitis, Fournier's gangrene, and testicular trauma. It defines acute scrotum as scrotal pain, swelling, and redness of acute onset. Testicular torsion is a medical emergency requiring surgery within 6 hours to prevent testicular necrosis. Epididymo-orchitis is usually caused by a urinary tract or sexually transmitted infection. Fournier's gangrene is a necrotizing infection of the genital region that can spread rapidly. Testicular trauma can result in hematoma, rupture, or torsion and may require surgical exploration.

1. Acute Scrotum
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2. Objectives
Anatomy of scrotum
Definition of acute scrotum, and differential diagnosis.
Testicular torsion
Epididymo-orchitis
Fournier gangrene
Testicular trauma

4. Anatomy
oProtect testis
oThermoregulation
oConnected to the abdominal wall via the spermatic cord.
oAverage wall thickness of the scrotum is 8 mm.
oContents: testes, epididymis and spermatic cord.

9. Definition and DDx
The acute scrotum is defined as scrotal pain, swelling, and
redness of acute onset.

11. Testicular Torsion

12. Testicular Torsion
Testicular torsion is a twist of the spermatic cord, resulting in
strangulation of the blood supply to the testis and epididymis. Associated
with a poorly secured testis.
It is considered as urologic emergency, Irreversible damage occurs after
6–12 hours of torsion!
Peak age 13-15, but it happens at any age.
Usually idiopathic.
Undescended testes? Malignancy?

13. Mechanisms of testicular torsion may be identified:
1) Intravaginal torsion: a congenital abnormality in which the tunica vaginalis
attaches to the superior pole of the testis (bell-clapper deformity) →
increased mobility of testis within tunica vaginalis, with possible abnormal
transverse lie of testis → torsion of the testis (along the spermatic cord)
2) Extravaginal torsion: lack of fixation of the tunica vaginalis to the
gubernaculum → concomitant torsion of the testis and tunica vaginalis (along
the spermatic cord)
3) Long mesorchium: elongated mesorchium → torsion of the testis along
the mesorchium

15. Testicular Torsion
Abrupt onset, typically swollen and tender testis and/or lower abdominal
tenderness
Nausea and vomiting
Abnormal position of the testis (high-riding testis and abnormal transverse
position)
Absent cremasteric reflex
Negative Prehn sign
In neonate: Possible absent testis and firm, painless scrotal mass

17. Diagnosis of testicular torsion
Clinical
Duplex ultrasound of the scrotum
Radionuclide imaging
Urinalysis (to r/o epididymitis)
Surgical intervention is recommended
for suspected testicular torsion,
regardless of radiological findings.

18. Treatment of testicular torsion
Manual detorsion (laterally toward the thigh, then to the midline if
failed to relive pain).
Exploratory surgery (must be done within 6 hrs)
Orchidopexy
Orchiectomy if the testis is grossly necrotic or nonviable
Because of the risk of infertility, surgical exploration of the scrotum is
recommended in any patient suspected of having testicular torsion,
even if manual detorsion has been attempted.

19. Prognosis of testicular torsion
Timely intervention within the recommended time period (6
hours from symptom onset) → restoration to previous condition
Late or absent surgical intervention → ischemia → necrosis of
the testicles

20. Epididymo-orchitis

21. Epididymo-orchitis
The most common cause of scrotal pain in adults in the outpatient
setting. It is the spread of infection from the epididymis to the testicle.
Epididymitis is commonly associated with genitourinary tract infections,
most commonly E. coli (most common) and Pseudomonas.
 In young age group most commonly due to STD (e.g. Chlamydia
trachomatis, Neisseria gonorrhoeae).
Chronic epididymitis (> 6-week course of the disease)

22. Epididymo-orchitis
Unilateral scrotal pain and swelling, which develops over several
days and radiates to the ipsilateral flank. Associated with tenderness.
Positive Prehn sign.
Red, shiny, and edematous scrotal skin.
Symptoms of lower urinary tract infection.
Low-grade fever

23. Epididymo-orchitis
Urinalysis: pyuria, bacteriuria and urine culture if a UTI is suspected.
Urethral swab for culture and nucleic acid amplification testing if an STI
is suspected.
CBC: leukocytosis
Scrotal ultrasound to r/o testicular torsion.
Findings in epididymitis: enlarged epididymis, increased blood flow

24. Treatment of epididymo-orchitis
Scrotal elevation, ice packs, and NSAIDs.
Empiric antibiotic therapy based on likely pathogens (until
the causative organism is known):
- Suspected UTI (with enteric organisms): fluoroquinolones
(e.g., ofloxacin, levofloxacin)
- Suspected STI: (with chlamydia or gonorrhea) ceftriaxone
PLUS doxycycline

25. Treatment of epididymo-orchitis
Chronic epididymitis:
NSAIDs and prolonged antibiotic therapy
If symptoms persist: epididymectomy and/or orchidectomy
If tuberculosis is suspected: antituberculous therapy
If an abscess develops: surgical drainage

27. Fournier’s gangrene

28. Fournier’s gangrene
Necrotizing fasciitis of the external genitalia that can spread
rapidly to the anterior abdominal wall and gluteal muscles.
Causes include:
Diabetes,
trauma to the genitalia and perineum
and surgical procedures.

29. Causative organisms in Fournier’s
gangrene
Culture of infected tissue reveals a mixed
polymicrobial infection with aerobic (E. coli,
enterococcus, Klebsiella) and anaerobic organisms
(Bacteroides, Clostridium, microaerophilic
streptococci)

30. Presentation of Fournier’s gangrene
Systemic symptoms: fever, chills, altered mental status
Pain that is disproportionate in intensity
Significant induration of the subcutaneous tissue
Crepitus
Purple skin discoloration (skin necrosis, ecchymosis)
Bullae
Loss of sensation in the affected area (paresthesias)
spontaneous fulminant gangrene of the genitalia.

31. Diagnosis of Fournier’s gangrene
Clinical
CT scan

32. Treatment of Fournier’s gangrene
Imaging and laboratory studies should not delay surgery.
Blood Cx, IVF, O2
Broad-spectrum antibiotics (ampicillin, gentamicin, and metronidazole or
clindamycin)
Debridement (testes and penile tissue usually spared)
Suprapubic catheter
Repeat operative debridement every 24–72 hours may be necessary to
remove newly necrotic tissue
Hyperbaric oxygen therapy?

33. Testicular trauma

34. Testicular trauma
Mostly blunt traumas.
Bleeding occurs into the parenchyma of the testis, and if
sufficient force is applied, the tunica albuginea of the testis
ruptures, allowing extrusion of seminiferous tubules.
Penetrating traumas.
Due to gunshot or knife wounds and from explosive blasts;
associated limb, perineal, pelvic, abdominal, and chest wounds
often occur.

35. Testicular trauma
Hematocele
Hematoma
Testicular rupture
Testicular torsion/dislocation

36. Testicular trauma
The testis may be under great pressure as a consequence of
the intratesticular hemorrhage confined by the tunica
vaginalis. This can lead to ischemia, pain, necrosis, and
atrophy of the testis.

37. Presentation of testicular trauma
Hx
Physical examination
Nausea and vomiting
Hematoma (may spread into the inguinal region and lower
abdomen)

38. Imaging in testicular trauma
Hypoechoic areas within the testis
(indicating intraparenchymal hemorrhage)
suggest testicular rupture

39. Treatment of testicular trauma
• Testicular rupture = Exploration
• Penetrating trauma = Exploration

40. Thank You
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