TAEM10: Acute Scrotal Pain
•
8 likes•3,331 views
This document provides an overview of acute scrotal pain, including potential causes, signs, symptoms, diagnostic tests and treatments. It discusses several conditions that can cause acute scrotal pain like torsion of the testis, epididymitis, orchitis and torsion of a testicular appendage. For each condition, it describes the pathophysiology, typical presentation with history, physical exam findings, investigations and treatment approach. The goal is to quickly diagnose or rule out torsion of the testis given its surgical emergency nature compared to other differential diagnoses that can often be initially managed medically.
More Related Content
What's hot
What's hot (20)
Similar to TAEM10: Acute Scrotal Pain
Similar to TAEM10: Acute Scrotal Pain (20)
More from taem
More from taem (20)
Recently uploaded
Recently uploaded (20)
TAEM10: Acute Scrotal Pain
- 1. Acute Scrotal Pain 13 Feb 2009 นพ.ประสิทธิ์ วุฒิสุทธิเมธาวี หน่วยเวชศาสตร์ฉุกเฉิน คณะแพทยศาสตร์ มหาวิทยาลัยสงขลานครินทร์
- 2. Background Not uncommon presentation Maybe cause from serious condition; rupture AAA, Strangurated IIH, Fournier’s gangrene Chalanging EP Early diagnosis can prevent function loss or complications
- 3. Anatomy
- 4. History & Clinical Age (host.) Pain characteristic Sexual function +/- Undescended testis
- 5. Pain Characteristic Painless VS Painful Sudden onset VS gradual onset Location Association symptoms: fever, dysuria
- 6. Age - Neonate Torsion of testis - Prepuberty - Post puberty : Epididymitis - Adult : STD
- 7. Physical Examination Relax Reassure Relate (compare) with other side
- 9. Signs Testis Scrotum location / axis edema size erythema tender size consistency tender erythema
- 10. Transillumination test Hydrocele +/- Chronic hydrocele Reactive hydrocele
- 12. Cremasteric Reflex Pinch inner thigh, observe testis Present : testis elevate > 0.5 cm. Absent : testis not elevate or elevate < 0.5 cm. Torsion of testis
- 13. Frehn’s Sign Scrotum elevation Positive : pain relief Negative : pain persist Torsion of testis
- 14. Investigations Urine analysis (UA.) +/- U/C Complete blood count Plain X-rays Color doppler USG Nuclear scintigraphy
- 15. Color Doppler USG No clinical strongly of testicular torsion No pain free intervals No pathognomonic findings No clinical diagnosis of epididymitis Scrotal trauma
- 16. Color Doppler USG Increase blood flow Epididymitis, Torsion of appendage Decrease blood flow Torsion of testis
- 19. Nuclear Scintigraphy (Testicular Scan) Radioisotope (Tc99m) Uptake at 30 min Positive : radioisotope uptake Negative : no radioisotope uptake
- 22. Nuclear Scintigraphy Limitations Availability Can not identify anatomy if testicular rupture Can not detect spontaneous detorsion Same result in epididymitis and torsion of testicular appendage
- 23. Common diagnosis
- 24. Differential Diagnosis Emergent Torsion of testis Rupture of testis Fournier’s gangrene Peritonitis AAA
- 26. Differential Diagnosis Non-emergent Torsion of appendage Epididymitis Orchitis Inguinal hernia Scrotal hematoma / abscess
- 27. Differential Diagnosis Non-emergent Testicular neoplasm Renal colic Hydrocele / Varicocele Venomous insect bite
- 30. Most common diagnosis Torsion of testis Torsion of testicular appendage Epididymitis Orchitis
- 32. Incidence 1/4,000 annual (men < 25 years old) Dimorphic Neonate : < 1 year Pre-puberty : 12-18 years old (14 yrs) Undescended testis
- 33. Pathophysiology “Bell-Clapper” deformity Redundant spermatic cord Medial rotation (aldolescence) Right: clockwise Left : counterclockwise
- 37. Signs & Symptoms Sudden scrotal pain +/- N/V, fever High riding testis Transverse axis of testis
- 38. Suspicion Torsion of Testis High riding testis Abnormal axis (upright position) Abnormal position of the epididymis in scrotum Abnormal axis in contralateral testis (bell clapper” deformity) except in 180o rotation
- 40. Investigations Urine analysis Complete Blood Count Color doppler USG: decrease blood flow Nuclear Scintigraphy: no isotope uptake (Duration > 12 hrs immediate Sx.)
- 42. Treatment General treatment Pain relief Cold application Correct Electrolyte imbalance Pre-operative evaluation
- 43. Treatment Specific treatment Manual detorsion (temporaly) Early Urologist (Gen Sx.) consultation Scrotal exploration, opened detorsion and bilateral orchiopexy
- 45. History, Physical Examination and urine analysis Short duration of symptoms Long duration of symptoms Negative urine analysis Positive urine analysis High probability of torsion Low probability of torsion < 6 hr > 6 hr Surgical exploration +/- Color doppler USG Nuclear scintigraphy
- 46. Color doppler USG Nuclear scintigraphy Decrease or absent blood flow Increase or Equivocal Normal blood flow Surgical exploration Non-operative management Observation
- 47. Epididymitis
- 48. Infection Bacteria UTI Congenital anomaly Retained foley catheter Chlamydia trachomatis STD : N. gonorrhea, Syphilis TB : Cold abscess
- 49. Symptoms Gradual onset Scrotal pain Fever (95%) Dysuria, Urethral d/c (30-50%) Scrotal edema
- 50. Signs Scrotal swelling Scrotal erythema Tender at scrotal and groin
- 51. Difficult to differentiate Torsion of testis Epididymitis Sudden onset torsion Gradual onset from of testis. High riding Normal position / axis Abnormal axis Tender at superior pole Tender at groin of testis abdomen Fever, dysuria
- 52. Investigations Urine analysis : pyuria (50%) Complete Blood Count: leukocytosis (30-50%) Color doppler USG: normal/increase blood flow Nuclear Scintigraphy: normal isotope uptake
- 54. Criteria for Diagnosis Gradual onset of pain Dysuria, Urethral d/c History of urinary tract infection Fever ( BT > 38.3 oc) Tenderness at epididymis Abnormal Urine analysis
- 55. Treatment General treatment Specific treatment Rest Antibiotic Scrotal support STD: partner Analgesia (NSAIDs) Cold application
- 56. Orchitis
- 58. Pathophysiology Highly resistance to infection Hematologic spread Mump Immunocompromise
- 59. Symptoms Pyogenic orchitis Viral orchitis Fever - Post parotitis 4-6 days Malaise - 70 % unilateral lesion Dysuria
- 61. Signs Gradual onset Scrotal swelling / pain / edema Prehn’s sign: positive
- 62. Investigations Urine analysis : pyuria Complete Blood Count: leukocytosis Color doppler USG: normal/increase blood flow Nuclear Scintigraphy: normal isotope uptake
- 63. Difficult to differentiate from epididymitis Orchitis Epididymitis tender at testis tender at superior pole of testis
- 64. Treatment General treatment Rest Scrotal support Analgesia (NSAIDs) Cold application
- 65. Treatment Specific treatment Pyogenic orchitis antibiotic Viral orchitis supportive treatment Usually improve in 3-5 days
- 66. Torsion of testicular appendage
- 67. Background Pre aldolescence Age 3- 13 years old (peak 7-12 yrs) Another diagnosis is torsion of epididymal appendage
- 68. Pathophysiology Unknown Increase estrogen level increase size of appendage strangulation Torsion obstruct venous flow decrease arterial flow ischemia and necrosis
- 71. Symptoms Acute onset Scrotal pain +/- swelling Nausea / Vomiting Fever Dysuria / Urethral d/c
- 72. Signs Palpate mass at superior pole of testis Tender at testis / swelling / Blue dot sign +/- reactive hydrocele Transillumination test Black dot sign Dysuria / Urethral d/c
- 73. Torsion of appendage Torsion of testis Sudden onset Sudden onset Normal position / axis High riding Tender at superior testis Abnormal axis Tender through testis
- 74. Investigations Urine analysis Complete Blood Count Color doppler USG: normal/increase blood flow Nuclear Scintigraphy: normal isotope uptake
- 76. Treatment General treatment Rest Scrotal support Analgesia (NSAIDs) Cold application Usually improve in 7-10 days
- 77. Conclusion
- 78. Goal To detect and exclude “Torsion of testis“
- 79. Thank you for your attention
Editor's Notes
- Good afternoonLast day of conferenceImportant topic; not only for men, but for woman due to infertility esp severe pain<number>
- Testis:vertical, foreward tiltEpididymis: superior pole of testis<number>
- Age: esp. child, aldolescent Pain: acute onset or gradual onsetSexual function: STD<number>
- Painless tumor Painful torsion or infectionSudden onset torsion Gradual onset infection<number>
- Location: high riding testisAxis:verticalEdema:orchitis VS CASize: normal symmetrical, orchitis VS epididymitis, Orchitis VS CAConsistency: fluid, soft, firm, hard<number>
- Reactive hydrocele: CA, orchitis, epididymitis<number>
- Absent in torsion of testis 100%<number>
- Positive epididymitis<number>
- UA: pyuria, KUB stoneCBC: leukocytosisPlain x-rays: gut obstruction, KUB stoneDoppler USG: blood flow, scrotal contentTesticular scan: isotope uptake <number>
- Sensitivity 86-100% (nearly testicular scan)specificity: 89100%Dx. other organs ex. Rupture testis, tumor <number>
- A: epididymis swollen, reactive hydroceleB: increase blood flow by color doppler<number>
- 1: rupture of testis2: on USG<number>
- Sensitivity 86-100%specificity 100%Accuracy 95%<number>
- Boy 3 years old Uptqke only on left testis undescended testis<number>
- Boy 5 years old sudden left scrotal painUptake only at left scrotum torsion of testis<number>
- AAA rupture esp. common iliac aneurysm (NEJM vol. 343, 2000)Case report; 77 yrs acute bilateral scrotal pain after sleep PE. Only both testis tender, no scrotal swelling, died and autopsy<number>
- AAA esp. iliac aneurysm<number>
- Renal calculi: referred pain<number>
- Epididymitis, orchitisTorsion of appendageHematocele<number>
- Bag of worm<number>
- Review in 750 childrens epididymitis 239 (32%), Torsion of appendage 217 (29%), Torsion of testis 140 (19%) <number>
- Undescended testis 10 times esp abdominal testisUsually at sleep or light activity or minor traumaLt. > Rt. 2 times<number>
- Spermatic cord torsion obstruction of venous return increase intrascrotal pressure arterial obstructionIschemia and necrosis3 types: intraavaginal aldolescent , extravginal (spermatic cord torsion) neonate and undescended testistorsion of mesochium distance between testis and epididymisNeonatal: opposite with alodolescence<number>
- Bell clapper deformity<number>
- Rt.: necrosis of testis<number>
- Sudden onset: 4-6 hrsDifficult ambulation<number>
- <number>
- Male 35 years old; MCA with mild head injury, in secondary survey tender at lt. testis, high riding testis with empty Lt. scrotum USG: torsion of testis testicular exploration and orchidoplexy<number>
- Heterogenous on USG suspected unsalvagableSalvage rate < 20%<number>
- Above: USG show heterogenousBelow: decrease blood flow at testis<number>
- Neonate: Rt. clockwise Lt. counter clockwiseAldolescence: Rt. counterclockwise Lt. clockwise Salvage rate: < 6 hr 90-100%, 6-12 hr 60-70%, > 12 hr 20 %<number>
- Aldeolescent75% in acute scrotal painInfection Trauma Reaction <number>
- Aldeolescent > 13 yrs, 75% in acute scrotal painInfection Trauma Reaction <number>
- Most correlation with UTI, prostatitis, urethritis, cystitis reflux from ejaculatory duct<number>
- Gradual onset > 12-24 hrsUA abnormal 60-80%<number>
- Coincidence with epididymitis epididymo-orchitis<number>
- Diagnosis 3 S&S criteria or 2 S&S + positive USG or scan<number>
- Antibiotic; Ofloxacine, Norfloxacine, Gentamycine, CeftriaxoneSTD:Usually improve in 3-5 days Sx. If not response and abscess formation <number>
- Coincidence with epididymitis epididymo-orchitis<number>
- Boy 4 years old Pain at Rt. Testis for 3 days, no fever, no dysuria<number>
- Testis: heterogenous, enlarge, hyperemiaHydrocele: common<number>
- Same as epididymitis<number>
- Antibiotic: same as epididymitisComplications: abscess, testicular ischemiaSx.only in complication and not response to antibiotic<number>
- Maybe torsion of epididymal appendage<number>
- Testis: 92% Epididymis 7 %<number>
- <number>
- Blue-black dot necrosis of appendageLike torsion of testis, but normal axis and position<number>
- No specific treatment<number>
- <number>