1. Torsion can involve the testicular appendages or the testis itself. Testicular torsion is the twisting of the spermatic cord that cuts off blood supply to the testis and can lead to necrosis if not treated within 5-6 hours.
2. Testicular torsion most commonly occurs in adolescence and presents with acute severe scrotal pain, swelling, nausea/vomiting, a retracted transverse testis with no pain relief from elevation. Diagnosis involves ultrasound or scintigraphy and may require examination under anesthesia.
3. Emergency surgery is required to manually detorse the testis within 12 hours for the best chance of testis survival, while after 24 hours, orchi
Approah to a child / adult presenting with acute scrotum - testicular pain.
The acute scrotum – definition and causes with differential diagnosis
Management of the acute scrotum
Testicular torsion
Torsion of a testicular or epididymal appendage
Epididymitis or epididymo-orchitis
Idiopathic scrotal oedema
Fat necrosis of the scrotum
Case Discussion
1. Undescended Testis : Along the normal path, but not reached scrotum.
2. Retractile Testis : Hyperreflexic Cremaster
3. Ectopic Testis : Deviation from normal path of descent
Absence of testis in scrotum since birth
Hemiscrotum empty, hypoplastic
Approah to a child / adult presenting with acute scrotum - testicular pain.
The acute scrotum – definition and causes with differential diagnosis
Management of the acute scrotum
Testicular torsion
Torsion of a testicular or epididymal appendage
Epididymitis or epididymo-orchitis
Idiopathic scrotal oedema
Fat necrosis of the scrotum
Case Discussion
1. Undescended Testis : Along the normal path, but not reached scrotum.
2. Retractile Testis : Hyperreflexic Cremaster
3. Ectopic Testis : Deviation from normal path of descent
Absence of testis in scrotum since birth
Hemiscrotum empty, hypoplastic
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
it is painful condition for boys , coming in emergency, ultrasound is basic imaging .it is to see testes and accordingly guide the surgeon whether testes could be saved
Disclaimer: A lot from this slides were taken also from https://www.slideshare.net/babysurgeon/scrotal-swellings-1 (Dr Selvaraj Balasubramani)
This covers only :
ANATOMY
CAUSES
TORSION OF TESTIS
EPIDIDYMO-ORCHITIS
HYDROCELE
EPIDIDYMAL CYST
VARICOCELE
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4. Torsion
❏ two types: torsion of appendices or testicles
1. Torsion of the appendices
2. Testicular torsion (spermatic cord torsion)
4
5. Torsion of the appendices
❏ twisting of testicular/ epididymal vestigial appendix
❏ often < 16 years of age
❏ signs and symptoms
• clinically similar to testicular torsion
• "blue dot sign" - blue infarcted appendage seen through scrotal skin
(can usually be palpated as small, tender lump)
• point tenderness over the superior-posterior portion of testicle
❏ treatment
• analgesia - most will subside over 5-7 days
• surgical exploration and excision if diagnosis uncertain or refractory pain
5
6. Testicular torsion (spermatic cord torsion)
❏ testis rotates from within outwards causing strangulation of the blood
supply ––> ultimately leads to necrosis of entire gonad if untreated within
5-6 hours
❏ possible at any age, but most common in adolescence (12-18 years) due to
pubertal increase in testicular volume
❏ incidence
• ~1/4000, males < 25 years
6
7. Testicular torsion (spermatic cord torsion)
❏ predisposing factors
• cryptorchid testis
• trauma (although 50% occur during sleep)
• bell clapper congenital deformity:
• narrow mesenteric attachment from cord on to testis/epididymis –
–> testis falls forward and is free to rotate within tunica
vaginalis
• anomalous development of tunica vaginalis or spermatic cord
7
9. Testicular torsion (spermatic cord torsion)
❏ signs and symptoms
• acute onset of severe scrotal pain, swelling +/- nausea/vomiting
• retracted and transverse testicle (horizontal lie)
• no pain relief with testicle elevation (negative Prehn’s sign)
• epididymis may be palpated anteriorly in the early stages
9
10. Testicular torsion (spermatic cord torsion)
❏ diagnosis
• ultrasound with colour-flow Doppler probe over testicular artery (if
torsion, no blood flow)
• decrease uptake on 99M Tc-pertechnetate scintillation scan
• examination under anesthesia and surgical exploration
10
15. Epididymitis
❏ etiology
• infection
• < 35 years - gonorrhea or Chlamydia (STDs)
• > 35 years - coliforms (from GI tract)
• prior instrumentation
• reflux
• increased pressure in prostatic urethra (straining, voiding, heavy
lifting)causes reflux of urine along vas deferens ––> sterile
epididymitis
15
16. Epididymitis
❏ signs and symptoms
• sudden onset scrotal pain and swelling +/– radiation along cord to flank
• scrotal erythema and tenderness
• fever
• irritative voiding symptoms
• reactive hydrocele, epididymo-orchitis
16
17. Epididymitis
❏ diagnosis
• urinalysis (pyuria), urine C&S
• +/– urethral discharge: Gram stain for gram-negative cocci or rods
• pain may be relieved with elevation of testicles (Prehn’s sign), absent in
testicular torsion
• if diagnosis clinically uncertain, must do
• colour-flow Doppler ultrasound
• nuclear medicine scan
• examination under anesthesia (EUA)
17
18. Epididymitis
❏ treatment
• antibiotics
• GC or Chlamydia - ceftriaxone 250 mg IM once followed by
doxycycline 100 mg BID x 21 days
• coliforms – broad spectrum antibiotics x 2 weeks
• scrotal support, ice, analgesia
18
20. Orchitis
❏ etiology
• usually a result of bacterial infection (epididymo-orchitis)
• 30% of post-pubertal males with mumps get orchitis
• mumps orchitis usually follows parotitis by 3-4 days
• other rare causes
• tuberculosis (TB)
• syphilis
• granulomatous (autoimmune) in elderly men
20