THE ACUTE SCROTUM

Dr.Dwimantoro Iman P, SpU

Bagian Urologi
SMF/Lab.Ilmu Penyakit Bedah FK.UNUSA /
RSI Jemursari Surabaya
THINGS YOU SHOULD KNOW
AS A JUNIOR DOCTOR
There are multiple causes
for acute scrotal pain
and it is often difficult to
differentiate them

Acute testicular torsion is a

urological emergency

Do not delay surgical

referral exploration for
unnecessary investigations
TOPIC OUTLINE

Causes Trauma

Ischaemia . Referred pain

Infection Other
 CAUSES

Testicular Referred
Ischaemia Infection Other
Trauma pain
Epididymitis Varicocoele
Torsion of testis Rupture Nerve root pain

Hydrocoele
Epididymo-orchitis

Spermatocoele
Contusion or
Torsion of appendage Orchitis Retrocaecal appendicitis
Haematoma
Strangulated inguinal
hernia

Fornier’s Gangrene
Heinrech-Scholein
purpura (HSP) vasculitis
Testicular infarction Haematocoele Urinary stone
Cellulitis Testicular tumour (rapidly
growing/necrotic)
ANATOMY OF TORSION
 Structures
Types  Testis
 << Intravaginal  Appendix epididymis
 twisted spermatic cord  Appendix testis
within tunica vaginalis
 Extravaginal >>
 twisted spermatic cord
AND tunica vaginalis (in
neonates)
RISK FACTORS

1. Bell-Clapper deformity (Testicle lacks

normal attachment at vaginalis)
Increased mobility
Tranverse lie of testes
Typically bilateral
Prevalence 1/125
2. Undescended testis

Bell-Clapper Deformity (blue is tunica vaginalis)

TORSION: EXAMINATION

Edematous, tender, swollen

Elevated from shortened spermatic cord
 Horizontal lie common (PPV 80%)
 Reactive hydrocele may be present
Cremasteric reflex absent in nearly all (unreliable in
<30mo old) (PPV 95%)
Prehn’s sign elevation relieves pain in epididymitis
and not torsion is unreliable
INVESTIGATIONS

Urinalisis
Doppler ultrasound

1. 2.
DIAGNOSIS – “TIME IS TESTICLE”

Ideally  prompt clinical diagnosis

Imaging
 Color doppler – decreased intratesticular flow
 False + in large hydrocele, hematoma
 Sens 69-100% and Spec 77-100%
 Lower sensitivity in low flow pre-pubertal testes
 Nuclear Technetium-99 radioisotope scan
 Show testicular perfusion
 30 min procedure time
 Sens and spec 97-100%
Acute torsion L testis
Dec blood flow on L

Late torsion on R
Inc blood flow around
but dec flow w/in testis
IMAGES - TORSION
 Decreased echogenicity
and size of right testicle

 Nuclear medicine scan

shows "rim sign“ =no flow
to testicle and swelling
DETORSION OF TESTICULAR TORSION
SURGERY

Immediate
exploration

Detorsion

Fixation OR
Orchidectomy
TESTIS/EPIDYDIMIS INFECTION

Bacterial
 UTI  younger/older patients
 usually gram negative bacteria
 STD  sexually active patients
 Chlamydia trachomatis
 Neisseria gonorrhoeae

Viral
 Mumps
INVESTIGATIONS

Urine cultures
Urinary STD screen in sexually
active Doppler ultrasound

Doppler ultrasound
(Bloods + blood cultures)

Microscopy of E. coli
TREATMENT
 Analgaesia & scrotal support
 Urinary tract source (for 14 days) –
empirical
 Trimethoprim 300mg PO daily
 OR cephalexin 500mg PO QID
 OR augmentin 1tab PO BD

 Sexually active young men – empirical

 Ceftriaxone 500mg IV
 AND Azithromycin 1g PO stat
 AND Doxycycline 100mg PO BD (14 days)

 If not improving exclude abscess

 Ensure urine clear at end of antibiotics with
U/A
 FOURNIER’S GANGRENE
 Necrotising fasciitis of genitalia & perineum
 High mortality (30%)
 Rapidly progressing
 Risk factors – Diabetic, Immunocompromised,
Alcoholic
 Treatment
 Rapid surgical debridement
 Supportive care & broad spectrum antibiotics
 Hypobaric oxygen
TRAUMA
Testicular Rupture
 Requires prompt surgical repair
 Can only be seen on US in 20% - go by clinical suspicion

Testicular Contusion/Intratesticular Haematoma

 Hypoechoic or haetrogenous area on ultrasound
 Usually explored because rupture cannot be excluded.
 Then managed symptomatically:
 Analgaesia
 Scrotal support & elevation
 Ensure resolution on follow-up ultrasound  could be a testicular
carcinoma!
REFERRED PAIN
 Retrocaecal appendicitis
 Urinary stones
 Nerve root pain
OTHER CAUSES
 Varicocoele
 Hydrocoele
 Spermatocoele

 Strangulated inguinal hernia

 Heinrech-Scholein purpura (HSP) vasculitis

 Testicular tumour (rapidly growing/necrotic)