THE ACUTE

SCROTUM

ROSFI F HUZAIMA
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

Ischaemi Testicular Referred

Infection Other
a Trauma pain
Epididymitis Varicocoele
Varicocoele
Epididymitis
Torsion
Torsion of
of testis
testis Rupture
Rupture Nerve
Nerve root
root pain
pain
Hydrocoele
Hydrocoele
Epididymo-orchitis
Epididymo-orchitis

Spermatocoele
Spermatocoele
Contusion
Contusion or
or
Torsion
Torsion of
of appendage
appendage Orchitis
Orchitis Retrocaecal
Retrocaecal appendicitis
appendicitis
Haematoma
Haematoma
Strangulated
Strangulated inguinal
inguinal
hernia
hernia
Fornier’s
Fornier’s Gangrene
Gangrene Heinrech-Scholein
Heinrech-Scholein
purpura (HSP)
purpura (HSP) vasculitis
vasculitis
Testicular
Testicular infarction
infarction Haematocoele
Haematocoele Urinary
Urinary stone
stone
Cellulitis
Cellulitis Testicular
Testicular tumour
tumour (rapidly
(rapidly
growing/necrotic)
growing/necrotic)
 ANATOMY OF TORSION
– Types – Structures
– << Intravaginal – Testis
– twisted spermatic cord within – Appendix epididymis
tunica vaginalis
– Appendix testis
– Extravaginal >>
– twisted spermatic cord AND
tunica vaginalis (in neonates)
RISK FACTORS

– Bell-Clapper deformity
– Undescended testis

Bell-Clapper Deformity (blue is tunica vaginalis)

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
– (Bloods + blood cultures)

Doppler ultrasound
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)

TERIMAKASIH