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 Nerve root
Rupture
testis pain
Epididymo- Hydrocoele
orchitis
Contusion Spermatocoele
Torsion of Retrocaecal
Orchitis or
appendage appendicitis Strangulated
Haematoma inguinal hernia
Fornier’s Heinrech-Scholein
Gangrene purpura (HSP)
Testicular Haematoco Urinary vasculitis

infarction Cellulitis ele stone Testicular tumour

(rapidly
growing/necrotic)
ANATOMY OF TORSION
• Structures
• Types • Testis
• << Intravaginal • Appendix epididymis
• twisted spermatic cord within • Appendix testis
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)