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Scrotal Pain and Swelling

Scrotal Pain and Swelling. Jesse Sturm, MD December, 20, 2006. Outline. Embryology and anatomy Causes of Pain and Swelling Torsion, Epididymitis, Orchitis, Trauma History, Physical, Radiologic Exams, Labs Causes of Swelling Hydrocele, Varicocele, Spermatocele, Tumor, Idiopathic.

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Scrotal Pain and Swelling

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  1. Scrotal Pain and Swelling Jesse Sturm, MD December, 20, 2006

  2. Outline • Embryology and anatomy • Causes of Pain and Swelling • Torsion, Epididymitis, Orchitis, Trauma • History, Physical, Radiologic Exams, Labs • Causes of Swelling • Hydrocele, Varicocele, Spermatocele, Tumor, Idiopathic

  3. Embryology • Descent of testes at 32-40 wks gestation • Descends within processes vaginalis • Outpouching of peritoneal cavity • Tunica vaginalis is potential space that remains after closure of process vaginalis

  4. Anatomy • Spermatic cord –testicular vessels, lymph, vas deferens • Epididymis - sperm formed in testicle and undergo maturation, stored in lower portion • Vas Deferens – muscular action propels sperm up and out during ejaculation • Gubernaculum – fixation point for testicle to tunica vaginalis • Tunica Vaginalis – potential space • Encompasses anterior 2/3’s of testicle • Tunica albuginea is inner layer opposing testis

  5. Anatomy – Nuts and Bolts Posterior Anterior

  6. Causes of Pain and Swelling • Pain • Testicular torsion • Torsion of appendix testis • Epididymitis • Trauma • Orchitis and Others • Swelling • Hydrocele • Varicocele • Spermatocele • Tumor

  7. Torsion • Inadequate fixation of testes to tunica vagnialis at gubernaculum • Torsion around spermatic cord • Venous compression to edema to ischemia

  8. Epidemiology • Accounts for 30% of all acute scrotal swelling • Bimodal ages – neonatal (in utero) and pubertal ages • 65% occur in ages 12-18yo • Incidence 1 in 4000 in males <25yo • Increased incidence in puberty due to inc weight of testes

  9. Predisposing Anatomy • Bell-clapper deformity • Testicle lacks normal attachment at vaginalis • Increased mobility • Tranverse lie of testes • Typically bilateral • Prevalence 1/125

  10. Torsion: Clinical Presentation • Abrupt onset of pain – usually testicular, can be lower abdominal, inguinal • Often < 12 hrs duration • May follow exercise or minor trauma • May awaken from sleep • Cremasteric contraction with nocturnal stimulation in REM • Up to 8% report testicular pain in past

  11. 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

  12. Intermittent Torsion • Intermittent pain/swelling with rapid resolution (seconds to minutes) • Long intervals between symptoms • PE: testes with horizontal lie, mobile testes, bulkiness of spermatic cord (resolving edema) • Often evaluation is normal – if suspicious need GU followup

  13. 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%

  14. Acute torsion L testis • Dec blood flow on L • Late torsion on R • Inc blood flow around but dec flow w/in testis

  15. Images - Torsion • Decreased echogenicity and size of right testicle • Nuclear medicine scan shows "rim sign“ =no flow to testicle and swelling

  16. Management • Detorsion within 6hr = 100% viability • Within 12-24 hrs = 20% viability • After 24 hrs = 0% viability • Surgical detorsion and orchiopexy if viable • Contralateral exploration and fixation if bell-clapper deformity • Orchiectomy if non-viable testicle • Never delay surgery on assumption of nonviability as prolonged symptoms can represent periods of intermittent torsion

  17. Manual Detorsion • If presents before swelling • Appropriate sedation • In 2/3rds of cases testes torses medially, 1/3rd lateral • Success if pain relief, testes lowers in scrotum • Still need surgical fixation

  18. Torsion: Special Considerations • Adolescents may be embarrassed and not seek care until late in course • Torsion 10x more likely in undescended testicle • Suspicious if empty scrotum, inguinal pain/swelling • Adult Emergency Physicians accurate in bedside US diagnoses with sens of 95% and specificity of 94% (missed 1 epididymitis, no torsion) Blavis M., Emergency Evaluation of Patients Presenting with A Cute Scrotum, Academy of Emergency Medicine. Jan 2001

  19. Neonatal Torsion • 70% prenatal, 30% post-natal • Post-natal typically 7-10 days after birth • Unrelated to gestation age, birth weight • Post-natal presents in typical fashion • Doppler U/S and radionucleotide scans less accurate with low blood flow in neonates • Surgical intervention if post-natal • Prenatal torsion presents with painless testicular swelling, rare testicular viability • Rare intervention in prenatal torsion

  20. Torsion of Appendix Testis • Appendix testis • Small vestigial structure, remnant of Mullerium duct • Pedunculated, 0.3cm long • Other appendix structures • Prepubertal estrogen may enlarge appendix and cause torsion

  21. Torsion of Appendix Testis • Peak age 3-13 yo (prepubertal) • Sudden onset, pain less severe • Classically, pain more often in abd or groin • Non-tender testicle • Tender mass at superior or inferior pole • May be gangrenous, “blue-dot” (21% of cases) • Normal cremasteric reflex, may have hydrocele • Inc or normal flow by doppler U/S

  22. Torsion of Appendix Testis Blue dot of gangrenous appendix testis

  23. Torsion of Appendix Testis • Management supportive • analgesics, scrotal support to relieve swelling • Surgery for persistent pain • no need for contralateral exploration

  24. Epididymitis • Inflammation of epididymis • Subacute onset pain, swelling localized to epididymis, duration of days • With time swelling and pain less localized • Testis has normal vertical lie • Systemic signs of infection • inc WBC and CRP, fever + in 95% • Cremasteric reflex preserved • Urinary complaints: discharge/dysuria PPV 80%

  25. Epididymitis • Scrotum has overlying erythema, edema in 60% • Normal vertical lie

  26. Epididymitis • Sexually active males • Chlamydia > N. gonorrhea > E. coli • Less commonly pseudomonas (elderly) and tuberculosis (renal TB) • Young boys, adolescents often post-infectious (adenovirus) or anatomic • Reflux of sterile urine through vas into epididymis • 50-75% of prepubertal boys have anatomic cause by imaging

  27. Etiologies of Epididymitis

  28. Epididymitis Diagnosis • Leukocytosis on UA in ~40% of patients • PCR Chlamydia + in 50%, GC + in 20% of sexually active • 95% febrile at presentation • Doppler and Nuclear imaging show increased flow • If hx consistent with STD, CDC recommends: • Cx of urethral discharge, PCR for C and G • Urine culture and UA • Syphilis and HIV testing

  29. Laboratory Adjuncts • Studies of acute phase reactants: CRP, IL-1, IL-6 • Documented epididymitis have 4 fold increase in CRP compared to testicular torsion • PPV 94% and NPV 94% (inc 2 fold) • Testicular tumor showed no increase in CRP Doehn C., Value of Acute Phase Proteins in the Differential Diagnosis of A Cute Scrotum, Journal of Urology. Feb 2001.

  30. Doppler Epididymitis • Left Epididymitis • Inc blood flow in and around left testis

  31. Epididymitis Treatment • Sexually active treat with Ceftriaxone/Doxycycline or Ofloxacin • Pre-pubertal boys • Treat for co-existing UTI if present • Symptomatic tx with NASIDs, rest • Referral all to GU for studies to rule out VUR, post urethral valves, duplications • Negative culture has 100% NPV for anomaly

  32. Orchitis • Inflammation/infection of testicle • Swelling pain tenderness, erythema and shininess to overlying skin • Spread from epididymitis, hematogenous, post-viral • Viral: Mumps, coxsackie, echovirus, parvovirus • Bacterial: Brucellosis

  33. Mumps Orchitis • Extremely rare if vaccinated • 20-30% of pts with mumps, 70% unilateral, rare before puberty • Presents 4-6 days after mumps parotitis • Impaired fertility in 15%, inc risk if bilateral

  34. Trauma • Result of testicular compression against the pubis bone, from direct blow, or straddle injuries • Extent depends on location of rupture • Tunica albuginea ruptures (inner layer of tuncia vaginalis) allows intratesticular hematoma to rupture into hematocele • Rupture of tunica vaginalis allow blood to collect under scrotal wall causing scrotal hematoma • Doppler often sufficient to assess extent • Surgery for uncertain dx, tunica albuginea rupture, compromised doppler flow

  35. Testicular Hematoma • Blood as a filling defect in testis

  36. Other Causes of Pain • Incarcerated inguinal hernia • Henoch-Schonlein Purpura • Vasculitis of testicular vessels • Rarely presents with only scrotal pain • Referred pain • Retrocecal appendix, urolithiasis, lumbar/sacral nerve injury • Non specific scrotal pain • Minimal pain, nl exam – return immediately for inc symptoms

  37. Scrotal Swelling • Hydrocele • Varicocele • Spermatocele • Testicular Cancer

  38. Hydrocele • Fluid accumulation in potential space of tunica vaginalis • May be primary from patent PV or secondary to torsion/epididymitis

  39. Hydrocele • Transilluminating anterior cystic mass

  40. Hydrocele • Mass increases in size during day or with crying and decreases at night if communicating • If non-communicating and <1 yo follow • If communicating (enlarging), scrotum tense (may impair blood flow) requires repair • Unlikely to close spontaneously and predisposes to hernia

  41. Varicocele • Collection dilated veins in pampiniform plexus surrounding spermatic cord • More common on left side • R vein direct to IVC • L vein acute angle to renal vein • ~20% of all adolescent males

  42. Varicocele • Often asymptomatic or c/o dull ache/fullness upon standing • Spermatic cord has ‘bag of worms’ appearance that increased with standing/valsalva • If prepubertal, rapidly enlarging, or persists in supine position rule out IVC obstruction • Most management conservatively • Surgery if affected testis < unaffected testis volume

  43. Spermatocele • Painless sperm containing cyst of testis, epipdidymis • Distinct mass from testis on exam • Transilluminates • Do not affect fertility • Surgery for pain relief only

  44. Testicular Cancer • Most common solid tumor in 15-30 yo males • 20% of all cancers in this group • Painless mass • Rapidly growing germ cell tumors may cause hemorrhage and infarction • Present as firm mass • Typically do not transilluminate • Diagnostic imaging with U/S initially

  45. Acute Idiopathic Scrotal Edema • Scrotal skin red and tender • underlying testis normal • no hydrocele • Erythema extends off scrotum onto perineum • Empiric tx, cause unknown • Antihistamine, steroids • Resolves w/in 48-72hrs

  46. Conclusions • Clinical history and careful exam are key factors in formulating accurate differential • Imaging and labs useful adjuncts in unclear cases • U/S superior to nuclear imaging if time essential • TIME IS TESTICLE • Early surgical intervention and GU involvement • Swelling without pain, usually less time sensitive diagnostically

  47. References • Ciftci, AO. Clinical Predictors for Diff. Diagnosis of Acute Scrotum, European J. of Ped. Surgery. Oct 2004. • Blavis M., Emergency Evaluation of Patients Presenting with Acute Scrotum, Academy of Emergency Medicine. Jan 2001 • Doehn C., Value of Acute Phase Proteins in the Differential Diagnosis of Acute Scrotum, Journal of Urology. Feb 2001. • Kaplan G., Scrotal Swelling in Children. Pediatrics in Review. Sep 2000. • Luzzi GA. Acute Epididymitis. BJU International. May 2001. • Fleisher G, Ludwig S, Henretig F. Textbook of Pediatric Emergency Medicine. 2006.

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