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Acute SCROTUM. Testicular torsion Appendage torsion Epidydimitis Orchitis Trauma Tumor ? Hernia ?. Testicular Anatomy. The normal testis is oriented in the vertical axis and the epididymis is above the superior pole in the posterolateral position.

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acute scrotum
Acute SCROTUM
  • Testicular torsion
  • Appendage torsion
  • Epidydimitis
  • Orchitis
  • Trauma
  • Tumor ?
  • Hernia ?
testicular anatomy
Testicular Anatomy
  • The normal testis is oriented in the vertical axis and the epididymis is above the superior pole in the posterolateral position.
  • Cremasteric reflex: Stroking/pinching the inner thigh should result in elevation of > 0.5 cm of the ipsilateral testicle
testicular torsion
Testicular Torsion
  • Incidence 1:4000
  • Only 50% salvageability w/ testicular loss from either atrophy or ochiectomy
  • Two peak periods: first year of life and at puberty
  • 10 times more likely in an undescended testis
testicular torsion5
Testicular Torsion

Most torsions due to bilateral anatomic abnormality. Tunica vaginalis has a high insertion about the spermatic cord.

Resultant bell-clapper deformity—testis dangles in the scrotum and is mobile

testicular torsion pathophysiology
Testicular Torsion: Pathophysiology
  • Initially venous return is obstructed and then venous thrombosis is followed by arterial thrombosis
  • Degree of obstruction is a function of the degree of rotation
  • Necrosis develops in testicle with complete obstruction and infarction develops after arterial thrombosis
testicular torsion7
Testicular Torsion
  • Rapid swelling and edema of the testis and scrotum, followed by scrotal erythema
  • Damage proportional to duration/extent of vascular obstruction
  • Salvage rate of testis is 80-100% if pain lasts less than 6 hours
  • Pain > 24 hours is associated w/ testicular infarction
testicular torsion8
Testicular Torsion
  • 40% report a hx of similar pain that resolved spontaneously in the past
  • Often occurs after exertion or during sleep
  • Typically no urinary symptoms
  • Sudden onset of scrotal pain, but can be inguinal or lower abdominal. May be constant or intermittent. Not positional
  • Nausea and Vomiting
testicular torsion9
Testicular Torsion
  • Hemiscrotum is swollen, tender, firm
  • High-riding testis with a transverse lie is classic sign
  • Loss of cremasteric reflex – almost universal
  • May see the bell-clapper deformity, with horizontal lie of the contralateral testicle
  • Prehn’s sign: Relief of scrotal pain by elevating testicle. NOT a reliable way to distinguish epididymitis from torsion
testicular torsion diagnosis
Testicular Torsion: Diagnosis
  • Doppler Ultrasononography now test of choice for Dx of torsion. Sensitivity comparable to radioisotope scans (86%-100%) and greater specificity (100%). Doppler U/S is more rapid and more available than radioisotope scans.
testicular torsion management
Testicular Torsion: Management
  • Immediate Urologic consultation for surgical exploration and possible bilateral orchidopexy if diagnosis is obvious
  • Manual detorsion - Only a temporizing measure. Endpoint for successful detorsion is pain relief.
  • Most torsions occur lateral to medial, therefore detorsion should be attempted in a medial to lateral direction - “open the book” maneuver
  • Imaging if diagnosis unclear, should NOT delay exploration if high suspicion exists
torsion of appendage
Torsion of Appendage
  • Torsion of appendages is more common than testicular torsion
  • Testicular and Epididymal appendages are vestigial remnants of the wolffian and mullerian ducts respectively
  • Most frequent in preadolescent males 3-13, appendix testis > epididymal appendix
  • Cause unclear
  • Twisting causes obstruction, edema and then painful necrosis
torsion of appendage14
Torsion of Appendage
  • Discrete, painful testicular mass
  • Symptoms less severe than torsion. No nausea, vomiting, or fevers
  • Transillumination of scrotum may reveal the cyanotic appendage as a pathognomonic blue dot
  • U/S or Nuclear scintigraphy should reveal normal to increased blood flow
torsion of appendage management
Torsion of Appendage: Management
  • Scrotal Support
  • Pelvic rest
  • Analgesia
  • Expect resolution of symptoms in 7-10 days with degeneration of appendages
epididymitis
Epididymitis
  • Average age 25 years
  • Most common misdiagnosis for testicular torsion
  • Rarely affects a prepubertal child without an underlying urinary tract infection
  • Result of retrograde ascent of urethral and bladder pathogens
  • Peritubular fibrosis may develop and occlude the ductules, if bilateral may lead to sterility
epididymitis17
Epididymitis

In men > 40, E. coli is the predominant pathogen. Other coliform organisms, Pseudomonas, and gram positive cocci. Associated w/ underlying urologic pathology -- Recent GU tract manipulation or bacterial prostatitis.

In men <40, Chlamydia and N. gonorrhoeae are the major pathogens

epididymitis18
Epididymitis
  • Gradual Scrotal pain, peaks over days
  • Low grade fever, average 38 degrees C
  • Cremasteric reflex usually preserved
  • Due to inflammatory nature of pain, may have some transient pain relief from scrotal elevation
  • Localized epididymal swelling initially, then may progress to single, large testicular mass
  • Urethral discharge and voiding symptoms may be present
epididymitis19
Epididymitis
  • Pyuria and bacteriuria on U/A
  • Urethral discharge should be examined for gram stain and culture
  • Leukocytosis between 10K-30K
  • Torsion should not be excluded by pyuria, fever, or dysuria. An equivocal exam demands Imaging. U/S with increased or normal testicular blood flow is c/w epididymitis
epididymitis management
Epididymitis: Management
  • Sexually acquired: Ceftriaxone 250 mg IM and Doxycycline 100 mg PO bid x 10d. Treat sexual partners.
  • Nonsexually acquired: TMP-SMX or Fluoroquinolone x 14d. Check urine C&S.
  • Bed rest, scrotal support, analgesics, sitz baths, and Urology follow up
complications of epididymitis
Complications of Epididymitis
  • Infertility - Sexually transmitted epididymitis
  • Abscess - Gonococcal epididymitis
  • Chronic epididymitis
  • U/S indicated if no response to medical therapy
orchitis
Orchitis
  • Acute infection of the testis
  • Rare without initial epididymitis. Consider testicular tumor.
  • Bacterial infection secondary to spread from epididymitis of E. coli, Klebsiella, Pseudomonas
  • Viral orchitis – Mumps. 4-6 days after onset of parotitis usually. 50% of involved testes atrophy but infertility rare
  • Syphilis
  • Treatment: Antibiotics for bacterial orchitis and local scrotal measures for viral orchitis
testicular tumor
Testicular Tumor
  • Testicular CA – Most common cause of malignancy to afflict young men
  • Average age of incidence 32
  • DDx: Epididymitis and torsion
  • Increased incidence with cryptorchidism in bilateral testes
  • Majority are Seminomas, then embryonal cell CA and teratomas
testicular tumor26
Testicular Tumor
  • Classic presentation – Painless, firm testicular mass
  • Acute hemorrhage within the tumor can lead to acute scrotal pain (10%)
  • Ultrasound – Distinct Intratesticular Mass
  • CXR if suspect Metastases
  • Treatment: Immediate Urology referral. Radical orchiectomy. Cisplatin chemotherapy and Radiation for seminomas.