Acute Scrotum

testicular trauma, torsion, Fournier gangrene, Epididymo-orchitis.

1. Acute Scrotum Abdullah Bin Eid - 437014987

2. Objectives Anatomy of scrotum Definition of acute scrotum, and differential diagnosis. Testicular torsion Epididymo -orchitis Fournier gangrene Testicular trauma

3. Anatomy Protect testis Thermoregulation Connected to the abdominal wall via the spermatic cord. Average wall thickness of the scrotum is 8 mm. Contents: testes, epididymis and spermatic cord.

4. Definition and DDx The acute scrotum is defined as scrotal pain, swelling, and redness of acute onset.

5. Testicular Torsion

6. Testicular Torsion Testicular torsion is a twist of the spermatic cord, resulting in strangulation of the blood supply to the testis and epididymis. Associated with a poorly secured testis. It is considered as urologic emergency, Irreversible damage occurs after 6–12 hours of torsion! Peak age 13-15, but it happens at any age. Usually idiopathic. Undescended testes? Malignancy?

7. Mechanisms of testicular torsion may be identified: 1) Intravaginal torsion: a congenital abnormality in which the tunica vaginalis attaches to the superior pole of the testis (bell-clapper deformity) → increased mobility of testis within tunica vaginalis, with possible abnormal transverse lie of testis → torsion of the testis (along the spermatic cord) 2) Extravaginal torsion: lack of fixation of the tunica vaginalis to the gubernaculum → concomitant torsion of the testis and tunica vaginalis (along the spermatic cord) 3) Long mesorchium : elongated mesorchium → torsion of the testis along the mesorchium

8. Testicular Torsion Abrupt onset, typically swollen and tender testis and/or lower abdominal tenderness Nausea and vomiting Abnormal position of the testis (high-riding testis and abnormal transverse position) Absent cremasteric reflex Negative Prehn sign In neonate: Possible absent testis and firm, painless scrotal mass

9. Diagnosis of testicular torsion Clinical Duplex ultrasound of the scrotum Radionuclide imaging Urinalysis (to r/o epididymitis) Surgical intervention is recommended for suspected testicular torsion, regardless of radiological findings.

10. Treatment of testicular torsion Manual detorsion (laterally toward the thigh, then to the midline if failed to relive pain). Exploratory surgery (must be done within 6 hrs ) Orchidopexy Orchiectomy if the testis is grossly necrotic or nonviable Because of the risk of infertility, surgical exploration of the scrotum is recommended in any patient suspected of having testicular torsion, even if manual detorsion has been attempted.

11. Prognosis of testicular torsion Timely intervention within the recommended time period (6 hours from symptom onset) → restoration to previous condition Late or absent surgical intervention → ischemia → necrosis of the testicles

12. Epididymo -orchitis

13. Epididymo -orchitis The most common cause of scrotal pain in adults in the outpatient setting. It is the spread of infection from the epididymis to the testicle. Epididymitis is commonly associated with genitourinary tract infections, most commonly E. coli (most common) and Pseudomonas. In young age group most commonly due to STD (e.g. Chlamydia trachomatis, Neisseria gonorrhoeae). Chronic epididymitis (> 6-week course of the disease)

14. Epididymo -orchitis Unilateral scrotal pain and swelling, which develops over several days and radiates to the ipsilateral flank. Associated with tenderness. Positive Prehn sign. Red, shiny, and edematous scrotal skin. Symptoms of lower urinary tract infection. Low-grade fever

15. Epididymo -orchitis Urinalysis: pyuria, bacteriuria and urine culture if a UTI is suspected. Urethral swab for culture and nucleic acid amplification testing if an STI is suspected. CBC: leukocytosis Scrotal ultrasound to r/o testicular torsion. Findings in epididymitis: enlarged epididymis, increased blood flow

16. Treatment of epididymo -orchitis Scrotal elevation, ice packs, and NSAIDs. Empiric antibiotic therapy based on likely pathogens (until the causative organism is known): - Suspected UTI (with enteric organisms): fluoroquinolones (e.g., ofloxacin, levofloxacin) - Suspected STI: (with chlamydia or gonorrhea ) ceftriaxone PLUS doxycycline

17. Treatment of epididymo -orchitis Chronic epididymitis: NSAIDs and prolonged antibiotic therapy If symptoms persist: epididymectomy and/or orchidectomy If tuberculosis is suspected: antituberculous therapy If an abscess develops: surgical drainage

18. Fournier’s gangrene

19. Fournier’s gangrene Necrotizing fasciitis of the external genitalia that can spread rapidly to the anterior abdominal wall and gluteal muscles. Causes include: Diabetes, trauma to the genitalia and perineum and surgical procedures.

20. Causative organisms in Fournier’s gangrene Culture of infected tissue reveals a mixed polymicrobial infection with aerobic (E. coli, enterococcus, Klebsiella) and anaerobic organisms (Bacteroides, Clostridium, microaerophilic streptococci)

21. Presentation of Fournier’s gangrene Systemic symptoms: fever, chills, altered mental status Pain that is disproportionate in intensity Significant induration of the subcutaneous tissue Crepitus Purple skin discoloration (skin necrosis, ecchymosis) Bullae Loss of sensation in the affected area ( paresthesias ) spontaneous fulminant gangrene of the genitalia.

22. Diagnosis of Fournier’s gangrene Clinical CT scan

23. Treatment of Fournier’s gangrene Imaging and laboratory studies should not delay surgery. Blood Cx , IVF, O2 Broad-spectrum antibiotics (ampicillin, gentamicin, and metronidazole or clindamycin) Debridement (testes and penile tissue usually spared) Suprapubic catheter Repeat operative debridement every 24–72 hours may be necessary to remove newly necrotic tissue Hyperbaric oxygen therapy?

24. Testicular trauma

25. Testicular trauma Mostly blunt traumas. Bleeding occurs into the parenchyma of the testis, and if sufficient force is applied, the tunica albuginea of the testis ruptures, allowing extrusion of seminiferous tubules. Penetrating traumas. Due to gunshot or knife wounds and from explosive blasts; associated limb, perineal, pelvic, abdominal, and chest wounds often occur.

26. Testicular trauma Hematocele Hematoma Testicular rupture Testicular torsion/dislocation

27. Testicular trauma The testis may be under great pressure as a consequence of the intratesticular hemorrhage confined by the tunica vaginalis. This can lead to ischemia, pain, necrosis, and atrophy of the testis.

28. Presentation of testicular trauma Hx Physical examination Nausea and vomiting Hematoma (may spread into the inguinal region and lower abdomen)

29. Imaging in testicular trauma Hypoechoic areas within the testis (indicating intraparenchymal hemorrhage ) suggest testicular rupture

30. Treatment of testicular trauma • Testicular rupture = Exploration • Penetrating trauma = Exploration

31. Thank You Questions?