ACUTE SCROTUM.....pdf. ACUTE SCROTAL CONDITIOND

Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.

There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent

1. THE ACUTE SCROTUM
DR SETH JOTHAM
LECTURER –DEPARTMENT OF SURGERY

2. The basic anatomy

3. ACUTE SCROTUM
•Acutescrotumisageneraltermreferringtoanemergency
conditionaffectingthecontentsorthewallofthescrotum.
•Thereareanumberofconditionsthatpresentacutely,
predominantlywithpainand/orswelling

4. Cont …
•Acarefulanddetailedhistoryandexamination,andinsome
cases,investigationsallowdifferentiationbetweenthese
diagnoses.Apromptdiagnosisisessentialasthepatient
mayrequireurgentsurgicalintervention

5. Aetiologyand Ddx:(urological emergency 1
st
ed2017)

6. 1. Testicular torsion
•Testiculartorsionreferstotwistingofthespermaticcord,
causingischaemiaofthetesticle.
•Testiculartorsionresultsfrominadequatefixationofthe
testistothetunicavaginalisproducingischemiafrom
reducedarterialinflowandvenousoutflowobstruction.
•Theprevalenceoftesticulartorsioninadultpatients
hospitalizedwithacutescrotalpainisapproximately25to50
percent

7. .

8. Risk factors
•Age
•Genetics
•Previous testicular torsion
•Trauma
•Climate
“ARTICLESREVIEWFORTHERISKS”
•GreearGM,RomanoMF,KatzMH,MunarrizR,
RagueJT.Testiculartorsion:epidemiological
riskfactorsfororchiectomyinpediatricand
adultpatients.InternationalJournalof
ImpotenceResearch.2021Mar;33(2):184-90.
•LacyA,SmithA,KoyfmanA,LongB.Highrisk
andlowprevalencediseases:Testiculartorsion.
TheAmericanJournalofEmergencyMedicine.
2023Apr1;66:98-104.

9. Clinical features and diagnosis
•Thediagnosisoftesticulartorsionisusuallydeterminedbyacute
onsetofseveresymptomsandcharacteristicphysicalfindings.
•Theonsetofpainintesticulartorsionisusuallysuddenandoften
occursseveralhoursaftervigorousphysicalactivityorminortrauma
tothetesticles.
•Theremaybeassociatednauseaandvomiting
•Anothertypicalpresentation,particularlyinchildren,isawakening
withscrotalpaininthemiddleofthenightorinthemorning.

10. On examination

11. Special tests
•Cremastericreflex
Thereflexisusuallyabsentinpatientswithtesticulartorsion
(Rabinowitz’sign)
•Prehen’ssign
Reliefofscrotalpainbyelevatingtesticle.

12. Investigations
•Diagnosisoftesticulartorsionisaclinicaloneandanytests
shouldbedoneonlyundertheprovisotheydonotdelay
surgicalexplorationincasesofsuspectedtorsion.
•Theyaregenerallyusefultoconfirmasuspectedalternative
diagnosissuchasepididymo-orchitis.Ifthereisdiagnostic
uncertainty,surgicalexplorationistheonlyinfallible
diagnostictest.

13. Doppler ultrasound
•Dopplerultrasoundmayshowabsentbloodflowtothe
testisbutincasesoftorsionwithlessthana360°twist,
somebloodflowmaystillbeapparent;therefore,ultrasound
cannotbereliedupontoaccuratelyexcludeatorsion.

14. Cont …
•Laboratorytestsmaybenormalorreportmildwhitecell
count(WCC)andC-reactiveprotein(CRP)elevation
correspondingwithtissueischaemiawithinthetestis.

15. Treatment: Surgery
•Immediatesurgicalexplorationwithintraoperative
detorsionandfixationofthetestes.
•Delayindetorsionofafewhoursmayleadtoprogressively
higherratesofnonviabilityofthetestis.
•Detorsionandfixationofboththeinvolvedtestisandthe
contralateraluninvolvedtestisshouldbedonesince
inadequategubernacularfixationisusuallyabilateraldefect.
•Longerperiodsofischemia(>12hours)maycause
infarctionofthetestiswithliquefactionrequiringorchiectomy.

16. …

17. 2. Torsion of the appendix testis
•Testicularpainfromtorsionoftheappendixtestisisusually
moregradualthanwithtesticulartorsionanditistheleading
causeofacutescrotalpathologyinchildhood.
•Torsionoftheappendixtestisrarelyoccursinadults.
•Itisnotuncommonforpatientstohaveseveraldaysof
scrotaldiscomfortbeforetheypresentforevaluation.
•Painrangeswidelyfrommildtosevere.

18. …..
•Carefulinspectionofthescrotalwallatthislocationmaydetecttheclassic
"bluedot"signcausedbyinfarctionandnecrosisoftheappendix
testis.

19. Management
•Managementofacutetorsionoftheappendixtestisusually
includesconservativetreatment,whichincludesrest,ice,
andNSAIDs.
•Recoveryisgenerallyslowwiththisapproach,andpainmay
lastforseveralweekstomonths.
•Surgicalexcisionoftheappendixtestisisreservedfor
patientswhohavepersistentpain.

20. 3. Epididymo-orchitis
•Epididymo-orchitisisaninfectiveprocessaffectingthetestis
(orchitis),epididymis(epididymitis)orboth(epididymo-
orchitis).

21. Aetiology
Theaetiologyvariesbetweenagegroups.
•Inyoung,sexuallyactivemen,sexuallytransmitted
infections(STIs)duetochlamydiaorgonorrhoeaarethe
mostlikelycauses,
•whileinoldermenascendingGram-negativeinfections,
predominantlywithEscherichiacolifromtheurinarytract,
onabackgroundofpoorbladderemptyingisthemore
commoncause

22. .

23. Hx& Presentation
•Graduallyincreasingpainandswellingofthehemiscrotum
•withorwithoutassociatedfeversistypicallyreported.
•Itisimportanttoenquireaboutsexualbehaviour,lower
urinarytractsymptoms(LUTS)andpreviousepisodesand
riskfactorsfortuberculosis(TB)asthiswillguide
appropriatemanagement.

24. Examination
•Typically,theaffected
hemiscrotumlooksmarkedly
enlargedanderythematous,
butchangesmayspreadand
involvethecontralateraltestis.
•Itiscrucialtoinspecttheentire
scrotalskin,includingthe
perinealaspectinordernotto
missanyareasofskinnecrosis
thatmaysuggestthe
developmentofFournier’s
gangrene
•Palpateandpercussthe
suprapubicareatoassess
foradistendedurinary
bladder.
•Rectalexaminationofthe
prostatelookingforan
enlargedglanddueto
benign prostatic
enlargement(BPE)causing
bladderoutletobstruction
(BOO)andforprostatitisor
prostaticabscess.

25. Investigations
•Aurinalysisandurinecultureshouldbeperformedinall
patientssuspectedofepididymioorchitis,althoughurine
studiesareoftennegativeinpatientswithouturinary
complaints.
•Aurethralswabshouldbeobtainedinpatientswithurethral
dischargeandsentforcultureshouldbeperformedin
patientswithacuteonsetoftesticularpaintoassessfor
testiculartorsion

26. …
•WCCandCRPshouldbetestedtoassessseverityofthe
infection.
•Ultrasound:shouldbedoneacutelytoexcludeacollection
oranabscess,orifthereisanydoubtaboutthediagnosis,
e.g.tumourormissedtorsion

27. Treatment
•AntibioticsshouldbegivenorallyorIVdependingonthe
severityofinfection.
•Inthecaseofsignificantsepsis,aminoglycosidesintheform
ofgentamicincouldbecombinedwitheitherbroad-spectrum
penicillins(e.g.co-amoxiclav)orfluoroquinolones(e.g.
ciprofloxacin,ofloxacin).

28. ….
•young,sexuallyactivemenshouldbetreatedwith
fluoroquinoloneswithactivityagainstChlamydiatrachomatis
(e.g.ofloxacinorlevofloxacin);alternatively,doxycycline
100mgtwice-dailyfortwoweeks.
•IfaSTIisnotsuspected,co-amoxiclavorciprofloxacincould
begiven.

29. 4.Scrotal abscess
•A collection of pus within the deep layers of the scrotum is termed
correctly as a scrotal abscess.
•Not infrequently, superficial infections within hair follicles or primary
perineal abscesses with some scrotal skin involvement are also
labelled the same.

30. Causes & risk factors
Scrotalabscessesalmostexclusivelydeveloponthebackgroundof
otherinfectiveconditionsincluding
•Immuno-supressiveconditions
•Epididymo-orchitis
•UTI
•Urineextravasation(riskincludingcalculus,strictureandurethral
injury)
•Postneglectedtesticulartorsion
•Drainageofappendicularabscesstothescrotumviaapatent
processusvaginalis

31. Presentation
•Graduallyincreasingswelling
andpainthatdeveloponthe
backgroundofanothercondition
•Febrileepisodes
O/E
•swellingandtenderness
associatedwitherythemacan
beseenontheipsilateralside
•Fluctuanceonpalpation

32. Investigations
•Inflammatory markers (WCC, CRP) are commonly elevated.
•Scrotal USS confirms an underlying collection, which may
have characteristics of purulent fluid and may also identify
underlying pathology
•Aspiration for C/S Can be done in selected cases unto
which conservative mx is contemplated

33. Treatment
Immediatemanagementconstitutes
•Broad-spectrumantibioticcover.
•FluidResuscitation
•painreliefshouldbeconsidered
•Bladdercatheterizationmightberequiredif(Postvoidalresidue)
PVRvolumesarehigh.
•Inmostcases,surgicalexplorationanddrainageoftheabscess
isindicated.
Nb:C/Sifnotdoneasinselectedcases

34. Feared complication: Fournier's gangrene

35. Further reading
•UrologicalemergencybyDavidThurtleetal:1
st
ed2017
•IbrahimAA,RefeidiA,ElMekkiAA.Etiologyandclinicalfeaturesofacute
epididymo-orchitis.AnnSaudiMed.1996Mar;16(2):171-4.PMID:17372435.
•MolokwuCN,SomaniBK,GoodmanCM.Outcomesofscrotalexplorationfor
acutescrotalpainsuspiciousoftesticulartorsion:aconsecutivecaseseriesof
173patients.BJUInt2011;107:990.
•CummingsJM,BoullierJA,SekhonD,BoseK.Adulttesticulartorsion.JUrol
2002;167:2109.