ACUTE SCROTUM POWER POINT PRESENTATION.pptx

Presentation on acute scrotum

1. THE ACUTE SCROTUM

2. outline Introduction Anatomy and physiology Causes Pathogenesis Clinical presentations Examination findings Investigations management

3. INTRODUCTION The spectrum of conditions that affect the scrotum and its contents ranges from incidental findings that may require patient reassurances only OR acute events that may require immediate surgical intervention. The acute scrotum is defined as urological emergency characterized by scrotal pain, swelling, and redness of acute onset.

4. RELATED ANATOMY The scrotum is a male reproductive structure located under the penis. It is a thin external sac composed of skin and smooth muscle. This sac is divided into two compartments by the scrotal septum. The average wall thickness of the scrotum is about 8 mm. It has a parietal and a visceral layer. The structures contained in the scrotal sac are the external spermatic fascia, testes, epididymis, and spermatic cord

5. DIFFERENTIAL DIAGNOSIS The most common causes of acute scrotal pain in adults are testicular torsion and epididymitis . Other conditions that may result in acute scrotal pathology include Fournier’s gangrene , torsion of the appendix testis , trauma/surgery, testicular cancer, strangulated inguinal hernia ,mumps and referred pain.

6. TESTICULAR TORSION T esticular torsion is a urologic emergency that is more common in neonates and postpubertal boys, although it can occur at any age. The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25- 50%. Torsion is the twisting of the spermatic cord. Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis leading to ischaemia from reduced arterial inflow and venous outflow obstruction. The testis suffers irreversible damage after 12 hours of ischaemia .

7. PATHOGENESIS Twisting of testicle around spermatic cord ↓ Venous drainage hindered ↓ Venous pressure rises ↓ Venous pressure equalizes arterial pressure ↓ Compromised arterial flow ↓ Testicular ischemia Note the horizontal lie, elevation, and edema of the affected testicle

8. CLINICAL FEATURES Symptoms Acute onset of testicular pain Pain is severe and constant May be associated with recent trauma or vigorous activity Associated S ymptoms : Nausea/vomiting (20-30%) Abdominal pain (20-30%) Fever (16%) Urinary frequency (4%)

9. Examination Findings Unilateral swelling Erythema or darkening of testicle Loss of rugae on affected side Elevated testicle Horizontal lie (compared to normal vertical lie) Pain and tenderness of testicle Unilateral loss of cremasteric reflex ( a distinguishing feature from epididymitis) No relief of pain with elevation of testicle Negative Prehn ‘s Sign

10. DIAGNOSIS Diagnosis is based on c linical suspicion from history and physical examination. Clinically evident cases require emergent urology consult F BC and urine assay may help narrow differential diagnosis but should not delay management. Consider imaging if diagnosis uncertain. Doppler Ultrasound – Test of Choice Check doppler flow to testes : decreased Doppler flow of the testicle indicating a torsion of the testicle. 88-100% sensitivity, 90-100% specificity

11. MANAGEMENT Treatment for suspected testicular torsion is immediate surgical exploration with intraoperative detorsion and fixation of the testis . Delay in detorsion of a few hours may lead to progressively higher rates of non-viability of the testis. Manual detorsion is performed if surgical intervention is not immediately available.

12. Manual detorsion (26-80% success) Should be done by urologist Patient should be sedated Most effective before significant edema present Rotate testicle up and away from midline (t o w ar ds thigh) Surgical detorsion with bilateral orchiopexy Bilaterally correction required since deformity usually bilaterally Surgical correction required even if manually detorsed Longer periods of ischaemia ( >12 hours ) may cause infarction of the testis with liquefaction requiring orchiectomy.

13. Successful detorsion is suggested by: Pain relief Resolution of the transverse lie of the testis to a longitudinal orientation Lower position of the testis in the scrotum Return of normal arterial pulsations detected with a color doppler study

14. PROGNOSIS OF TORSION Testicular viability related to time since onset of pain Within 6 hours – 90-100% viable At 12 hours – 20-50% viable At 24 hours – 0-10% viable Do not delay surgery b ecause of assumed nonviability based on duration of symptoms .

15. EPIDIDYMITIS Epididymitis is inflammation of the epididymis (inflammation of the testes is termed orchitis). Classically, these two conditions are thought to occur together (termed epididymo-orchitis), however most cases are solely epididymitis, whilst a sole orchitis is very rare and is mostly of viral origin The condition has a bimodal age distribution, occurring most commonly in males aged 15-30yrs and then again in males >60yrs.

16. It is the most common cause of scrotal pain in adults in the outpatient setting. Epididymitis is most commonly infectious in etiology, but can also be due to non-infectious causes (eg trauma, autoimmune disease). Incidence 1/1000 men/year Most common 15-30 y ear o ld males Risk Factors usually includes: STDs, UTIs

17. PATHOPHYSIOLOGY Epididymo-orchitis is usually caused by local extension of infection from the lower urinary tract (bladder and urethra), either via enteric (i.e. classic UTI) or non-enteric (i.e. sexually transmitted) organisms.

18. In males aged <35 years old , the most likely mechanism is sexual transmission , therefore the most common organisms are N. gonorrhoeae and C. trachomatis In males aged >35 years old, an enteric organism from a urinary tract infection is the more likely mechanism of the disease. Therefore, the most common pathogens are E. coli , Proteus spp ., Klebsiella pneumoniae , and Pseudomonas aeruginosa .

19. CLINICAL FEATURES Epididymitis usually presents as unilateral scrotal pain and associated swelling. Fever and rigors can also be present. Associated symptoms (secondary to the underlying cause) may also be present, such as dysuria, storage LUTS, or urethral discharge. Ensure to clarify a sexual history in all cases.

20. On examination, the affected side will be red and swollen. The epididymis +/- the testis will be very tender on palpation, and there may be an associated hydrocele. The remainder of the cord structures usually normal; bilateral epididymitis is very rare. Specific tests include assessing for the cremasteric reflex, which is intact in cases of epididymitis, and Prehn’s sign, which when positive is also suggestive of epididymitis .

21. INVESTIGATIONS Urinalysis and urine culture Urethral swab FBC - leucocytosis CRP Scrotal ultrasound

22. MANAGEMENT Bed Rest with scrotal elevation NSAIDS for pain control Empiric treatment with antibiotics Prepubertal – target UTI organisms ( Ciprofloxacin) Postpubertal /sexually active – N. gonorrhoeae/ C . T rachomatis(ceftriaxone and doxycycline/azithromycin) Excellent prognosis with pain relief in 3 days Acute febrile patients with sepsis often require hospitalization for intravenous hydration and parenteral antibiotics.

23. TORSION OF APPENDIX TESTIS Twisting of small vestigial structure on anterosuperior aspect of testis . Testicular pain from torsion of the appendix testis is usually more gradual than with testicular torsion. It is the leading cause of acute scrotal pathology in childhood. Torsion of the appendix testis rarely occurs in adults. It is predominantly seen in the prepubescent male . It is more common than testicular torsion with a much better prognosis.

24. PRESENTATION History: Acute unilateral pain, erythema, and swelling Pain is less severe than torsion Physical Exam: Tender focal mass at superior pole of testicle -Careful inspection of the scrotal wall may detect the classic “blue dot” sign caused by infarction and necrosis of the appendix testis. Normal cremasteric reflex May have reactive hydrocele

25. DIAGNOSIS AND MANAGEMENT Diagnosis: Clinical diagnosis Can get ultrasound to rule-out torsion of testis Ultrasound may be normal or have increased blood flow to the affected area Management: Supportive care Treat with bed rest, scrotal support, and NSAIDS Pain resolves in 5-10 days

26. FOURNIER’S GANGRENE It is a necrotitizing fascitis of the perineum caused by a polymicrobial infection which often involves the scrotum. It commonly occurs in older men, but it can also occur in women and children. It is more likely to occur in diabetics, alcoholics, or those who are immunocompromised.

27. Clinical Features Scrotal swelling Sudden pain in the scrotum Fever, pallor, and generalized weakness. It is characterized by pain that extends beyond the border of the demarcated erythema. Most cases present mildly, but can progress in hours.

28. Subcutaneous emphysema is often one of the specific clinical signs, but is not seen in >50% of presenting clinical cases. More marked cases are characterized by a foul odor and necrotic infected tissue.

29. Fournier’s gangrene is usually diagnosed clinically, but laboratory tests and imaging studies are used to confirm diagnosis, determine severity, and predict outcomes. Most cases of Fournier gangrene are infected with both aerobic and anaerobic bacteria such as Clostridium perfringens . It can also result from infections caused by Group A streptococcus (GAS) , as well as other pathogens such as Staphylococcus aureus and Vibrio vulnificus . Lack of access to sanitation, medical care, and psychosocial resources has been linked to increased mortality.

30. Management Urological emergency (ABCD) Fluid resuscitation Pass catheter and monitor urine output Broad spectrum antibiotics Surgical debridement Daily wound dressing Monitor vitals and check FBC Add vitamin C for wound healing

31. OTHERS TRAUMA Only rarely does trauma result in severe testicular injury, usually due to compression of the testis against the pubic bones from a direct blow or straddle injury. The spectrum of traumatic complications can range from a haematocoele to infection with pyocele to testicular rupture. Testicular rupture requires surgical repair. Lesser injuries are managed according to the clinical severity and often can be treated conservatively.

32. TESTICULAR CANCER While most testicular tumors present as painless nodules or masses, rapidly growing germ cell tumours may cause acute scrotal pain secondary to haemorrhage and infarction. A mass is generally palpable and ultrasound is usually sufficient to make a diagnosis of testicular cancer.

33. REFERRED PAIN Men who have the acute onset of scrotal pain without local inflammatory signs or scrotal massmon examination may be suffering from referred pain to the scrotum. Causes of referred pain include: abdominal aortic aneurysm urolithiasis lower lumbar or sacral nerve root compression retrocaecal appendix retroperitoneal tumour post herniorrhaphy pain

34. SUMMARY OF SCROTAL PAIN DDX Symptoms Onset Pain Location Cremasteric Reflex Other Clinical Findings Torsion Acute Diffuse testicular pain Negative High riding testis, bell-clapper deformity, profound testicular swelling Epididymitis Acute or chronic Epididymal (posterior + superior to testis) Positive (Intact) Epididymal induration and tenderness, positive urinalysis or culture Torsion Of Appendix Testis Subacute Localized to upper pole of testicle Positive (Intact) Blue-dot sign , tenderness over anterosuperior testis Fournier’s gangrene Acute Diffuse Postive (Intact) Tense oedema outside of involved skin, blisters/bullae, crepitus, fever, rigors, hypotension

35. conclusion Acute scrotum is urological emergency and is equivalent to the general surgeon’s “acute abdomen” and therefore needs an immediate intervention Although the differential diagnosis of the acute scrotum is broad, an accurate history and physical examination can frequently determine the cause of the problem.

36. REFERENCES BAJA Principles and Practice of Surgery, 5 th Edition Brenner JS, Ojo A. Causes of Scrotal Pain in Children and Adolescents. UpToDate Online. Updated April 2009. Gatti JM, Murphy JP. Current Management of the acute scrotum. Semin Pediatr Surg. 2007;16:58-63. Gatti JM, Murphy JP. Acute Testicular Disorders. Pediatr Rev. 2008 Jul;29(7):235-41. Allison Tadros , MD. West Virginia University, Testicular torsion, November 2019

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