akute scrotum 2
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Scrotal Pain and Swelling
Jesse Sturm, MD
December, 20, 2006
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Outline
Embryology and anatomy
Causes o Pain and Swelling
! "orsion, E#ididymitis, Orc$itis, "rauma
! %istory, P$ysical, &adiologic E'ams, (abs
Causes o Swelling
! %ydrocele, )aricocele, S#ermatocele, "umor,
*dio#at$ic
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Embryology
Descent o testes at +2-0 w.s gestation
Descends wit$in #rocesses /aginalis
! Out#ouc$ing o #eritoneal ca/ity
"unica /aginalis is #otential s#ace t$at remains
ater closure o #rocess /aginalis
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natomy
S#ermatic cord !testicular /essels, lym#$, /asdeerens! E#ididymis s#erm ormed in testicle and undergo
maturation, stored in lower #ortion
! )as Deerens ! muscular action #ro#els s#erm u# andout during e1aculation
ubernaculum ! i'ation #oint or testicle totunica /aginalis
"unica )aginalis ! #otential s#ace! Encom#asses anterior 23+4s o testicle
! "unica albuginea is inner layer o##osing testis
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natomy ! 5uts and olts
AnteriorPosterior
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Causes o Pain and Swelling
Pain! "esticular torsion! "orsion o a##endi' testis! E#ididymitis! "rauma! Orc$itis and Ot$ers
Swelling! %ydrocele
! )aricocele! S#ermatocele! "umor
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"orsion
*nade7uate i'ation o testes to tunica /agnialis
at gubernaculum
"orsion around s#ermatic cord
! )enous com#ression to edema to isc$emia
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E#idemiology
ccounts or +08 o all acute scrotal swelling
imodal ages ! neonatal 9in utero: and #ubertal
ages
! 6;8 occur in ages
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Predis#osing natomy
ellcla##er deormity
! "esticle lac.s normal
attac$ment at /aginalis
! *ncreased mobility
! "ran/erse lie o testes
! "y#ically bilateral
! Pre/alence
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"orsion? Clinical Presentation
bru#t onset o #ain ! usually testicular, can be
lower abdominal, inguinal
! Oten >
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"orsion? E'amination
Edematous, tender, swollen
Ele/ated rom s$ortened s#ermatic cord
! %oriAontal lie common 9PP) =08:
! &eacti/e $ydrocele may be #resent
Cremasteric rele' absent in nearly all
9unreliable in >+0mo old: 9PP) B;8:
Pre$n4s sign ele/ation relie/es #ain ine#ididymitis and not torsion is unreliable
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*ntermittent "orsion
*ntermittent #ain3swelling wit$ ra#id resolution
9seconds to minutes:
(ong inter/als between sym#toms
PE? testes wit$ $oriAontal lie, mobile testes,bul.iness o s#ermatic cord 9resol/ing edema:
Oten e/aluation is normal ! i sus#icious need
@ ollowu#
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Diagnosis ! "ime is "esticle
*deally #rom#t clinical diagnosis
*maging! Color do##ler ! decreased intratesticular low
alse F in large $ydrocele, $ematoma
Sens 6B
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cute torsion ( testis
Dec blood low on (
(ate torsion on &
*nc blood low around
but dec low w3in testis
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*mages "orsion
Decreased ec$ogenicity
and siAe o rig$t testicle
5uclear medicine scan
s$ows Hrim sign Ino low
to testicle and swelling
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Management
Detorsion wit$in 6$r I
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Manual Detorsion
* #resents beore swelling
##ro#riate sedation
*n 23+rdso cases testes
torses medially,
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"orsion? S#ecial Considerations
dolescents may be embarrassed and not see.care until late in course
"orsion
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5eonatal "orsion
G08 #renatal, +08 #ostnatal
Postnatal ty#ically G
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"orsion o ##endi' "estis
##endi' testis
! Small /estigial structure,
remnant o Mullerium duct
! Pedunculated, 0K+cm long
Ot$er a##endi' structures
Pre#ubertal estrogen may enlarge a##endi' and cause
torsion
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"orsion o ##endi' "estis
Pea. age +
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"orsion o ##endi' "estis
lue dot o gangrenous a##endi' testis
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"orsion o ##endi' "estis
Management su##orti/e
! analgesics, scrotal su##ort to relie/e swelling
Surgery or #ersistent #ain
! no need or contralateral e'#loration
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E#ididymitis
*nlammation o e#ididymis
Subacute onset #ain, swelling localiAed to
e#ididymis, duration o days
! it$ time swelling and #ain less localiAed
"estis $as normal /ertical lie
Systemic signs o inection
! inc C and C&P, e/er F in B;8 Cremasteric rele' #reser/ed
@rinary com#laints? disc$arge3dysuria PP) =08
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E#ididymitis
Scrotum $as o/erlying eryt$ema, edema in 608
5ormal /ertical
lie
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E#ididymitis
Se'ually acti/e males
! C$lamydia L 5K gonorr$ea L EK coli
(ess commonly #seudomonas 9elderly: and
tuberculosis 9renal ":
oung boys, adolescents oten #ostinectious9adeno/irus: or anatomic! &elu' o sterile urine t$roug$ /as into e#ididymis
! ;0G;8 o #re#ubertal boys $a/e anatomic cause byimaging
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Etiologies o E#ididymitis
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E#ididymitis Diagnosis
(eu.ocytosis on @ in N-08 o #atients
PC& C$lamydia F in ;08, C F in 208 o
se'ually acti/e
B;8 ebrile at #resentation
Do##ler and 5uclear imaging s$ow increased low
* $' consistent wit$ S"D, CDC recommends?
! C' o uret$ral disc$arge, PC& or C and ! @rine culture and @
! Sy#$ilis and %*) testing
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(aboratory d1uncts
Studies o acute #$ase reactants? C&P, *(
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Do##ler E#ididymitis
(et E#ididymitis
! *nc blood low in
and around let testis
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E#ididymitis "reatment
Se'ually acti/e treat wit$
Cetria'one3Do'ycycline or Olo'acin
Pre#ubertal boys
! "reat or coe'isting @"* i #resent
! Sym#tomatic t' wit$ 5S*Ds, rest
! &eerral all to @ or studies to rule out )@&,
#ost uret$ral /al/es, du#lications 5egati/e culture $as
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Orc$itis
*nlammation3inection o testicle
! Swelling #ain tenderness, eryt$ema and s$ininess to
o/erlying s.in
S#read rom e#ididymitis,
$ematogenous, #ost/iral
! )iral? Mum#s, co'sac.ie,
ec$o/irus, #ar/o/irus
! acterial? rucellosis
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Mum#s Orc$itis
E'tremely rare i /accinated
20+08 o #ts wit$ mum#s, G08 unilateral, rare
beore #uberty
Presents -6 days ater mum#s #arotitis
*m#aired ertility in
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"rauma
&esult o testicular com#ression against t$e#ubis bone, rom direct blow, or straddle in1uries
E'tent de#ends on location o ru#ture
! "unica albuginea ru#tures 9inner layer o tuncia/aginalis: allows intratesticular $ematoma to ru#tureinto $ematocele
! &u#ture o tunica /aginalis allow blood to collectunder scrotal wall causing scrotal $ematoma
Do##ler oten suicient to assess e'tent
Surgery or uncertain d', tunica albuginearu#ture, com#romised do##ler low
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"esticular %ematoma
lood as a illing
deect in testis
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Ot$er Causes o Pain
*ncarcerated inguinal $ernia %enoc$Sc$onlein Pur#ura
! )asculitis o testicular /essels
! &arely #resents wit$ only scrotal #ain
&eerred #ain! &etrocecal a##endi', urolit$iasis, lumbar3sacral ner/e in1ury
5on s#eciic scrotal #ain
! Minimal #ain, nl e'am ! return immediately or inc sym#toms
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Scrotal Swelling
%ydrocele
)aricocele
S#ermatocele "esticular Cancer
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%ydrocele
luid accumulation
in #otential s#ace o
tunica /aginalis
May be #rimary rom
#atent P) or secondary
to torsion3e#ididymitis
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%ydrocele
"ransilluminating
anterior cystic
mass
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%ydrocele
Mass increases in siAe during day or wit$ crying
and decreases at nig$t i communicating
* noncommunicating and >< yo ollow
* communicating 9enlarging:, scrotum tense9may im#air blood low: re7uires re#air
! @nli.ely to close s#ontaneously and #redis#oses to
$ernia
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)aricocele
Collection dilated /eins in
#am#iniorm #le'us
surrounding s#ermatic cord
More common on let side
! & /ein direct to *)C
! ( /ein acute angle to renal /ein
N208 o all adolescent males
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)aricocele
Oten asym#tomatic or c3o dull ac$e3ullness
u#on standing
S#ermatic cord $as bag o worms4 a##earance
t$at increased wit$ standing3/alsal/a * #re#ubertal, ra#idly enlarging, or #ersists in
su#ine #osition rule out *)C obstruction
Most management conser/ati/ely! Surgery i aected testis > unaected testis /olume
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S#ermatocele
Painless s#erm containing
cyst o testis, e#i#didymis
Distinct mass rom testis
on e'am
"ransilluminates
Do not aect ertility
Surgery or #ain relie only
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"esticular Cancer
Most common solid tumor in
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cute *dio#at$ic Scrotal Edema
Scrotal s.in red and tender
! underlying testis normal
! no $ydrocele
Eryt$ema e'tends o
scrotum onto #erineum
Em#iric t', cause un.nown
!nti$istamine, steroids
! &esol/es w3in -=G2$rs
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Conclusions
Clinical $istory and careul e'am are .ey actors in
ormulating accurate dierential
*maging and labs useul ad1uncts in unclear cases
! @3S su#erior to nuclear imaging i time essential
"*ME *S "ES"*C(E
! Early surgical inter/ention and @ in/ol/ement
Swelling wit$out #ain, usually less time sensiti/ediagnostically
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&eerences
Citci, OK Clinical Predictors or DiK Diagnosis o cute Scrotum,
Euro#ean JK o PedK SurgeryK Oct 200-K
la/is MK, Emergency E/aluation o Patients Presenting wit$ cute
Scrotum, cademy o Emergency MedicineK Jan 200
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