Acute scrotum

ACUTE SCROTUM

Acute scrotum is a medical condition present as acute pain or swelling of the scrotum. Causes of acute scrotum are in Tab.1.

Tab.1. Causes of acute scrotum
Ischemia Torsion of the testis Torsion of the appendix testis or epididymis Testicular infarction Trauma Testicular contusion Testicular rupture Infection Acute epididymitis Fournier´s gangrene Other (acute on chronic condition) Hernia (incarceration) Hydrocele (rupture, infection) Spermatocele (hemorrhage, infection) Testicular tumour (rupture, hemorrhage, infarction, infection) Torsion of the testis

Typically testicle has around potential space created by tunica vaginalis. Torsion can occur intravaginal (within the tunica vaginalis) or extravaginal (around the entire spermatic cord). Normally, there is very little mobility of the testicle within the scrotum because the tunica vaginalis attaches to the posterior surface of the testicle. About 10 % of males have congenitally a high attachment of the tunica vaginalis (mostly bilaterally), that the testicle can rotate freely on the spermatic cord within the tunica vaginalis and this condition can lead to intravaginal testicular torsion. Degree of twist can be different, partial twist can lead to venous occlusion and engorgement, double twist (720°) usually leads to compromising flow through testicular artery and results in ischaemia and infarction. Undescended testicle is usually attached to tunica vaginalis and this predisposes to extravaginal testicular torsion (also prenatally). Incidence is approximately 1:4 000. Salvation rate in patients undergoing detorsion within 6 respective 24 hours of the start of pain is nearly 100%, respective 0%. Late diagnosis and/or treatment leads to testicular loss. Testicular torsion presents with rapid onset of severe testicular pain and swelling, sometimes with abdominal pain, nausea or vomiting, sometimes after physical activity or trauma. Nearly all cases are in children or adolescents. The physical examination reveals tender hard testicle with high mostly horizontal lie, swelling, early on with palpable torsed cord and testicle, later on confluent mass („appearance of orchiepididymitis“). Cremasteric reflex is absent. Scrotal ultrasonography with Doppler flow reveals absent or decreased arterial flow in the testis (usefull is comparation to the other healthy testicle). CT, MRI or nuclear scans have no role in management of acute scrotum. Treatment comprise of urgent surgical exploration and detorsion. Correction beyond 6 hours of onset leads often to subsequent atrophy of the testicle. Rarelly is posible manual detorsion (from medial to lateral : right resp. left testicle counterclockwise resp. clockwise) with subsequent surgical fixation. During surgical exploration testicle is detorsed and fixed with anchoring suture from tunica albuginea of the testis to tunica vaginalis and tunica dartos scroti. Fixation is performed on the opposite (healthy) side simultaneosly. If during exploration there are no signs of viability after detorsion (dark, cyanotic color of the testis) orchiectomy (with mandatory fixation of the opposite testicle) is performed. Torsion of testicular or epididymal appendix. Appendices of the testis and epididymis are remnants of Mullerian or Wolffian ducts. Their torsion can lead to acute pain and mass, mostly testicle is normally palpable and has normal lie and often appendix is palpated. Later enlargement and edema can occur. Doppler ultrasound demonstrate normal perfusion of the testicle. Treatment consist of pain medication. Trauma Laceration of tunica albuginea (as result of blunt or penetrating trauma) of the testis results to testicular rupture with extrusion of testicular parenchyma. Penetrating injuries to the scrotum and blunt trauma with with rupture of tunica albuginea should be surgically explored (scrotal incision, repair and suture of ruptured tunica albuginea or orchiectomy). Blunt trauma without rupture doesn´t need exploration – observation, rest, cold packs and analgesics are appropriate therapy.

Epididymitis
Epididymitis is usually caused by bacterial infections – in young men mostly chlamydial or gonorrheal and in older men (often with lower urinary symptoms caused by benign prostatic hyperplasia, prostate cancer, urethral stricture etc.) mostly escherichia coli. On physical examination there is tenderness posterior and lateral to the testis. Scrotal ultrasound shows enlarged, hypervascular epididymis and normal blood flow in the testis. Management is conservative – antibiotics, antiinflammantory drugs, analgetics, rest, scrotal elevation and cold packs. In cases when abscess is present, surgical exploration (drainage or orchiectomy) may be necessary. Fournier´s gangrene Fournier´s gangrene is infectious condition within the scrotal wall. Physical examination reveals inflammed (diffuse thickening and erytema), sometimes necrotic (black, ulceration) scrotal and in advanced cases also penile and groin skin (fasciitis) and normal testicle. Signs of sepsis are often present. Treatment should be urgent – aggressive surgical debridement, broad-spectrum antibiotics and hyperbaric oxygen therapy in anaerobic infections.

Inguino-scrotal hernia
An acute inguino-scrotal hernia can cause pain and swelling in groin and scrotal area. Physical examination and ultrasound can help to differentiate from scrotal issues. In case of incarceration there is obstructed bowel and it is surgical emergency. Hydrocele, spermatocele, testicular tumor These are chronic lesions, which can present sometimes acutely (rupture, hemorrhage, inflamation, infarction). Symptoms are scrotal pain and swelling. Careful history, physical examination and ultrasound examination are usually helpfull in diagnose these conditions. Urgent surgical exploration is sometimes needed.

Courses

• Surgery 4 (Trauma Surgery, Urology) [ChK/CH-V4/09]