Acute Scrotum

Dr. Rajesh Menon. M

MS Gen Surgery PG
KMCH
December 15, 2017
Anatomy of scrotum and its contents
 Introduction
• The acute scrotum many times is a medical
emergency.
• Various diseases can produce this clinical picture.
• Inadequate evaluation and delays in diagnosis
and treatment can result in irreversible harm.
• Doppler USG plays a critical role
• Immediate Surgical exploration- in case of uncertainty
• The testis is ischemic in only about
20% of cases.
 Acute scrotum
• Is defined as scrotal pain,
swelling, and redness of acute
onset.
• Testicular torsion accounts for
about 25% cases
• Testicular parenchyma is highly
sensitive to ischemia – hence
the important of the condition
• Thorough Physical examination
is important.
• Timely performed Doppler
ultrasonography is
complimentary.
 History-taking in the acute scrotum

• Age
• Past medical history
• General symptoms
• First local symptom: pain before swelling?
• Pain: where? what kind? sudden onset?
• Trauma
• Prior surgery
• Nausea and vomiting
• Fever
• Dysuria
• Petechiae
 Physical Examination
• Position and orientation of the testes
• (Brunzel sign = secondary high
position of a testis)
• Size of the testes
• Prehn’s sign.
• Cremasteric reflexes
• Site of maximal tenderness
• Color of the scrotum
• “Blue dot sign”
• Inguinal and abdominal examination
 Differential Diagnosis

Ischemia:
Torsion of the testis
Appendiceal torsion, testis or epididymis
Testicular infarction due to other vascular insult (cord
injury,thrombosis)
Trauma: (penetrating or blunt)
Testicular rupture
Intratesticular hematoma, testicular contusion Hematocele
Infectious conditions:
Acute epididymitis
Acute epididymorchitis
Acute orchitis
Abscess (intratesticular, intravaginal, scrotal cutaneous cysts)
Gangrenous infections (Fournier's gangrene)
 Differential Diagnosis (cont’d)
Hernia:
Incarcerated, strangulated inguinal hernia, with or without associated
testicular ischemia

Acute on chronic events:

Spermatocele, rupture or hemorrhage
Hydrocele, rupture, hemorrhage or infection
Testicular tumor with rupture, hemorrhage, infarction or infection
Varicocele

Inflammatory conditions:
Henoch-Schonlein purpura (HSP) vasculitis of scrotal wall
Idiopathic scrotal edema
Fat necrosis of scrotal wall
 Investigations
• CBC and C reactive protein may be helpful
• Urine analysis is useful to rule out UTI
• Pyuria with or without bacteria suggests infection

• Imaging studies- most important

– Doppler USG- corner stone (helped to reduce unwanted surgical
explorations )
– MRI
– Nuclear scintigraphy
 Colour doppler- what to look for?
• Central arterial and venous flow
• The resistance index (RI) of the testicular vessels should be
determined as well. An RI above 0.7 (mean: 0.43–0.75 ) with reversal
of diastolic flow may indicate partial torsion . This cutoff value is
appropriate from puberty onward ; for pre-pubertal children, RI values
up to 1.0 are considered normal (mean: 0.39–1.0 ).
• Diastolic flow and the venous flow curve may be hard to demonstrate
in infants and small children.
• To demonstrate the testicular vessels in the area of the funiculus.
Here, the finding of a spiral course is highly sensitive (96%) for
testicular torsion.
• A comparison of the two sides is obligatory
• Enlarged epididymis, a hydatid, a hematoma, or a tumor all should be looked
for by USG
Doppler ultrasonographic demonstration of testicular parenchymal perfusion with
flow-curve registration in the triplex mode.

a) central arterial and b) venous perfusion

(with the kind permission of PD Dr. J. P. Schenk, pediatric radiology, Dept. of Diagnostic and
Interventional Radiology, Heidelberg).
 Torsion testes-Introduction
• Testis torsion is the one of the most common
cause of testis loss.
• The incidence in males <25 years old is
approximately 1:4000.
• Torsion more often involves the left testicle.
• Among neonatal testicular torsion cases, 70%
occur prenatally and 30% occur postnatally.
 Torsion testes
• The testicle is typically covered
by the tunica vaginalis,
creating a potential space
around the testis.
• Normally, the tunica vaginalis
attaches to the posterior
surface of the testicle and
allows for very little mobility
of the testicle within the
scrotum.
 Pathophysiology
• During testis torsion, the testicle twists spontaneously on
the spermatic cord, causing venous occlusion and
engorgement, with subsequent arterial ischemia and
infarction.
• The processes of ischemia and reperfusion lead to a
cascade of reactions in which neutrophilic leukocytes are
activated and inflammatory cytokines (TNF-α and IL-1β,
among others) and adhesion molecules are released.
• N-acetylcysteine (NAC) has been found to have a protective
effect on testicular tissue in animal models; thus, in the
future, there may well be a form of drug therapy that will
be given to patients with testicular torsion in addition to
surgery
 Bell-Clapper deformity
• Some patients have an inappropriately
high attachment of the tunica vaginalis,
such that the testicle can rotate freely on
the spermatic cord within the tunica
vaginalis (intravaginal testicular torsion)

• This congenital anomaly, called the "bell

clapper deformity," consists of a
transverse as opposed to longitudinal lie
of the affected testis; it can be unilateral
or bilateral and is a risk factor for a
torsion event .
• Abnormality is present in approximately
12% of human males.
 Course of the disease
• Experimental evidence indicates that 720°
twist is required to compromise flow
through the testicular artery and result in
ischemia.
• The testis salvage rate approaches 100% in
patients who undergo detorsion within 6
hours of the start of pain.
• However there is only a 20% viability rate if
detorsion occurs >12 hours; and virtually
no viability if detorsion is delayed >24
hours
• In neonates the prognosis is grave
 Clinical features
• Presents with the rapid onset of
severe testicular pain and swelling.
• The onset of pain may be preceded
by trauma, physical activity, or by no
activity (e.g. during sleep).
• Most common in children or
adolescents, but can occur at any
age.
• Occasionally occur in men 40-50
years old.
• Torsion should be in the differential
for any sudden acute scrotal pain or
swelling.
 Physical examination
• The classic physical examination findings with testis torsion are an
exquisitely tender testicle with a high, horizontal lie.
• Early on, one may be able to palpate the torsed cord and the testis
below it; later in the course, however, progressive edema and
inflammation ensues, such that after 12-24 hours, the entire
hemiscrotum appears as a confluent mass without identifiable
landmarks.
• At this stage, the physical examination may be indistinguishable
from that seen with epididymoorchitis.
• Patients are usually afebrile, free of irritative voiding symptoms
such as dysuria, and harbor a normal urinalysis and normal white
blood cell count. (In later torsion, however, an elevated WBC may
be seen in response to the inflammation).
Torsion confirmed mostly by Doppler USG and it helps us to
differentiate from other acute Conditions like Epididymo orchitis.
 Treatment- emergency surgical
exploration
• After detorsion of the vessels, the degree of ischemic
damage of the testicular parenchyma should be
assessed. Primary orchiectomy should be performed
only if the testis is clearly necrotic.
• In other cases, the testis should be anchored to the
scrotum with two sutures.
• Having been left in place, the testis can later be
reassessed ultrasonographically for reperfusion and
potential secondary parenchymal changes .
• Contralateral orchiopexy is obligatory as well, because
the second testis is also at elevated risk of torsion .
• Manual detorsion may also tried.
 Extravaginal torsion
• In neonates, the testicle
frequently has not yet
descended into the
scrotum, after which it
becomes attached
within the tunica
vaginalis.
• This increased mobility
of the testicle Among neonatal testicular torsion
predisposes it to torsion cases, 70% occur prenatally and 30%
(extravaginal testicular occur postnatally.
torsion).
 Extra vaginal torsion- mgt options
• Clinically, extra-vaginal torsion appears as an asymptomatic
swelling of the scrotum. Erythema or a bluish discoloration
of the scrotum is also frequently seen.
• Controversial.
• Some surgeons advocate a non operative approach.
• Others, argue that leaving a neonatal testis in place may
have adverse effects on the contra lateral testis and note
that cases of bilateral neonatal torsion have been
reported.
• However, surgery urgently is not warranted unless the
neonate has clear documentation of a normal examination
at birth and subsequently experiences testicular torsion.
 Intermittent" testicular torsion
• Is a well recognized entity in which a classic
torsion history is obtained, but physical
examination and ultrasound findings are normal.
• Doppler ultrasonography reveals a hyperperfused
testis.
• In such cases, it is reasonable to offer an elective
bilateral scrotal orchiopexy for the possibility of
intermittent symptoms becoming full fledged
torsion.
 Torsion of appendices
• Both appendix of testes and epididymus can get torsioned. (they are
mullerian and wolffian duct remnants respectively)
• The clinical manifestations resemble those of testicular torsion.
• An important point for differential diagnosis is that the point of
maximal tenderness is often directly above the testis; in some
cases, resistance can be palpated in this area.
• On transillumination, a bluish shimmering structure (the “blue dot
sign”) is often visible . (only in 30% of cases)
• Ultrasonography often reveals a twisted hydatid as a hyper- or
hypoechogenic structure between the testis and the epididymis ,
but demonstration of a hydatid alone is not pathognomonic for torsion, as non-
twisted hydatids can be seen as well.
• Doppler ultrasonography also often reveals accompanying
hyperemia of the epididymis
Hydatid torsion.

Ultrasonographic
demonstration of a round,
hyperechogenic, non-perfused
structure (marked) next to the
upper pole of the testicle:
hydatid in torsion

Treatment:
•Hydatid torsion is generally treated symptomatically, with bed rest, local cooling,
and, in some cases, anti-inflammatory drugs .

•For severe and persistent symptoms, operative removal of the hydatid can be
considered in rare cases .
 Acute epididymitis
• Acute epididymitis is the most common cause of acute
scrotal pain in post-pubertal men, representing 75% of
all acute intra-scrotal inflammatory diseases.
• It is clinically defined by pain, swelling and
inflammation of the epididymis in the acute (up to 6
weeks) or chronic (> 6 weeks) stages.
• Although epididymitis can occur at any age group, it is
most common between 18 and 35 years of age.
• In children, epididymitis accounts for 6 to 47% of cases
of acute scrotal pain.
 Etiopathogenesis
• Frequently, epididymitis is caused by a retrograde ascent of
pathogens from the lower urinary tract, such as the
bladder or prostate, via the lymphatics of the spermatic
cord to the epididymis.
• Rarely from hematogenous spread.
• Epididymitis is typically caused by sexually transmitted
pathogens such as Neisseria gonorrhoeae or Chlamydia
trachomatis in adolescents.
• Less common pathogens are Escherichia coli, Ureaplasma
urealyticum, Proteus mirabilis, Klebsiella pneumoniae,
Haemophilus influenza, and Pseudomonas aeruginosa are
seen with different age groups.
 Risk factors
• High-risk sexual behaviors,
• Strenuous physical activities,
• Prolonged sitting periods,
• Prostate invasive procedures,
• Prostate and urinary tract infections,
• Hypertrophy,
• Urinary tract surgeries,
• Urogenital anomalies and posterior urethral
valves in prepubertal boys,
• Human immunodeficiency virus (HIV),
• Mycobacterium tuberculosis,
• Medications (amiodarone),
• Trauma.
• Less commonly, epididymitis can be idiopathic
 Clinically
• Scrotal tenderness, edema, erythema, dysuria,
fever, urethral discharge,and hematospermia have
also been reported.
• The symptoms of both conditions generally arise
more slowly than those of testicular torsion;
• unlike in testicular torsion, the testis is neither
fixed nor in a higher position.
• The cremasteric reflex is usually preserved.
• Acute epididymitis can occur anywhere along the epididymis with the head
being most commonly affected.
 Diagnosis
• Urinalysis is an obligate part of the work-up of
these infectious conditions .
• In USG : reveals a thickened, enlarged, and
edematous epididymis with decreased
(hypoechoic) or coarse (heterogeneous)
echogenicity with or without abscess formation
• In cases of recurrent infection, extended
diagnostic evaluation is indicated for the
exclusion of structural anomalies. (Uroflowmetry,
Scopies and MCU etc)
USG_ Doppler
images of acute
Epididymitis and
acute Epididymo
orchitis
 Complications
• testicular infarction,
• chronic pain,
• orchitis, abscess,
• pyocele,
• gangrene,
• atrophy,
• cutaneous scrotal fistula,
• and infertility
• Hence prompt treatment is required.
 Epididymitis -treatment
• AIM: focus on specific microbial agent, reduce
symptoms, preventing progression and
transmission and minimize further complications.
• Antibiotics should be started empirically.
• Can be changed if required based on culture and
sensitivity.
• In addition to antibiotic treatment, analgesics,
scrotal elevation, limitation of activity, and use of
cold packs are helpful.
• Admission is reserved for cases with severe
infection and impending complications
 Orchitis
• Orchitis is an infection of the testicle, which is
rarely isolated, and when in conjunction with
the epididymis is called epididymo-orchitis.
• Usually bacteria retrogradely seed into the
testis from the bladder or prostate. Can also
be secondary to viral infection (e.g. mumps,
Coxsackie virus).
• Isolated orchitis can be seen in Syphilis.
 Diagnosis and Treatment
• Ultrasound is the gold standard investigation
• Orchitis treatment is mostly supportive and
should include bed rest and the use of hot or cold
packs for pain.
• Antibacterial medications are not indicated for
the treatment of viral orchitis, and most cases of
mumps-associated orchitis resolve spontaneously
after three to 10 days.
• Epididymoorchitis requires appropriate antibiotic
coverage, as with epididymitis.
 Tuberculous epididymitis
• Another chronic granulomatous infection.
Children thru blood spread and adults mainly
direct from Urinary tract.
• It generally occurs in the tail of epididymis as
it is most vascular and its relation with the vas
deferens to be involved with urinary reflux.
• Presents as uncomfortable discrete swellings
at the lower pole of Epididymus.
 It is chronic infection
• There is a lax secondary hydrocele in 30 per cent of cases,
• a characteristic beading of the vas may be apparent as a result of
subepithelial tubercles.
• The seminal vesicles feel indurated and swollen.
• In neglected cases, a tuberculous ‘cold’abscess forms, which may
discharge.
• The body of the testis may be uninvolved for years, but the contralateral
epididymis often becomes diseased. In most cases, there is evidence of
renal tuberculosis or previous disease.
• Otherwise, patients typically appear healthy.
• The urine and semen should be examined repeatedly for tubercle bacilli in
all patients with chronic epididymo-orchitis.
• A chest x-ray should be performed as should imaging of the upper urinary
tract.
• Ultrasound will demonstrate a thickened epididymis.
 Treatment
• Secondary tuberculous epididymitis may
resolve when the primary focus is treated.
• Treatment with anti-tuberculous drugs is less
effective
• If resolution does not occur within two
months, epididymectomy or orchidectomy is
advisable.
• A course of ATT should be adminstered
irrespectively
 Syphilitic orchitis is now uncommon
• It can cause bilateral orchitis (which is a feature
of congenital syphilis),
• interstitial fibrosis, which causes painless
destruction of the testis
• rarely it may lead to a gumma of the testis, which
presents as a unilateral slowly growing painless
swelling.
• The latter presentation may be difficult to
distinguish from a neoplasm without surgical
exploration.
• Diagnosis is confirmed by serology.
 Syphilitic orchitis- chronic
granulomatous infection
• Syphilitic orchitis is a rare manifestation of
gummas in patients with tertiary syphilis.
• Syphilitic gummas may present as a testicular
mass and mimic malignant neoplasms clinically.
• This type of orchitis usually begins painlessly in
the body of the gland and is apt to be bilateral.
• It causes dense, irregular, knotty induration but
little enlargement in size.
 Scrotal Wall Inflammations
• Henoch-Schonlein purpura (HSP) is a vasculitis of scrotal wall that
causes thickening and erythema in the absence of infection.
• Filarial infections can also cause chronic, relatively painless, scrotal
swelling.
• Lastly, scrotal edema secondary to hypoalbuminemia, portal
hypertension and lymphadenopathy are also rare but significant
conditions that may occur under the aegis of the acute scrotum.
• In most of these conditions, the history of a slowly progressive
disease process helps differentiate them from more classically
acute conditions.
• Treatment of the underlying, non-scrotal cause is most effective to
relieve the scrotal symptoms.
 Fournier's gangrene of the scrotum.
• Fournier's gangrene (FG) is a rapidly
progressing necrotizing fasciitis of the
perineal, genital, or perianal regions.
• FG is an uncommon, but aggressive,
disease.
• The average age was 54 (range, 20-
82). Cases even occur in children
younger than 3 months.
• The most frequent disorders associated
with FG include diabetes (40%-60% of
patients) and chronic alcoholism (25%-
50% of patients).
 Etio-Pathogenesis
• FG results when normal flora with low to moderate
virulence gain entry into the skin.
• Colorectal or urogenital diseases provide the portal for
most cases.
• The combination of immune suppression and synergistic
organisms sparks an infectious conflagration.
• The infection begins near the portal of entry and
progresses rapidly through the deep fascial planes.
• An obliterative endarteritis causes vascular thrombosis and
tissue necrosis.
• This allows the commensal flora to enter previously sterile
areas, progressively destroying tissue.
 Causative agents
• FG is typically polymicrobial.
• Both aerobes and anaerobes are usually
present.
• The most commonly isolated species include
the enterobacteria, especially E. coli,
Bacteroides, and streptococcal species.
• Clostridium is the anaerobe most often
identified.84
 Clinically
• The most common presenting symptoms are
scrotal pain, perineal erythema, and swelling,
often associated with fever.
• The patient develops induration, cyanosis,
and blistering of the skin as the infection
deepens.
• Soft-tissue crepitus may be present.
• Patients are often critically ill at initial
presentation.
 Treatment
• Should be managed aggressively
• Improve general condition
• Fluid and electrolyte balance
• Manage co-morbidities
• Broad spectrum antibiotics
• Wound debridement
• Pus culture and sensitivity
• Regular wound care.
Prognosis: poor if not actively managed. Mortality
ranges from 0-80%
 Idiopathic Scrotal Edema
• This entity is usually seen in prepubertal males.
• It presents as erythema and sudden onset of unilateral or bilateral
scrotal edema with mild pain or even no pain.
• The patient is afebrile and non-toxic, and the testis and epididymis
are non-tender and of normal size.
• No blood or urine tests are necessary.
• The condition usually resolves in 2-5 days without therapy, although
some physicians prescribe H1 and/or H2 blockers in hopes of
accelerating resolution.
 Henoch-Schonlein Purpura
• Ig A Vasculitis or HSP is a pediatric disease that usually presents in
patients 4-5 years of age.
• Is an idiopathic systemic vasculitis of uncertain etiology characterized
by nonthrombocytopenic purpura , arthralgia, renal disease,
abdominal pain, gastrointestinal bleeding and, occasionally, scrotal
pain. Hematuria may be present.
• The petechial rash is especially prominent over the buttocks and
lower extremities.
• The onset can be acute or insidious.
• Genitourinary findings include acutely painful scrotal swelling.
• The scrotum is involved in 2%-38% of cases of HSP but is very rarely
the initial presentation.
• Treatment is correction of underlying cause and supportive. The
syndrome has no specific treatment.
 Hernia as a cause for acute scrotum
The presentation of a acute scrotal pain in hernia will
depend upon whether the hernia is irreducible,
incarcerated, or strangulated.
In a strangulated hernia, the patient will give a history
consistent with intestinal obstruction.
The scrotal contents may be tender, and in the case of
advanced pathology, peritoneal signs may be present.
In scrotal hernias, there will be inguinal as well as scrotal
swelling.
A normal testis can usually be palpated below the hernia.
Treatment is repair of Hernia with or without Prolene Mesh
 Testicular Tumor
• Acute pain involving a mass is thought to be
due to hemorrhage within the tumor. The
testis is enlarged, irregular, and tender.
• A reactive hydrocele is sometimes present.
• Color-flow Doppler is the best means to
diagnose this condition.
 Trauma
• Penetrating or blunt injuries
• Hematoma can occur
• Progress into hematocoele and pyocoele
• May need exploration
• Complications can be rupture of testes,
avulsion, necrosis, fibrosis/atrophy and
secondary infections.
• May cause infertility if both testes are involved
 Acute on Chronic events
• Conditions that are chronic in nature can also
present with acute symptoms and include
testicular neoplasms, spermatocele and
hydrocele.
• Varicocoele can cause dragging discomfort
• On right side, rule out IVC obstruction with
unilateral varicocoele pain.
 Peritonitis Or Intra-abdominal
Hemorrhage
• This is a very rare cause of scrotal pain.
• but it can be seen in a patient with a patent
processus vaginalis.
• It can occur with appendicitis.
• Consider ruptured abdominal aortic aneurysm in
the differential diagnosis in the older patient.
• The scrotum and scrotal contents appear normal
and non-tender on physical examination.
 Dr. Rajesh Menon. M
MS General Surgery PG
KMCH