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Acute SCROTUM. Testicular torsion. Appendage torsion. Epidydimitis . Orchitis. Trauma. Tumor ? Hernia ? – PowerPoint PPT presentation

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Title: Acute SCROTUM

  • Testicular torsion
  • Appendage torsion
  • Epidydimitis
  • Orchitis
  • Trauma
  • Tumor ?
  • Hernia ?

Testicular Anatomy
  • The normal testis is oriented in the vertical
    axis and the epididymis is above the superior
    pole in the posterolateral position.
  • Cremasteric reflex Stroking/pinching the inner
    thigh should result in elevation of gt 0.5 cm of
    the ipsilateral testicle

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Testicular Torsion
  • Incidence 14000
  • Only 50 salvageability w/ testicular loss from
    either atrophy or ochiectomy
  • Two peak periods first year of life and at
  • 10 times more likely in an undescended testis

Testicular Torsion
  • Most torsions due to bilateral anatomic
    abnormality. Tunica vaginalis has a high
    insertion about the spermatic cord.
  • Resultant bell-clapper deformitytestis dangles
    in the scrotum and is mobile

Testicular Torsion Pathophysiology
  • Initially venous return is obstructed and then
    venous thrombosis is followed by arterial
  • Degree of obstruction is a function of the degree
    of rotation
  • Necrosis develops in testicle with complete
    obstruction and infarction develops after
    arterial thrombosis

Testicular Torsion
  • Rapid swelling and edema of the testis and
    scrotum, followed by scrotal erythema
  • Damage proportional to duration/extent of
    vascular obstruction
  • Salvage rate of testis is 80-100 if pain lasts
    less than 6 hours
  • Pain gt 24 hours is associated w/ testicular

Testicular Torsion
  • 40 report a hx of similar pain that resolved
    spontaneously in the past
  • Often occurs after exertion or during sleep
  • Typically no urinary symptoms
  • Sudden onset of scrotal pain, but can be inguinal
    or lower abdominal. May be constant or
    intermittent. Not positional
  • Nausea and Vomiting

Testicular Torsion
  • Hemiscrotum is swollen, tender, firm
  • High-riding testis with a transverse lie is
    classic sign
  • Loss of cremasteric reflex almost universal
  • May see the bell-clapper deformity, with
    horizontal lie of the contralateral testicle
  • Prehns sign Relief of scrotal pain by elevating
    testicle. NOT a reliable way to distinguish
    epididymitis from torsion

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Testicular Torsion Diagnosis
  • Doppler Ultrasononography now test of choice for
    Dx of torsion. Sensitivity comparable to
    radioisotope scans (86-100) and greater
    specificity (100). Doppler U/S is more rapid
    and more available than radioisotope scans.

Testicular Torsion Management
  • Immediate Urologic consultation for surgical
    exploration and possible bilateral orchidopexy if
    diagnosis is obvious
  • Manual detorsion - Only a temporizing measure.
    Endpoint for successful detorsion is pain relief.
  • Most torsions occur lateral to medial, therefore
    detorsion should be attempted in a medial to
    lateral direction - open the book maneuver
  • Imaging if diagnosis unclear, should NOT delay
    exploration if high suspicion exists

Torsion of Appendage
  • Torsion of appendages is more common than
    testicular torsion
  • Testicular and Epididymal appendages are
    vestigial remnants of the wolffian and mullerian
    ducts respectively
  • Most frequent in preadolescent males 3-13,
    appendix testis gt epididymal appendix
  • Cause unclear
  • Twisting causes obstruction, edema and then
    painful necrosis

Torsion of Appendage
  • Discrete, painful testicular mass
  • Symptoms less severe than torsion. No nausea,
    vomiting, or fevers
  • Transillumination of scrotum may reveal the
    cyanotic appendage as a pathognomonic blue dot
  • U/S or Nuclear scintigraphy should reveal normal
    to increased blood flow

Torsion of Appendage Management
  • Scrotal Support
  • Pelvic rest
  • Analgesia
  • Expect resolution of symptoms in 7-10 days with
    degeneration of appendages

  • Average age 25 years
  • Most common misdiagnosis for testicular torsion
  • Rarely affects a prepubertal child without an
    underlying urinary tract infection
  • Result of retrograde ascent of urethral and
    bladder pathogens
  • Peritubular fibrosis may develop and occlude the
    ductules, if bilateral may lead to sterility

  • In men gt 40, E. coli is the predominant
    pathogen. Other coliform organisms, Pseudomonas,
    and gram positive cocci. Associated w/ underlying
    urologic pathology -- Recent GU tract
    manipulation or bacterial prostatitis.
  • In men lt40, Chlamydia and N. gonorrhoeae are
    the major pathogens

  • Gradual Scrotal pain, peaks over days
  • Low grade fever, average 38 degrees C
  • Cremasteric reflex usually preserved
  • Due to inflammatory nature of pain, may have some
    transient pain relief from scrotal elevation
  • Localized epididymal swelling initially, then may
    progress to single, large testicular mass
  • Urethral discharge and voiding symptoms may be

  • Pyuria and bacteriuria on U/A
  • Urethral discharge should be examined for gram
    stain and culture
  • Leukocytosis between 10K-30K
  • Torsion should not be excluded by pyuria, fever,
    or dysuria. An equivocal exam demands Imaging.
    U/S with increased or normal testicular blood
    flow is c/w epididymitis

Epididymitis Management
  • Sexually acquired Ceftriaxone 250 mg IM and
    Doxycycline 100 mg PO bid x 10d. Treat sexual
  • Nonsexually acquired TMP-SMX or Fluoroquinolone
    x 14d. Check urine CS.
  • Bed rest, scrotal support, analgesics, sitz
    baths, and Urology follow up

Complications of Epididymitis
  • Infertility - Sexually transmitted epididymitis
  • Abscess - Gonococcal epididymitis
  • Chronic epididymitis
  • U/S indicated if no response to medical therapy

  • Acute infection of the testis
  • Rare without initial epididymitis. Consider
    testicular tumor.
  • Bacterial infection secondary to spread from
    epididymitis of E. coli, Klebsiella, Pseudomonas
  • Viral orchitis Mumps. 4-6 days after onset of
    parotitis usually. 50 of involved testes atrophy
    but infertility rare
  • Syphilis
  • Treatment Antibiotics for bacterial orchitis and
    local scrotal measures for viral orchitis

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Testicular Tumor
  • Testicular CA Most common cause of malignancy
    to afflict young men
  • Average age of incidence 32
  • DDx Epididymitis and torsion
  • Increased incidence with cryptorchidism in
    bilateral testes
  • Majority are Seminomas, then embryonal cell CA
    and teratomas

Testicular Tumor
  • Classic presentation Painless, firm testicular
  • Acute hemorrhage within the tumor can lead to
    acute scrotal pain (10)
  • Ultrasound Distinct Intratesticular Mass
  • CXR if suspect Metastases
  • Treatment Immediate Urology referral. Radical
    orchiectomy. Cisplatin chemotherapy and Radiation
    for seminomas.