Acute Scrotal Pathology

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Acute Scrotal Pathology

• Henry Yao
• Pre-SET Urology Trainee
• Royal Melbourne Hospital

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Case History

• You are working in ED at night
• It is 4am and you are tired hungry
• As you are about to go to get a snack
• 12 year old male presents with 2 hour history of
  pain in right side of scrotum

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Question

• What are your differential diagnoses?

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Differential diganoses

• Hydatid of Mortgagni (60)
• Testicular Torsion (30)
• Epididymo-orchitis (lt5)
• Idiopathic scrotal oedema (lt5)

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Question

• What history questions would you ask?

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Case History

• Scrotal pain came on over an hour
• Steadily getting worse
• Vomited once
• Some vague lower abdominal and back pain
• No trauma to testicles
• Two years ago had an STI rx with antibiotics
• Stable girlfriend for 12 months

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Question

• What would you look for on examination?

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Cresmateric Reflex
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Testicular Torsion

• Intravaginal vs Extravaginal

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Testis Anatomy

• Paired solid viscera
• Oval shaped
• Left lies slightly lower than right
• Epididymis posteriorly
• Vas deferens postero-medially
• Tunica albuginea covering
• Tunica vaginalis antero-laterally
• Appendix of testis located in upper pole

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Testis Anatomy

• Arterial supply
• Testicular artery
• Venous drainage
• Pampiniform plexus
• Lymphatic supply
• Para-aortic nodes at origin of testicular artery
  (L2)
• Nervous supply
• T10 sympathetic supply (sensory follows this)

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Presentation

• Most commonly age 12-18
• Acute onset of severe testicular pain /-
  swelling
• On examination
• Tender firm testicle
• High riding testicle
• Horizontal lie of testicle
• Absent cremasteric reflex
• No pain relief with elevation of testis
• Thick or knotted spematic cord
• Epididymis not posterior to the testis

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Diagnosis

• Clinical suspicion
• More likely when the onset of pain is acute and
  extremely intense
• C.f. epididymitis more likely when onset of pain
  is gradual and progresses from mild to more
  intense
• DO NOT WAIT FOR IMAGING if suspect torsion

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Management

• IMMEDIATE SURGICAL EXPLORATION if suspected
  testicular torsion
• Most testicles remain viable if detorsed within 6
  hours
• Few testicles remain viable after gt 24 hours of
  torsion

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Surgical Exploration

• Median raphe incision
• Cut through all layers to get to testis
• Detorse the testis
• Three point fixation to Dartos
• Do the contralateral side

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Imaging

• Doppler USS
• Torsion decrease blood flow
• Epididymitis increased blood flow
• Nuclear testicular scan
• Torsion decrease uptake
• Epididymitis increased uptake of radiotracer
  activity

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Hydatid of Mortgani

• Torsion of appendage
• Acute pain
• Blue dot in upper pole
• If in doubt ? explore

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Epididymo-orchitis

• Rare in childhood
• Virtually never between 6 months and puberty
• LUTS
• Tender epididymis
• Prehns sign
• Dipstick and urine MCS
• Rest, antibiotics, high fluid intake,
  alkalinisation of urine

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Idiopathic Scrotal Oedema

• Causes unknown ?allergy, ?insect bites
• Scrotum symmetrically swollen, pink and less
  painful c.f. other causes
• Erythema spread beyond the scrotum
• Scrotal skin hard but testis and epididymis not
  painful

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Case 2

• 36 year old male
• Day 2 post vasectomy
• Presents with painful scrotum

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Question

• What do you do?

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Case History
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Case History

• Vital signs
• Tachycardia 110
• Blood pressure 100/60
• Very tender scrotum
• Hardened scrotal skin
• Spreading beyond scrotum

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Question

• What do you think is going on?

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Fourniers Gangrene

• Necrotizing fascitiis of male genitalia and
  perineum
• 30 mortality
• Rapidly progressive
• Sources of bug from perianal region
• Most common bug is E. coli but must also consider
  GPC and anaerobes

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Fourniers Gangrene

• Risk factors
• T2DM
• Alcohol
• Other immunosuppressed patients
• Spread across superficial fascial planes
• Colles
• Scarpa
• Bucks

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Presentation

• Painful swelling and induration of the penis,
  scrotum or perineum
• Oedema spread beyond area of erythema
• Eschar, necrosis, ecchymosis, crepitus are later
  signs
• Foul odour
• Fever
• Diagnosis is clinical ? dont wait for imaging

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Management

• Broad spectrum IV antibiotics consult VIDS
• Cover GP, GN and anaerobes
• Immediate aggressive tissue debridement ? cut
  down to normal tissue
• Send tissue for MCS
• May require flaps
• (Consider hyperbaric oxygen therapy)

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TGA Antibiotics
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Questions
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Acknowledgement

• Dr. Kevin OConnor (Urology Fellow)

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Thank You for Your Attention