Acute Scrotum Flashcards
What does a hemi-scrotum vs bilateral scrotum affected tell you about the aetiology of the illness?
- Hemi-scrotum: pathology limited by tunica vaginalis - peritoneal extension containing ipsilateral testis
- Bilateral scrotum: pathology outside tunica vaginalis i.e. in skin or on skin
What are some DDx for an affected hemi-scrotum?
- Testicular torsion
- Torsion of testicular appendage
- Epididymo-orchitis
- Hydrocoele
What is the main DDx for an affected bilateral scrotum? What can cause this?
Idiopathic scrotal oedema e.g.:
- urticaria e.g. from flea bite
- cellulitis
- systemic disease e.g. nephrotic syndrome
What size is the testis before puberty?
Same as glans penis
What is testicular torsion?
- Twisting of the testicles on spermatic cord
At what age is testicular torsion most common?
- Two peaks of incidence: neonates and adolescents 13-16yo
What can precipitate testicular torsion?
- Trauma
- Increased mobility in sport
- Spontaneous
What increases risk of testicular torsion, and why?
- Increased length of mesorchium (anatomical variation) i.e. ‘bell-clapper testis’ predisposes to torsion
- Torsion common in adolescence because testis has recently enlarged with testosterone and increased size predisposes to torsion
Clinical features of testicular torsion
- Sudden onset*unilateral testicular pain/swelling
- can present as iliac fossa/abdo pain
- Associated Nausea/vomiting*
- Very tender, discoloured, swollentestes
- High riding/ horizontal testis
- Cremasteric reflex absent
- Reactive hydrocele
- Impaired gait
- Neonate – does not transilluminate
What is the cremaster reflex?
contraction of the cremaster muscle, in response to the stroking of the thigh, which results in retraction of the testicle
What Ix should be done before Mx of testicular torsion
None - time is key. An US/blood tests are not recommended prior to referral.
How long do you have before testicular infarct in torsion?
Infarct in 8-12h
What surgery is done to fix testicular torsion?
- Remove gangerenous testis
- Fixation of other testis to prevent metachronous torsion, as bell-clapper anomaly is present in > 80-90% bilaterally.
What is the DDx for a painless scrotal mass at birth?
US to determine peri-natal torsion/tumour of testis
What is the most common natal testicular tumour?
Teratoma
Where is the pathology in peri-natal torsion?
- Extra-vaginal torsion - twist is outside the tunica in the spermatic cord
What is the testicular appendage?
- = Hydatid of Morgani
- Normal remnant of cranial end of Mullerian duct (which would form fimbriae of fallopian tube)
- = Testicular appendage at upper pole
In which age is torsion of testicular appendage most common, and why?
10-12yo boys
- Low level oestrogens in blood in early puberty stimulate normal remnants of the Műllerian duct (which in girls forms fallopian tube, uterus and upper vagina).
Clinical features of torsion of testicular appendage
- Pain, gradual ~1-2 days
- No N/V
- Tender upper pole of testis
- ‘Blue pea’ (does not represent the entire testis - is necrotic appendage seen through skin)
- Reactive hydrocoele possible
In a case where testicular torsion is excluded, how is torsion of the appendage managed?
Surgery is elective, as torsion of hydatid is self-limiting (with infarction of hydatid and resorption, without damaging testis).
When is epididymo-orchitis more common, and why?
- Rare in pre-pubertal boys (requires patent vas deferens) unless there is an underlying genitourinary anomaly or urethral instrumentation.
- Adolescents with STI more common
Possible aetiology of epididymo-orchitis
- Infectious (travelling by retrograde extension from the urinary tract into the vas deferens)
- Most commonly chlamydia and gonorrhoea
- Bacterial infection is uncommon in non-sexually active boys
- Trauma
- Autoimmune disease
Possible clinical features of E-O
- Acute scrotum + severe swelling
- Usually unilateral Sx, pain may radiate to iliac fossa
- May be insidious onset
- Tenderness most marked posterior-lateral testis
- Tenderness improved with testicular elevation
- Fever, N/V
- Urinary Sx: dysuria, frequency, urethral discharge
When does mumps orchitis happen?
Mumps orchitis occurs 4-6days after parotitis
Mx of E-O
- Supportive Mx: analgesia, scrotal elevation, ice
- Encourage fluid intake and alkalisation of urine
- Empiric antibiotics, usually co-trimoxazoleif well
- Young infants or systemically unwell children may require admission with IV benpen and gentamicin
(+STI general measures e.g. education, notification)
Ix for E-O
- Urine MCS
- First-pass urine for adolescents: urine PCR for chlamydia and gonorrhoea
- Urethral swab for patients with urethral discharge
What might you see in the testes with testicular/epididymal rupture?
- Tender, swollen testis
- bruising/haematocoele/haematoma
- oedema
What is a hydrocoele?
- = collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis, the investing layer that directly surrounds the testis and spermatic cord. It is the same layer that forms the peritoneal lining of the abdomen
What is the natural history of hydrocoele?
- 1-2% male babies born
- Resorb and tunica vaginalis closes spontaneously in the first year- 90% by 2 yearsas the processus vaginalis obliterates
Clinical features of hydrocoele
○ Painless cystic swelling around the testis in the scrotum
• A bilateral hydrocoele appears in a dumb-bell shape
○ Irreducible: processus acts like a one-way valve and the peritoneal fluid cannot be squeezed back out(if it does, usually a hernia - intraperitoneal fluid is a transudate from omentum)
○ Transillumination
○ Get above swelling - spermatic cord not enlarged (if not, consider hernia)
Mx of hydrocoele
• Only operate if after 2 year of age - inguinal herniotomy (division of the patent processus vaginalis)
Main ddx of hydrocoele to rule out
Inguinal hernia
Which other scrotal conditions might you see hydrocoele in?
torsion, trauma, tumour, epididymitis
What is a varicocoele?
- = dilatation of pampiniform plexus of veins, a network of many small veins found in the male spermatic cord
Which age group is varicocoele most common in?
- Peri-pubertal males
Clinical features of varicocoele
- Dull, aching, usually left scrotal pain(more common left)
- Non-tender
- Lying down: relieved, and asymmetrical testis obvious
- worse on standing like ‘bag of worms’
- Sign of varicocoele when boy is horizontal is an asymmetrical testis
- Cf hernia: no lump visible at neck of scrotum
Mx for varicocoele
- Surgery if retarded growth of affected testis/testicular atrophy (ligate gonadal vein)
- Conservative treatment with scrotal support and NSAIDs may suffice for an older man who has completed his family and who presents with minor scrotal discomfort as his only symptom
What does the scrotum look like in idiopathic scrotal oedema?
- Rapid onset of painless but notable scrotal oedema
- Bland, purplish swelling over both hemiscortum, perineum + penis
- Testes non tender
