Acute Scrotum

Question 1

What are ischaemic causes of testicular torsion?

Answer 1

Ischemia:
Torsion of the testis (synonymous with torsion of the spermatic cord)


Intravaginal; extravaginal (prenatal or neonatal)

Appendiceal torsion, testis or epididymis

Testicular infarction due to compressive hydrocele or hernia

Testicular infarction due to other vascular insults (cord injury, thrombosis)

Question 2

What are traumatic causes of testicular torsion?

Answer 2

Trauma:
Testicular rupture

Intratesticular hematoma, testicular
contusion Hematocele

Question 3

Describe testicular torsion

Answer 3

Twisting or rotation of the testis -> ischaemia

Surgical emergency as it causes strangulation of the gonadal blood supply (causing venous occlusion and engorgement, with subsequent arterial ischemia and infarction) leading to testicular necrosis and atrophy
Torsion can be partial or complete (varies from 180-720 °)
Torsion more often involves the left testicle

Question 4

Describe the salvagibility of a testicular torsion

Answer 4

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

Question 5

How does testicular torsion present?

Answer 5

Testicular torsion 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). It most often occurs in children or adolescents, but this diagnosis should be considered in evaluating men with scrotal pain of any age, as it may occasionally occur in men 40-50 years old. In this age group, the diagnosis is often delayed or missed due to a low suspicion because of age.

Torsion should be in the differential for any sudden acute scrotal pain or swelling.

Question 6

How to manage testicular torsion?

Answer 6

With a high degree of suspicion, surgical exploration should be performed without delay.

Scrotal ultrasonography is the single most useful adjunct to the history and physical examination in the diagnosis of torsion.

Ultrasonography may also exclude significant testicular trauma, show a hernia extending into the scrotum, and can distinguish epididymitis from torsion by demonstrating increased flow to the epididymis and adnexal structures along with preserved testicular perfusion.

Remember, Testicular perfusion is the key to the ultrasound diagnosis of torsion.

Question 7

How to manage testicular torsion?

Answer 7

When torsion is diagnosed, urgent surgical exploration and detorsion is mandated, as testicular torsion is a true vascular emergency.

Testicular preservation is excellent when corrected within 4-6 hours of onset. Beyond 12 hours, the risk of subsequent testis atrophy is significant with detorsion

After sharply entering the scrotum, the tunica vaginalis is opened. Then the testis detorsed and wrapped in a warm, moist gauze. The contralateral side then undergoes orchidopexy to prevent torsion on that side.

The affected testis is reinspected for signs of improved perfusion (“pinking up”). If the testis appears viable, then orchiopexy is performed by anchoring the tunica albuginea of the testis to the overlying parietal tunica vaginalis and scrotal dartos muscle

Question 8

How does acute epipidymitis present and how to treat?

Answer 8

scrotal swelling 
tender epididymus 
fever 
\+/- leukocytes on dipstick
2-3 week antibiotic therapy

Question 9

What to do when testis and epididymus are normal on examination but tender on palpatation?

Answer 9

Consider:
inguinal hernia
chronic testicular pain

Scrotal US
Urine culture
Outpatient urology referral