Scrotal emergency (Acute scrotum)

Question 1

What are some forms of scrotal emergency?

Answer 1

• Torsion of spermatic cord
• Torsion of appendix testis
• Epididymitis/epididymo-orchitis
• Inguinal hernia
• Hydrocoele
• Trauma/insect bite
• Dermatological lesions
• Inflammatory vasculitis
• Tumour

Question 2

When is torsion of the spermatic cord most common?

Answer 2

Most common at puberty/teenage

Question 3

What causes torsion of the spermatic cord?

Answer 3

Can occur with trauma or athlectic activity but is usually spontaneous

Question 4

What anatomical anomaly can predispose to torsion of the spermatic cord?

Answer 4

Bell clapper deformity

Question 5

What is meant by torsion of the spermatic cord?

Answer 5

Occurs when a testicle rotates, twisting the spermatic cord that brings blood to the scrotum

Question 6

How can bell clapper deformity predispose to torsion of the spermatic cord?

Answer 6

insertion of the tunica vaginalis is high, meaning testis can rotate and even sit laterally

Question 7

How will torsion of the spermatic cord present?

Answer 7

• Sudden, severe, testicular pain (in the groin and lower abdomen) and tenderness
• There is often associated nausea and vomiting
• The testis may be higher than its normal position
• Mild pyrexia and redness of overlying area may be found
• The cremasteric reflex is often reduced or absent
• Possible acute hydrocoele and oedema which may obliterate landmarks

Question 8

What investigation may be useful in torsion of the spermatic cord?

Answer 8

Dopler USS

Question 9

How is torsion of the spermatic cord managed?

Answer 9

• Prompt exploration
• Surgery - 2-3 point fixation with fine, non-absorbable sutures
• Fix contralateral side

Question 10

Why is a necrotic testicle usually removed in surgery?

Answer 10

This is because necrosis will cause breakdown of the blood-testes barrier, which allows antibodies to form against testes tissue, and so the body will begin to attack the healthy testis

Question 11

What is the testicular appendage?

Answer 11

The appendage is a normal but defunct piece of tissue after birth, found in around 80% of males

Question 12

What is the range of symptoms in torsion of the appendage?

Answer 12

ranging from insidious onset of pain to similar symptoms to torsion of the cord

Question 13

What is an early sign of torsion of the appendage?

Answer 13

localised tenderness at the upper pole and a “Blue-dot sign” in the testes, which is the appendage

Question 14

What is the cremasteric reflex?

Answer 14

When the inner part of the thigh is touched, the ipsilateral testicle will rescind to protect from danger

Question 15

How is torsion of the appendage managed?

Answer 15

Resolves spontaneously without surgery

Question 16

What is epididymoorchitis?

Answer 16

Inflammation of the testis and epididymis secondary to infection

Question 17

What is the most common cause of epidiymoorchitis in those under 35?

Answer 17

STIs (E.g. Gonorrhoea)

Question 18

What is the most common cause of epididymoorchitis in those over 35?

Answer 18

E. coli- originating from the GI tract

Question 19

How will epididymoorchitis present?

Answer 19

• Acute onset, severe testicular pain
• Patient may feel unwell and have a history of dysuria and urethral discharge (due to an STI)

Question 20

What are some signs of epididymoorchitis on examination?

Answer 20

• testis is warm, red, hot and swollen and is tender to touch
• The classic finding on testicular examination that supports epidydmo-orchitis is the alleviation of pain upon elevation of the testes
• Cremasteric reflex present and possible pyrexia

Question 21

What investigations are required in epidydimoorchitis?

Answer 21

Doppler scan - Swollen epididymis and increased bloodflow

Send urine for cultures and chlamydia PCR

Question 22

How is epididymoorchitis managed?

Answer 22

• Analgesia and antibiotics
  
  • Ofloxacin 400mg/day for 14 days

Question 23

What is idiopathic scrotal oedema?

Answer 23

This is a self-limiting condition of unknown cause, not usually associated with scrotal erythema or fever

There may be minimal tenderness and possible pruritis