Scrotal pain Flashcards
Layers of scrotum
- Skin
- Superficial “Dartos” fascia
- External spermatic fascia
- Cremaster muscle
- Internal spermatic fascia
- Tunica vaginalis
What is cremasteric reflex?
- Stroking proximal and medial thigh
- Normal response = contraction of cremater muscle causing retraction of testes upwards on ipsilateral side
- Absence of this reflex = sign for torsion
What is Phrens sign?
- Alleviation of scrotal pain by lifting testes
- Suggestive of acute epididymitis
Investigations for scrotal pain - bloods and bedside
- Urine dipstick
- Urine MC&S
- Urethral swab if suspect STI
- Bloods - FBC, CRP, U&E
Imaging for scrotal pain
- USS scrotum
- Identify inflammatory process and patency of blood vessels
- BUT if suspect torsion - do not delay surgical exploration for imaging
Differentials for scrotal pain
- Testicular torsion
- Torsion of testicular and epididymal appendages
- Epididymitis
- Testicular cancer
- Non-urological - Henoch-Schoenlein Purpura, viral orchitis
Testicular torsion - what is it
- Twisting of spermatic cord
- Occlusion of testicular and cremasteric arteries
- = ischaemia and subsequent testicular infarction
History for testicular torsion
- Young adults
- Pain sudden onset
- Very severe
- N+V
Examination testicular torsion
- Unilateral scrotal tenderness
- High testicular position
- Abnormal lie
- Absent cremasteric reflex
Management testicular torsion
- Urgent surgical exploration
- If torsion present - untwist
- If return of vascularity –> bilateral orchidopexy (fix teste to scrotum)
- Orchidectomy if infarcted, fix contralateral testicle
What is torsion of testicular and epididymal appendages?
- Hydatid of Morgagni = testicular appendix
- This and epididymal appendage are remnants of embryological development
- They can twist and result in torsion
Presentation testicular torsion vs torsion of appendages
- Appendages = normal testicular lie and present cremasteric reflex
- BUT both present with unilateral scrotal pain and tenderness
What is blue dot sign?
- Upper half of hemi scrotum
- Occurs due to infarction of appendices
Management of torsion of testicular and epididymal appendages
- Analgesia
- BUT if clinical uncertainty, need surgical exploration to rule out testicular torsion
What is epididymitis?
- Inflammation of epididymis
- Most common cause sexual transmission in under 35
- If above 35, likely enteric organism from UTI
Presentation of epididymitis
- Worsening pain in scrotum - can spread to groin
- Fevers
- Dysuria
- Urethral discharge
Examination of epididymitis
- Epidiymis affected is swollen and tender - unilateral
- Overlying scrotal skin looks inflamed
- Cremasteric reflex present
- Prehns sign positive
Management of epididymitis
- Antibiotics
- If STI - organism unknown = IM ceftriaxone + doxycycline BD for 2 weeks
- UTI - organism unknown = quinolone for 2 weeks eg ofloxacin
How can testicular cancer present with pain?
- Usually painLESS
- Acute scrotal pain if internal haemorrhage within malignancy
- Pain associated with palpable mass
+ve Investigations for testicular cancer
- USS testes definitive
- Raised tumour markers eg b-HCG and AFP
Management of testicular cancer
- Surgical - radical inguinal orichidectomy
- May need adjuvant chemotherapy
Referred pain causing scrotal pain
- Anterior scrotum = supplied by branches of genitofemoral and ilioinguinal nerve
- Posterior = perineal branches of pudendal and posterior femoral cutaneous nerve
- Things such as ureteric stones or strangulated inguinal hernia can irritate these nerves and cause pain
What is Henoch-Shoenlein Purpura?
- IgA mediated
- Small vessel vasculitis
- Commonly affects skin, mucous membranes and kidneys
Triad of HSP
- Purpuric rash on limbs
- Arthiritis
- Abdominal pain
Can present in some cases with scrotal symptoms inc pain, erythema and swelling
Bloods and definitive diagnosis for HSP
- Raised CRP or ESR
- Raised serum IgA
- Diagnosis made via biopsy to kidney or skin - shows IgA deposition
What causes viral orchitis?
- Inflammation of testes due to viral infection
- Most common = mumps
Presentation of viral orchitis?
- Bilateral scrotal pain - unlike other causes
- Scrotal swelling and pain 4-8 days following parotitis
Management viral orchitis
- Analgesia
- Self limiting
- BUT scrotal swelling may persist up to 6 weeks post infection
When to US suspected testicular torsion
- If present within 48hrs - no just straight to surgery
- If >48hrs history - US testis can support diagnosis of delayed presentation or identify other cause
