Scrotum & Testes

Question 1

What anatomical abnormality predisposes to testicular torsion?

Answer 1

Enlarged tunica vaginalis (Bell Clapper)

Question 2

What are the clinical features of testicular torsion? How reliable are these?

Answer 2

Pain (testis, or just low abdo)
Swollen
Tender
High-riding testis
–> only if 360deg of twist
Loss of cremasteric reflex

Only 60% sensitive

Always examine the testes in males with abdo pain

Question 3

Describe the role and procedure of manual testicular untwisting:

Answer 3

ONLY bridging measure if Urology not available in timely manner.

Twist them out away from midline (like opening a book)

Question 4

How rapidly should a testicular torsion patient get to OT?

Answer 4

4 hours- 100% salvage.

50% by 24/24.

Poor spermatogenesis in survivors

Question 5

Answer 5

‘Blue dot sign’ of torsion of testicular appendix

If elicit this clinically, confirms Dx.
–> anterior scrotum

Analgesia only.

Question 6

What would you expect on a urine dipstick in testicular torsion?

Answer 6

Normal in 90%

Can get sterile pyuria…. don’t be tricked into misdiagnosing epididymorchitis.

Question 7

Common causes of epididymorchitis based on demographic:

Answer 7

RARE IN ADOLESCENCE- suspect torsion.

<35 = STI
- Chlamydia, gonorrhoea
- Mumps
- In MSM: E.Coli + other coliforms

>35 = Obstructed UTI
- E.Coli + other coliforms

Question 8

Causes of pyuria:

Answer 8

Balanitis
Urethritis
Prostatitis
Cystitis
Epididymorchitis

Systemic bacteraemia

STERILE PYURIA:
- Hyperthermia
- Hypertensive emergencies
- Renal stones
- Urological surgery/ instrumentation
- Steroid use
- Testicular torsion

Question 9

Management of epididymorchitis:

Answer 9

• Ensure NOT TORSION
• Colour doppler ultrasound
• Urethral swabs and first pass urine (Chlamydia + gono)
• MSU dipstick + MCS
• Antibiotics as per UTI/STI.
• Simple analgesia
• Rest
• Testicular elevation- ie. firm briefs

Question 10

DDx testicular lump:

Answer 10

Tumour

Hydrocele
Haematocele
Varicocele

Epididymal cyst

Indirect inguinal hernia –> can’t get above it

Question 11

DDx ‘acute scrotum’:

Answer 11

TORSION (spermatic cord)
Torsion of appendix
Strangulated hernia (indirect inguinal)

Trauma
–> Haematocele)
–> Rupture

Epididymorchitis
Fourniere’s

Henoch-schonlein purpura (kids)

Question 12

Fournier’s Gangrene

Answer 12

Polymicrobial nec fasc.
Abdo wall –> perineum.

Typically:
- Men
- Elderly
- Diabetic, alcoholic or otherwise immunosuppressed

Very sick
Rapid cellulitis, extreme pain
+- blisters, crepitus
CT: thickened fascia, collections, fat stranding, gas in fascial planes

Meropenam + Vanc + Clinda
+
Radical debridement
+
HBO