The Acute Scrotum Flashcards
What does the term “acute scrotum” refer to?
The term “acute scrotum” refers to acute scrotal pain with or without swelling or erythema.
Why is the acute scrotum considered an emergency?
The acute scrotum is considered an emergency because the most serious cause, testicular torsion, can lead to testicular necrosis
How should a patient presenting with an acute scrotum be managed?
A patient with an acute scrotum should be urgently referred to an appropriate unit or facility for scrotal exploration if needed, as diagnosis is difficult based on clinical grounds alone.
Is it easy to diagnose the acute scrotum based on clinical examination alone?
No, it is very difficult to establish the diagnosis on clinical grounds alone, so further investigation is needed.
At what age can patients present with an acute scrotum?
Patients may present with an acute scrotum at any age.
What are the common causes of acute scrotum?
Common causes include testicular torsion, testicular appendage torsion, and epididymo-orchitis.
How are orchitis or epididymitis investigated in acute scrotum cases?
Patients with orchitis or epididymitis require investigation through ultrasound to check for underlying renal tract anomalies.
What are the characteristics of testicular torsion?
Testicular torsion causes sudden onset of pain and extreme tenderness. It has two age peaks: neonatal and early teens. Neonatal torsion is intra-vaginal.
What is torted appendix testis and how is it identified?
Torted appendix testis is the torsion of the embryonal remnant of Mullerian structures, causing sudden to progressive pain. Examination often reveals a small blue dot or a firm, pea-sized mass under the scrotal skin.
What are the characteristics of epididymitis or orchitis?
Epididymitis or orchitis usually has a slower onset. Symptoms may include dysuria, and dipstick tests may be positive. A history of urinary tract anomalies suggests orchitis. An ultrasound is needed to rule out urinary tract abnormalities.
What are the signs of testicular or scrotal trauma?
Testicular or scrotal trauma typically follows a history of trauma or a straddle injury. Examination usually reveals signs of a hematoma.
How is a strangulated inguinal hernia identified?
A strangulated inguinal hernia is clinically evident with a groin mass that cannot be palpated above and signs of bowel obstruction on examination.
What are some miscellaneous conditions that can present with acute scrotal symptoms?
Miscellaneous conditions include idiopathic scrotal edema (edematous, not too tender, extending to perineum, inguinal area, and opposite side), rheumatoid purpura, viral orchitis, epididymal cysts, and testicular tumors.
What are the differential diagnosis of acute scrotum
Testicular torsion
Torted appendix testis
Epididymitis/ Orchitis
Testicular/ scrotal trauma
Inguinal hernia
Miscellaneous conditions
What should be ascertained about the pain’s acuity and onset in a patient with acute scrotum?
It is important to determine whether the pain came on suddenly (as in torsion) or gradually (as in infection, where pain increases slowly).
What history should be taken regarding the duration of symptoms and previous episodes?
The duration of symptoms should be noted. A history of previous episodes may indicate torsion-detorsion.
How does a history of trauma or systemic illness help in diagnosing acute scrotum?
A history of recent significant trauma may point to testicular/scrotal trauma. Current systemic illness or fever could suggest an infective cause.
Why is a history of urinary tract infections or predisposing conditions important?
A history of UTIs or conditions like spinal dysraphism, congenital genitourinary abnormalities, or chronic constipation may predispose the patient to infections such as epididymitis or orchitis.
What should be examined on the scrotum during the physical examination?
Look for a red, hot, painful, tender scrotum, acutely tender scrotum (unilateral or bilateral), scrotal edema (unilateral or bilateral), and testicular swelling (uniform or small pea-sized mass).
How is a hernia or torsion detected during examination?
Presence of a bulge at the external ring may indicate a hernia. A retracted, ‘high riding’ testicle is often a sign of torsion.
What reflexes and systemic symptoms should be assessed during examination?
Check for an absent cremasteric reflex, which can be present in torsion. Also, assess for symptoms of systemic illness, such as pyrexia, which could indicate infection.
How can urine dipstick be helpful in investigating acute scrotum?
A urine dipstick can help screen for urinary tract infections that may predispose to epididymo-orchitis.
Why is ultrasound Doppler not recommended in diagnosing acute scrotum?
Ultrasound Doppler is operator-dependent and may show increased flow in a torted testicle, potentially creating a false negative. It is generally not recommended unless performed by a clinician with significant pediatric surgical or urological experience.
What is the role of nuclear medicine or other scans in acute scrotum cases?
Some units may use nuclear medicine or other scans to assess blood supply, but delays for these investigations can risk losing the testicle. The default approach is to take patients with an acute scrotum to theatre immediately.
What is the initial management for a patient with acute scrotum?
The patient should be urgently referred to a unit that performs scrotal explorations in the pediatric population. The patient should be kept NPO (nothing by mouth) and provided with analgesia.
What happens if the testicle or its appendage is not torted?
A pus swab will be taken, and the patient will be treated for epididymo-orchitis, followed by workup as for any urinary tract infection
What is the management for a torted appendix testis?
A torted appendix testis is excised surgically.
How is testicular torsion managed?
In cases of testicular torsion, the testis is detorted. If viable, it is left in situ, and both testes are pexied to prevent further torsion. If the testis is necrotic, it is excised, and the other testis is pexied to the scrotum to prevent torsion.
What is done if a scrotal haematoma is found?
If a haematoma is found, it is evacuated surgically.
How is torsion of the testicular appendix managed if the diagnosis is certain?
If torsion of the testicular appendix is certain, it can be managed conservatively with analgesics for a week, though surgery remains the definitive treatment.
What are the typical outcomes following scrotal exploration?
Scrotal exploration is usually uneventful with few complications, and most patients are discharged within 24 hours.
What is the risk of long-term testicular atrophy after testicular torsion?
Ischaemia of the testicle may lead to long-term atrophy, especially if the testicle has been torted for more than 8 hours, with almost certain atrophy if torted for more than 24 hours.
How does testicular torsion affect future fertility?
Studies show that the rate of pregnancy and time to pregnancy in couples where the male had testicular torsion is the same as in the general population.
