The Acute Scrotum Flashcards
What are the differentials for a painful or painless swollen testicle?
Painless – inguinal hernia, hydrocele, epididymal cyst, varicocele or tumour
Painful – trauma (haematocele), torsion of testis, torted hydatid of Morgagni and epididymal orchitis
How do you differentiate between a hernia and a hydrocele?
Can you get above it? – If not then it’s a hernia
Hydrocele will transilluminate whilst hernias may not
How are hydroceles and hernia managed?
Hydrocele and Hernia are repaired in the same way
Surgical management of the patent processes vaginalis however hydroceles usually disappear at 2 years whilst hernias can cause problems.
Younger children should be repaired sooner as they are more likely to be complicated. Rule of 6 2s, <6weeks old, repair within 2 days, <6months months old repair within 2 weeks and <6years old repair within 2 months.
What complications can occur from an inguinal hernia?
Incarcerated – irreducible
Obstructed bowel
Strangulated – cut off blood supply
How can you differentiate between a torted testis, a torted hydatid and epipidymo-orchitis?
Timing of the pain helps to differentiate
Pain came on over 0-10 minutes – full torsion
Pain came on over 0-8 hours – torted hydatid
Dysuria first then pain and swelling – epididymo-orchitis
Blue dot sign – torted hydatid
What other features are common in a torted testis
Abdominal pain and nausea
Loss of Cremasteric reflex
What is balanitis xerotica obliterans?
Disease of the foreskin where it becomes white (similar to lichen sclerosis). It is a chronic progressive disease and can lead to phimosis and urethral stenosis.
How is balanitis xerotica obliterans managed?
Treatment is circumcision
What is a smegma retention cyst?
Foreskin becomes slowly more retractile as the boy ages. This occurs as the cells connecting the foreskin to the glans atrophy slowly. As this happens smegma can get caught and lead to a smegma retention cyst.
When does the foreskin become fully retractile?
50% of boys will be full retractile by age 10 and 97% by age 17.
What is a torted testis?
Twist of the spermatic cord resulting in testicular ischaemia and necrosis. Most commonly seen in males between 13 and 15 years.
What are the risk factors for torted testis?
Age <25 Neonate Bell clapper deformity Trauma/exercise Undescended testicle Cold weather
How does a torted testis usually present?
Sudden onset severe testicular pain which may radiate or simply be referred to abdomen
Tender and pain not easer be elevation
Swelling/oedema and erythema
Cremasteric reflex may be absent
Can sometimes get histories of intermittent torsion
Nausea and vomiting
How should torted testis be investigated?
Surgical exploration is gold standard
Doppler USS can help to see testicular blood flow
FBC and CRP to rule out other causes
How are torted testis managed?
Surgical exploration and fixation
Often due to bell clapper testis and so other testis should be fixed too
What is a torted hydatid of Morgagni?
Torsion of the appendix of the testes – a small embryological remnant. Can present in very similar way to torsion of the testis. However, usually the pain is less severe is less sudden onset and you may see a ‘Blue dot sign’. If in any doubt surgical exploration is warranted.
What causes epidiymo-orchitis?
Usually chlamydia but may be other gram-negative organisms and association underlying structural abnormality
What are the clinical features of epidiymo-orchitis?
History of Dysuria and urethral discharge
Unilateral testicular pain
Tender on examination, eased by elevating testis
Cremasteric should still be present
Fever
How should epidiymo-orchitis be investigated?
Urine dip
Urethral swab and gram stain
Must rule out torsion – likely if <20, severe pain and acute onset
How is epidiymo-orchitis managed?
Ceftriaxone IM single dose plus doxycycline PO for 10-14 days
What features would suggest a lump in the scrotum is an epididymal cyst?
Can be single or multiple and clear or opaque containing spermatoceles. Painless and lie above and behind the testis. Possible to get above the lump on examination. Usually seen in adults.
