The Acute Scrotum

Question 1

What are the differentials for a painful or painless swollen testicle?

Answer 1

Painless – inguinal hernia, hydrocele, epididymal cyst, varicocele or tumour
Painful – trauma (haematocele), torsion of testis, torted hydatid of Morgagni and epididymal orchitis

Question 2

How do you differentiate between a hernia and a hydrocele?

Answer 2

Can you get above it? – If not then it’s a hernia

Hydrocele will transilluminate whilst hernias may not

Question 3

How are hydroceles and hernia managed?

Answer 3

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.

Question 4

What complications can occur from an inguinal hernia?

Answer 4

Incarcerated – irreducible
Obstructed bowel
Strangulated – cut off blood supply

Question 5

How can you differentiate between a torted testis, a torted hydatid and epipidymo-orchitis?

Answer 5

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

Question 6

What other features are common in a torted testis

Answer 6

Abdominal pain and nausea

Loss of Cremasteric reflex

Question 7

What is balanitis xerotica obliterans?

Answer 7

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.

Question 8

How is balanitis xerotica obliterans managed?

Answer 8

Treatment is circumcision

Question 9

What is a smegma retention cyst?

Answer 9

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.

Question 10

When does the foreskin become fully retractile?

Answer 10

50% of boys will be full retractile by age 10 and 97% by age 17.

Question 11

What is a torted testis?

Answer 11

Twist of the spermatic cord resulting in testicular ischaemia and necrosis. Most commonly seen in males between 13 and 15 years.

Question 12

What are the risk factors for torted testis?

Answer 12

Age <25
Neonate 
Bell clapper deformity 
Trauma/exercise 
Undescended testicle 
Cold weather

Question 13

How does a torted testis usually present?

Answer 13

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

Question 14

How should torted testis be investigated?

Answer 14

Surgical exploration is gold standard
Doppler USS can help to see testicular blood flow
FBC and CRP to rule out other causes

Question 15

How are torted testis managed?

Answer 15

Surgical exploration and fixation

Often due to bell clapper testis and so other testis should be fixed too

Question 16

What is a torted hydatid of Morgagni?

Answer 16

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.

Question 17

What causes epidiymo-orchitis?

Answer 17

Usually chlamydia but may be other gram-negative organisms and association underlying structural abnormality

Question 18

What are the clinical features of epidiymo-orchitis?

Answer 18

History of Dysuria and urethral discharge
Unilateral testicular pain
Tender on examination, eased by elevating testis
Cremasteric should still be present
Fever

Question 19

How should epidiymo-orchitis be investigated?

Answer 19

Urine dip
Urethral swab and gram stain
Must rule out torsion – likely if <20, severe pain and acute onset

Question 20

How is epidiymo-orchitis managed?

Answer 20

Ceftriaxone IM single dose plus doxycycline PO for 10-14 days

Question 21

What features would suggest a lump in the scrotum is an epididymal cyst?

Answer 21

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.