The Acute Scrotum Flashcards
A 1-month-old boy presents to the emergency room with an inconsolable pain and left scrotal swelling for the past 6 h. An ultrasound demonstrates no blood flow to the testicle. Which of the following is true of management in this condition?
A. The contralateral testicle does not need any intervention.
B. The testicle can almost never be salvaged after 2 h.
C. This is a surgical emergency.
D. The likely cause is epididymitis.
E. A bell clapper deformity is rarely the cause of this condition in adolescence.
ANSWER: C
COMMENTS: This infant has testicle torsion. The lack of testicular blood flow on ultrasound and a painful hemiscrotum on examination make the diagnosis.
This is a surgical emergency and must be corrected immediately. Irreversible necrosis usually occurs by 24 h but has been described as early as 2h after the onset.
Surgical correction involves orchiopexy of not only the affected side but also the contralateral testicle to prevent torsion from occurring in the future.
In the neonatal period, torsion is the result of either a bell clapper deformity or extratunical torsion; however, beyond this period, it is almost always associated with a bell clapper deformity.
A bell clapper deformity is the horizontal positioning of the testicle within the scrotum resulting from a failure of normal anchoring of the gubernaculum, epididymis, and testis to the tunica vaginalis.
Other presentations of acute scrotum include epididymitis, mumps orchitis, and fat necrosis; however, testicle torsion should always be considered when a patient presents with an acute scrotum to avoid prolonged ischemia and possible necrosis to the testicle.
What are the types of testicular torsion?
Torsion of the testis results from twisting of the spermatic cord that compromises testicular perfusion, resulting in infarction. Even if the testis is not removed, the consequent ischemic damage can affect testicular morphology and fertility.
There appears to be a 4–8-hour window before significant damage occurs once torsion develops. The probability of testicular salvage declines significantly beyond 6 hours. Emergency exploration is indicated beyond this window because testicular viability is difficult to predict.
Two types of torsion occur: intravaginal and extravaginal.
Intravaginal
Intravaginal torsion is more common in children and adolescents (compared with neonates).
Normally, the tunica will invest the epididymis and posterior surface of the testis, fixing it to the dartos layers of the scrotum with a vertical lie.
Abnormal fixation occurs when the tunica vaginalis attaches more proximally on the spermatic cord, creating a long mesorchium around which the testis can twist. The testis will then lie horizontally, and the pendulous testis is vulnerable to twisting with leg movement or cremasteric contraction.
This anatomic variant is classically described as the “bell-clapper” deformity and has an incidence as high as 12% in cadaveric studies. Often, it is bilateral.
It is theorized that torsion occurs in the adolescent period when the testis is growing rapidly with puberty and increase in mass predisposes the testis to spin on an axis. This same concept describes an increased risk of torsion after testicular trauma or with testicular malignancy.
Extravaginal
Extravaginal torsion occurs perinatally because the tunica vaginalis is not firmly fixed to the dartos layer of the scrotum, allowing the testis and tunica both to spin on the vascular pedicle.
A familial pattern of testicular torsion has more recently been confirmed and may span generations. This is an important consideration when obtaining a family history and should be included in counseling a family with regard to future episodes of torsion in other male family members as salvage rates in familial torsion are surprisingly lower than in non-familial cases.
Testicular torsion typically occurs before age 3 years or after puberty. It is less common in prepubertal boys and after age 25 years.
Patients present with the sudden onset of severe, unilateral pain in the testis, lower thigh, or lower abdomen, often associated with nausea and vomiting.
Episodes of intermittent testicular pain may precede the acute presentation, suggesting prior incomplete torsion and detorsion.
Physical examination may reveal an enlarged testis that is retracted up toward the inguinal region with a transverse orientation and an anteriorly located epididymis.
However, it is usually difficult to obtain a good exam because of generalized scrotal pain and tenderness. (In contrast, focal tenderness at the superior pole of the testis or along the epididymis is often found with a torsed appendix testis or epididymitis.)
Depending on the duration of the testicular torsion, the hemiscrotum can show varying degrees of swelling and erythema, which may obliterate landmarks and make the examination more difficult.
The cremasteric reflex is often absent with testicular torsion, but presence of the reflex does not exclude it.
H&A
How is testicular torsion diagnosed?
Testicular torsion typically occurs before age 3 years or after puberty. It is less common in prepubertal boys and after age 25 years.
Patients present with the sudden onset of severe, unilateral pain in the testis, lower thigh, or lower abdomen, often associated with nausea and vomiting.
Episodes of intermittent testicular pain may precede the acute presentation, suggesting prior incomplete torsion and detorsion.
Physical examination may reveal an enlarged testis that is retracted up toward the inguinal region with a transverse orientation and an anteriorly located epididymis. However, it is usually difficult to obtain a good exam because of generalized scrotal pain and tenderness.
(In contrast, focal tenderness at the superior pole of the testis or along the epididymis is often found with a torsed appendix testis or epididymitis.)
Depending on the duration of the testicular torsion, the hemiscrotum can show varying degrees of swelling and erythema, which may obliterate landmarks and make the examination more difficult.
The cremasteric reflex is often absent with testicular torsion, but presence of the reflex does not exclude it.
The diagnosis of testicular torsion is usually clinically apparent and managed by immediate scrotal exploration.
The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score has been described as an algorithm for surgeons and primary care physicians to assess risk of torsion based on a symptom score. Parameters include testis swelling (2 points), hard testis (2), absent cremasteric reflex (1), nausea/vomiting (1), and high-riding testis (1). Point sum total scores of 6–7 correlate with high positive and negative predictive values, particularly in pubertal boys (Tanner 3–5), and can be used to avoid unnecessary ultrasound (US) confirmation of torsion prior to surgical exploration.
This system is less reliable in Tanner stages 1–2, so imaging is recommended even for high TWIST scores.
When torsion is difficult to diagnosis, other studies may be beneficial.
A urinalysis revealing pyuria and bacteriuria is more indicative of infectious epididymitis/orchitis, but can also be found with torsion.
High-resolution US with color flow Doppler and radionuclide imaging allows determination of testicular blood flow. US is more commonly used because it allows determination of the blood flow, is less time consuming, is more readily available, and does not expose the patient to ionizing radiation.
In one study, color flow Doppler US imaging had a sensitivity of 89.9%, a specificity of 98.8%, and a false-positive rate of 1%. Also, Doppler US may detect coiling of the spermatic cord, indicating torsion, even with normal blood flow within the testis. US should be used only when the diagnosis is equivocal because imaging studies will only delay scrotal exploration.
Other modalities have been proposed to assess the acute scrotum. Shear wave elastography is a newer sonographic modality that evaluates the stiffness of tissues. The finding of higher Young’s modulus values in testicular torsion compared with normal testes may add to the accuracy of Doppler US.
Near-infrared spectroscopy uses tissue oxygen saturation to compare the affected testis with the normal control testis. In Tanner 3–5 boys without scrotal edema or with pain of shorter duration, this modality has a high positive predictive value.
This tool is particularly appealing, as it requires a small probe and device, similar to a pulse oximeter, that could be performed at the point of initial medical evaluation.
If testicular torsion is suspected but a delay to the operating room is unavoidable, manual detorsion can be attempted.
Detorsion is performed with a medial to lateral, “open book” rotation because this will be the correct direction in twothirds of patients.
If successful, the testis will drop lower in the scrotum and the patient will report sudden pain relief.
If the initial attempt is unsuccessful, an attempt in the reverse direction may be warranted.
Although these maneuvers may decrease the degree of ischemia, prompt exploration and fixation remain mandatory because the detorsion may not be complete and torsion can reoccur.
H&A
How is surgical exploration done for testicular torsion?
Exploration is typically performed using a median raphe scrotal incision.
The symptomatic hemiscrotum is entered and the testis delivered, detorsed, and placed in warm, moist sponges while the contralateral hemiscrotum is explored.
The unaffected testis should be fixed to the scrotal wall with multiple nonabsorbable suture.
Excluding the tunica vaginalis allows better fixation of the testis to the scrotum.
Attention is then turned back to the affected testis. If the testis is clearly nonviable, it should be removed to avoid potential damage to the contralateral testis from the formation of antisperm antibodies.
If the torsed testis becomes reperfused or is bleeding from the cut surface, it should be fixed in the same manner as the contralateral testis.
Several centers have described decompression of the testicular compartment on compromised gonads by incising the tunica albuginea and covering it with a tunica vaginalis patch.
A subset of compromised testes seems to be salvageable by these maneuvers.
Although this technique may benefit testicular survival, the impact of this alteration of a “privileged site” on ultimate fertility, given the potential for formation of antisperm antibodies, has dampened enthusiasm in the setting of a normal contralateral testis.
Bilateral fixation reduces the probability of torsion in the future, but cases of torsion after fixation have been described.
Any patient with symptoms of testicular torsion should be evaluated and managed appropriately, regardless if previous fixation was performed.
How is intermittent testicular pain evaluated?
Intermittent testicular pain is not uncommon in adolescent males and may represent intermittent torsion with spontaneous resolution.
This diagnosis should be strongly considered in patients with significant testicular pain that has resolved, especially if there have been multiple episodes.
This suspicion is reinforced if the testis has a transverse orientation or excess mobility.
The diagnosis could be confirmed with Doppler US while symptomatic.
If clinical concern remains despite a normal physical examination, elective scrotal exploration looking for a “bellclapper” deformity with bilateral orchiopexy should be considered.
How is perinatal testicular torsion evaluated?
The term perinatal torsion involves both prenatal and postnatal events, with most (75%) occurring prenatally.
Distinguishing between the two types can be difficult, but affects the timing of operation.
Prenatal torsion presents as a hard, nontender scrotal mass noted at birth, usually with underlying dark skin discoloration and fixation of the skin to the mass. These findings suggest testicular infarction secondary to a prior torsion.
Postnatal torsion presents as an acutely inflamed scrotum with erythema and tenderness. The scrotum is often reported as normal at delivery, suggesting an acute postnatal event. This diagnosis requires emergent exploration with detorsion and bilateral fixation.
The timing of exploration for prenatal torsion has been controversial. Some surgeons believe exploration is not indicated because of negligible salvage rates and increased neonatal anesthetic risks. However, this approach is challenged by reports of asynchronous torsion with loss of the remaining contralateral testis. Furthermore, if the torsion were to happen at or just prior to delivery, testicular salvage may be possible.
One series of 30 neonates with torsion who were explored within 6 hours of birth found two testes that could be salvaged and demonstrated normal growth 1 year later. Therefore, many surgeons have become more aggressive with earlier exploration of these infarcted testes to fix the contralateral side and prevent the potential for bilateral torsion.
Although a testicular teratoma or a hernia sac filled with meconium or blood can mimic prenatal torsion, our practice has been early exploration.
Postnatal torsion clearly mandates emergent exploration because salvage rates have been reported as high as 40–50%, which is similar to torsion later in life. Scrotal exploration is performed through an inguinal incision because a testicular tumor may actually be present and a scrotal incision could lead to spread to the inguinal nodes.
Contralateral exploration is accomplished through a transverse scrotal incision, with placement of the testis in a dartos pouch between the external spermatic fascia of the scrotum and the dartos fascia. This technique is less traumatic to the small, delicate neonatal gonad and provides similar fixation to using sutures.
How is torsion of the testicular appendages evaluated and managed?
Torsion of the appendix testis or appendix epididymis is the most common cause of an acute scrotum and is frequently misdiagnosed as acute epididymitis or epididymo-orchitis.
The testicular appendage represents a vestigial remnant of the Müllerian duct, and the epididymal appendage is of Wolffian duct origin.
Torsion of these appendages occurs most commonly between ages 7 and 10 years.
It is hypothesized that a prepubertal hormonal boost stimulates these structures, producing an increase in size, rendering them susceptible to twisting.
Patients with appendage torsion present with sudden onset of pain and nausea. The appendage can usually be palpated and is exquisitely and focally tender. The examiner may be able to elicit differential tenderness between the upper and lower poles of the affected testis.
Classically called the “blue dot” sign, the inflamed and ischemic appendage may be seen through the scrotal skin as a subtle bluecolored mass.
As inflammation increases, the epididymis, testis, and scrotal tissues become edematous and erythematous, and the diagnosis becomes more difficult.
US early in the presentation demonstrates a discrete appendage. Later, it may only show increased blood flow to the adjacent epididymis and testis or, possibly, a reactive hydrocele, resulting in the misdiagnosis of acute epididymitis or epididymo-orchitis.
Torsion of these appendages is self-limited and is best treated with nonsteroidal anti-inflammatory medications and comfort measures such as warm compresses.
The pain resolves as the appendage infarcts and necroses. It may become a calcified free body within the tunica vaginalis.
Appendage torsion can occur at five anatomic sites: appendix testis, appendix epididymis, paradidymis/organ of Giraldes, and superior and inferior vas aberrans of Haller.
Exploration is indicated when the diagnosis is unclear or when the symptoms are prolonged and fail to resolve spontaneously.
The torsed appendage can be easily excised through a small scrotal incision with immediate symptom relief.
How is epididymitis diagnosed and managed?
True bacterial epididymitis is rare in children, accounting for 10–15% of patients with an acute scrotum.
The bacterial infection extends from the bladder and urethra to the epididymis in a retrograde direction via the ejaculatory ducts and can be associated with a clinical urinary tract infection or urethritis.
The scrotal pain and swelling typically have a slow onset, worsening over days rather than hours.
Examination reveals induration, swelling, and tenderness of the hemiscrotum.
A positive urinalysis and culture, or urethral swab in sexually active adolescents, confirms the diagnosis. Neisseria gonorrhoeae and Chlamydia are classically found in sexually active boys, but common urinary pathogens, including coliforms and Mycoplasma species, are more likely in younger children.
When studies suggest a bacterial infection, appropriate antibiotic therapy is initiated and adjusted according to the culture results.
If acute epididymitis is found on scrotal exploration, cultures should be obtained, but the contralateral side should not be opened to avoid spreading the infection.
As with any urinary tract infection in a boy, a renal bladder sonogram and voiding cystourethrogram should be obtained after the infection has resolved.
Vesicoureteric reflux is the most common finding, but an ectopic ureter (to the vas, ejaculatory duct, or seminal vesicle), ejaculatory duct obstruction, or urethral valves can also be found.
Viral infections are believed to be a common cause for acute epididymitis but are usually diagnosed presumptively.
Mumps orchitis is rare and occurs in approximately one-third of infected postpubertal boys. Adenovirus, enterovirus, influenza, and parainfluenza virus infections have also been found.
Management is supportive, antibiotics are not indicated, and the pain is generally self-limited.
How is idiopathic scrotal edema diagnosed and managed?
Scrotal swelling of unknown etiology is termed idiopathic scrotal edema and usually affects boys between the ages of 5 and 9 years.
The syndrome is characterized by the insidious onset of swelling and erythema that typically begins in the perineum or inguinal region, and spreads to the hemiscrotum.
Pruritus can occur, but the testis is not tender and US shows normal testicular blood flow.
Contact dermatitis, insect bites, and minor trauma are often misdiagnosed as the etiology.
Evaluation should seek to exclude cellulitis from an adjacent infection (inguinal, perirectal, or urethral).
Treatment is with antihistamines or topical corticosteroids. If cellulitis is a concern, oral antibiotics can be administered.
How is Henoch-Schonlein Purpura diagnosed and managed?
Henoch–Schönlein purpura is a vasculitic syndrome that can involve the skin, joints, and gastrointestinal and genitourinary systems.
Up to one-third of patients develop pain, erythema, and swelling of the scrotum and spermatic cord, most commonly in boys younger than 7 years of age.
Doppler US demonstrates normal blood flow to the testis. Patients can also experience skin purpura, joint pain, and hematuria.
Supportive measures are typically adequate, although systemic corticosteroids may be helpful.
Despite the rarity of coincident diagnoses, patients with Henoch–Schönlein purpura and testicular torsion have been described.
How is testicular trauma diagnosed and managed in the Pediatric patient?
Testicular trauma in children is rare. The diagnosis is made by taking a complete history and paying close attention to factors suggesting sexual abuse.
The injured testis is swollen. and is markedly tender. Often there is swelling and bruising of the scrotum.
The most common injury is a hematoma of the testis.
US should be obtained to evaluate for rupture of the tunica albuginea, which is an indication for operative repair.
Repair is particularly important in postpubertal boys because of the potential for autoimmune injury to the contralateral testis, which remains largely theoretical.
A large hematoma in the space between the tunica vaginalis and the tunica albuginea should be evacuated to avoid pressure necrosis of the testis.
Epididymal injuries can occur, including disruption of the epididymis from the testis, with a poor outcome even after repair.
A 10-year-old boy is brought to the emergency department with a 3-hour history of severe, acute right-sided scrotal pain that woke him from sleep. No fever, nausea, or vomiting is reported. The affected testicle is very tender to touch with a focal area of discoloration.
No obvious testicular swelling or erythema is present. The opposite testicle is normal in size and shape and is nontender. Urination and urinalysis are normal. What is the best next step in the management of this patient?
Choices:
1. Scrotal ultrasound
2. Immediate surgical exploration for torsion
3. Immediate surgical exploration for incarcerated hernia
4. Radionuclide imaging of the scrotum
Answer: 1 - Scrotal ultrasound
Explanations:
• Torsion of the appendix testis is the most likely diagnosis given the relatively young age, lack of “angel wing” or “bell clapper deformity” on the opposite side, no erythema, normal urination, and normal urinalysis. Testicular appendage torsion is the most likely diagnosis of an acute scrotum in this age group.
• Scrotal ultrasound should be done in all patients with acute scrotum to confirm the diagnosis. A finding of a testicular appendage larger than 5.6 mm is strongly suggestive of a torsed appendix testis.
• Radionuclide imaging of the scrotum would demonstrate a “hot dot” sign at the site of the torsed testicular appendage but is useful only if the symptoms and torsion have been present for at least 5 hours. Even after 5 hours, this sign is only found in about 45% of patients ultimately found to have a torsed testicular appendage. For these reasons, ultrasound imaging is usually the preferred option for the initial evaluation of all acute scrotal pathologies.
•There is no need for surgical exploration unless the pain is not controllable or there is doubt about the diagnosis. Treatment for torsion of the appendix testis is supportive.
StatPearls
Regarding features of testicular torsion, all of the following are true except:
A. Extravaginal torsion is more common.
B. Peak age is 13–16 years.
C. Torsion of appendix testes is more common than true torsion of testes.
D. Sudden pain, swelling, and redness of scrotum is best treated as torsion of testes.
E. Doppler ultrasound is less helpful in infants.
A
Intravaginal (intratunical) torsion is common.
There is abnormally high investment of spermatic cord by the tunica vaginalis, which allow testes to lie horizontally and may readily twisted by leg movement and cremaster contraction.
In adolescence beyond puberty, Doppler ultrasound can be used to determine bloodflow to the testes, but before puberty, when the testes are 1–2 ml of volume, such investigation is of low accuracy.
Syed/MCQ
Regarding torsion of testes, which one is false?
A. Immediate operative exploration is required.
B. Testes should be untwisted and assessed for viability.
C. Do orchiectomy of ischaemic gonad in child above 10 years in case of dead testes.
D. In adolescents with recurrent testicular pain, bilateral orchidopexy is justified.
E. Idiopathic scrotal oedema is not a differential diagnosis.
E
Idiopathic scrotal oedema is one of the differential diagnosis.
Other differential diagnoses include epididymitis, mumps orchitic, and torsion of testicular appendage, fat necrosis, strangulated inguinal hernia, acute hydrocele and trauma.
Syed/MCQ
Which of the following is true of testicular torsion?
A It is the most likely cause of acute scrotum in an 8-year-old boy.
B In children it can be reliably diagnosed by Doppler ultrasound.
C In neonates it is due to intravaginal torsion.
D Scrotal inflammatory change is a late sign associated with necrosis.
E Bilateral fixation (after de-rotation) of the testes is best performed with dissolving sutures.
D
Testicular torsion can occur at any age but it is the most common cause of acute scrotum at puberty.
There is a second peak of incidence in infancy.
The aetiology in this age group is different as the torsion is extravaginal.
At puberty the torsion is intravaginal due to an abnormally high insertion of the tunica vaginalis.
Typically torsion presents with acute onset of scrotal pain, often accompanied by nausea and vomiting.
Early examination reveals a hard tender testicle, which may be lying high in the scrotum.
The cord is often tender and the cremasteric reflex is absent.
The overlying scrotum is of a normal appearance until late when inflammation, secondary to testicular necrosis, causes swelling and redness.
Diagnosis is essentially clinical. While Doppler ultrasound can be helpful in postpubertal testicular torsion it is unreliable in younger children.
Bilateral fixation is essential although the exact technique of doing this remains controversial, including whether to use permanent or dissolving sutures.
In general the fixation should be at multiple points with the tunica everted.
SPSE 1
