Acute Scrotal Pathology

Henry YaoPre-SET Urology Trainee

Royal Melbourne Hospital

Case History

• You are working in ED at night• It is 4am and you are tired + hungry• As you are about to go to get a snack• 12 year old male presents with 2 hour history

of pain in right side of scrotum

Question

• What are your differential diagnoses?

Differential diganoses

• Hydatid of Mortgagni (60%)• Testicular Torsion (30%)• Epididymo-orchitis (<5%)• Idiopathic scrotal oedema (<5%)

Question

• What history questions would you ask?

Case History

• Scrotal pain came on over an hour• Steadily getting worse• Vomited once• Some vague lower abdominal and back pain• No trauma to testicles• Two years ago had an STI rx with antibiotics• Stable girlfriend for 12 months

Question

• What would you look for on examination?

Cresmateric Reflex

Testicular Torsion

• Intravaginal vs Extravaginal

Testis Anatomy

• Paired solid viscera• Oval shaped• Left lies slightly lower than right• Epididymis posteriorly• Vas deferens postero-medially• Tunica albuginea covering• Tunica vaginalis antero-laterally• Appendix of testis located in upper pole

Testis Anatomy

• Arterial supply– Testicular artery

• Venous drainage– Pampiniform plexus

• Lymphatic supply– Para-aortic nodes at origin of testicular artery (L2)

• Nervous supply– T10 sympathetic supply (sensory follows this)

Presentation• Most commonly age 12-18• Acute onset of severe testicular pain +/- swelling• On examination– Tender firm testicle– High riding testicle– Horizontal lie of testicle– Absent cremasteric reflex– No pain relief with elevation of testis– Thick or knotted spematic cord– Epididymis not posterior to the testis

Diagnosis

• Clinical suspicion– More likely when the onset of pain is acute and

extremely intense– C.f. epididymitis more likely when onset of pain is

gradual and progresses from mild to more intense– DO NOT WAIT FOR IMAGING if suspect torsion

Management

• IMMEDIATE SURGICAL EXPLORATION if suspected testicular torsion

• Most testicles remain viable if detorsed within 6 hours

• Few testicles remain viable after > 24 hours of torsion

Surgical Exploration

• Median raphe incision• Cut through all layers to

get to testis• Detorse the testis• Three point fixation to

Dartos• Do the contralateral

side

Imaging

• Doppler USS– Torsion: decrease blood flow– Epididymitis: increased blood flow

• Nuclear testicular scan– Torsion: decrease uptake– Epididymitis: increased uptake of radiotracer

activity

Hydatid of Mortgani

• Torsion of appendage• Acute pain• Blue dot in upper pole• If in doubt explore

Epididymo-orchitis

• Rare in childhood• Virtually never between 6 months and puberty• LUTS• Tender epididymis• Prehn’s sign• Dipstick and urine MCS• Rest, antibiotics, high fluid intake, alkalinisation

of urine

Idiopathic Scrotal Oedema

• Causes unknown: ?allergy, ?insect bites• Scrotum symmetrically swollen, pink and less

painful c.f. other causes• Erythema spread beyond the scrotum• Scrotal skin hard but testis and epididymis not

painful

Case 2

• 36 year old male• Day 2 post vasectomy• Presents with painful scrotum

Question

• What do you do?

Case History

Case History

• Vital signs– Tachycardia 110– Blood pressure 100/60

• Very tender scrotum• Hardened scrotal skin• Spreading beyond scrotum

Question

• What do you think is going on?

Fournier’s Gangrene

• Necrotizing fascitiis of male genitalia and perineum

• 30% mortality• Rapidly progressive• Sources of bug from perianal region• Most common bug is E. coli but must also

consider GPC and anaerobes

Fournier’s Gangrene

• Risk factors– T2DM– Alcohol– Other immunosuppressed patients

• Spread across superficial fascial planes– Colles– Scarpa– Buck’s

Presentation

• Painful swelling and induration of the penis, scrotum or perineum

• Oedema spread beyond area of erythema• Eschar, necrosis, ecchymosis, crepitus are

later signs• Foul odour• Fever• Diagnosis is clinical don’t wait for imaging

Management

• Broad spectrum IV antibiotics – consult VIDS– Cover GP, GN and anaerobes

• Immediate aggressive tissue debridement cut down to normal tissue

• Send tissue for MCS• May require flaps• (Consider hyperbaric oxygen therapy)

TGA Antibiotics

Questions

Acknowledgement

• Dr. Kevin O’Connor (Urology Fellow)

Thank You for Your Attention