Acute Scrotal Pathology

Report
Acute Scrotal Pathology
Henry Yao
Pre-SET Urology Trainee
Royal Melbourne Hospital
Case History
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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
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Hydatid of Mortgagni (60%)
Testicular Torsion (30%)
Epididymo-orchitis (<5%)
Idiopathic scrotal oedema (<5%)
Question
• What history questions would you ask?
Case History
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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
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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
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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
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Torsion of appendage
Acute pain
Blue dot in upper pole
If in doubt  explore
Epididymo-orchitis
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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

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