Editing Acute Scrotum

== Definition ==
*Acute scrotum refers any new onset of the following (or combination) of symptoms (3):
**Pain
**Swelling
**Tenderness of intrascrotal contents
==Differential diagnosis==
*'''(see CW11 box 146-2)'''
*'''Torsion of the appendix testis is the most common diagnosis followed by spermatic cord torsion, epididymitis'''
**'''Although all of these diseases can occur at any time during childhood,'''
***'''Torsion of the appendix testis is typically most common after infancy and before puberty'''
***'''Epididymitis and spermatic cord torsion are most common in the perinatal and pubertal periods'''
**'''Torsion of an appendage and epididymitis are managed conservatively with limited consequence'''
**'''Prompt surgical exploration for spermatic cord torsion is imperative because the gonad is at considerable risk of ischemic damage or loss'''
==Spermatic Cord Torsion==

=== Acute Intravaginal Spermatic Cord Torsion ===
*Left-sided predominance
*'''Epidemiology'''
**May occur at any age, but the '''vast majority of cases occur after age 10 years with a peak at age 12-16 years'''
*'''Predisposing Factors'''
**'''Commonly attributed to excess mobility of the testis within a “bell-clapper deformity”, wherein the tunica vaginalis abnormally fixes proximally on the cord'''
**'''Familial predisposition'''
**'''Cryptorchid testes'''
*'''Diagnosis and Evaluation'''
**History and Physical Exam
***History
****The inciting event for torsion is unknown
****History of prior episodes may be elicited
****Nausea/vomiting occurs in 10-60% of boys
****Dysuria and fever are uncommon
***'''Physical exam'''
****'''The most common physical findings are:'''
*****'''Generalized testicular tenderness'''
*****'''Abnormal (horizontal) orientation of the testis'''
*****'''High-riding testis''' from a foreshortened cord
*****'''Absent cremasteric/genitofemoral reflex'''
******'''Elicited by scratching the inner thigh with resultant testis elevation'''
******'''Normally present age >2 years'''
******'''Some studies report reduced or absent reflex in all cases of testicular torsion, but intact in up to 10% of proven cases of torsion in other series'''
****Scrotal edema and erythema may be present, depending on the duration or degree of torsion.
**'''Imaging'''
***'''Before the advent of reliable and rapid scrotal imaging, immediate scrotal exploration was routine'''
***'''CDUS findings consistent with testicular torsion include:'''
***#'''Reduced or absent Doppler color or waveforms'''
***#'''Parenchymal heterogeneity compared with the contralateral testis'''
*'''Management'''
**'''Surgical emergency'''
**'''Risk of orchiectomy based on onset of pain'''
***'''0-6 hours: 5%'''
***'''7-12 hours: 20%'''
***13-18 hours: 40%
***'''19-24 hours: 60%'''
***24-48 hours: 80%
***'''>48 hours: 90%'''
**'''Irreversible ischemic injury to the testicular parenchyma may begin as soon as 4 hours after occlusion of the cord.'''
**'''Manual detorsion can be attempted. However, manual detorsion may not totally correct the rotation that has occurred and that prompt exploration is still indicated'''
**Step by step:
***Sutures
****3-0 Vicryl x 4
****4-0 PDS x 6
****4-0 chromic x 1
****If orchiectomy, 2-0 silk ties to ligate vas deferens and vessels
****Antibiotics
*****Cefazolin
***Position: supine
***Incision: midline raphe, length of largest testicle that needs to be delivered
***Surgical plan:[https://pubmed.ncbi.nlm.nih.gov/23217129/]
***#Outline an incision in the midline raphe. Incision should be large enough to deliver twisted testicle.
***#Dissect towards twisted testicle. Use scalpel to make skin incision. Continue to divide layers of scrotum towards testicle.
***#Deliver twisted testicle. Open the tunica vaginalis and deliver the testicle
***#Untwist the testicle. Ensure proper orientation with lateral sulcus being lateral. Feel spermatic cord to ensure no more twists
***##Median degree of rotation was 540° in orchiectomy testes and 360° when the testis was salvaged
***#Attempt salvage of twisted testicle. Wrap twisted testicle in warm saline
***#Deliver contralateral testicle. Repeat steps 2-3 on contralateral (healthy) testicle. Bring contralateral healthy testicle to midline incision.
***#Orchiopexy to reduce the risk of metachronous torsion.
***##Trim excess tunica vaginalis. Obtain hemostasis along the edge with careful fulguration.
***##Reapproximate tunica vaginalis. Evert tunica vaginalis and reapproximate edges behind testicle, in Jaboulay fashion, with running 3-0 Vicryl
***##Place three 4-0 PDS interrupted sutures through the everted tunica. Then place these sutures into the dartos of the posterior scrotal wall. Replace the testicle into the hemiscrotum and tie sutures.
***#Evaluate twisted testicle for salvageability. If not salvageable, divide vas and vessels separately with 2-0 silk ties. If salvageable, perform orchiopexy similar to above. In cases of orchiectomy, prosthesis placement is usually offered after complete healing or later in puberty
***#Reapproximate dartos. Use 3-0 Vicryl to reapproximate dartos.
***#Reapproximate skin. Use 4-0 chromic suture with horizonal mattress to reapproximate skin
***#Inject local anesthetic. Local anesthetic solutions containing epinephrine should never be used to anesthetize the penis, scrotum, or spermatic cord.[https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683&sectionid=45343633]
***#Apply dressing
*'''Prognosis'''
**'''Subtle abnormalities of semen quality are common'''
***Semen density is often within the normal range
**'''Global testicular dysfunction may exist after torsion'''
***'''May be due to ischemia-reperfusion injury after release of testicular torsion'''
****'''Hypothesis of an autoimmune phenomenon has been dispelled'''
***'''Serum FSH, LH, and testosterone were within the reference range.'''

=== Intermittent Intravaginal Spermatic Cord Torsion ===
*'''Scrotal swelling''' or nausea and/or vomiting '''may or may not be present'''
*'''A normal vertical testicular orientation is most common'''
*'''Whirlpool sign or an abnormal boggy cord and pseudomass formation below the twisted spermatic cord may also signify intermittent torsion'''
*Diagnosis requires a high index of suspicion unless the testis is noted to untwist
*'''Once the condition is confirmed or highly suspected, elective bilateral orchidopexy is indicated to avert torsion and possible organ loss.'''
*Patients and parents should know that absolute confirmation of the diagnosis may not be possible and that symptoms may persist postoperatively.

=== Extravaginal Spermatic Cord Torsion (Perinatal Testicular Torsion) ===
*'''Perinatal spermatic cord torsion is a term applied to infants regardless of whether the event occurred prenatally''' (hours, days, weeks, months), '''during delivery, or postpartum'''.
*'''Torsion of the entire cord occurs before fixation of the tunica vaginalis and dartos within the scrotum (extravaginal).'''
*'''Most commonly occurs well before delivery, yielding a “vanishing” testis or a hemosiderin-containing nubbin in the scrotum or less commonly in the inguinal canal.'''
*'''The testis that sustains loss of blood supply close to delivery is a hard, painless testis fixed to the overlying erythematous or dark scrotal skin with or without edema'''
*'''[Urgent exploration is not needed.] However, if torsion is suspected after a normal postnatal scrotal examination, then prompt exploration should be performed as for intravaginal torsion.''' If torsion is confirmed, contralateral scrotal exploration with testicular fixation should be performed.
==Torsion of the Appendix Testis and Epididymis==
*Appendix testis
**From the müllerian duct
**Present in 76-83% of testes
*Appendix epididymis
**From the wolffian duct
**Present in 22-28% of testes
*'''The peak age at occurrence is 7 to 12 years'''
*'''Diagnosis and Evaluation'''
**'''History and Physical Exam'''
***'''Physical Exam'''
****'''A “blue dot sign”, a discoloration at the upper pole of the testis representing the ischemic appendage, may be seen through stretched scrotal skin'''
**'''Imaging'''
***'''US'''
****'''The normal appendix testis contains no internal blood flow, whereas the twisted appendage may appear as an ovoid hyperechoic, hypoechoic, or heterogeneous nodule without blood flow'''
****'''CDUS rarely demonstrates an abnormal appendage but commonly shows hyperperfusion of the epididymis.'''
*'''Management'''
**'''Torsion of an appendage is a self-limited process; surgery is rarely indicated'''
==Epididymitis==
*'''Symptoms have a more insidious onset than torsion of the cord or an appendage''' but may be present rapidly
*'''The cremasteric reflex should be intact'''
*'''The majority of infants with epididymitis have sterile urine and apparently radiographically normal urinary tracts.'''
*'''The management goal is to relieve inflammation and any associated infection'''
*'''In a prepubertal child with a positive urine culture, renal US and VCUG are indicated''' (different than elsewhere that only describe a renal US for child with first UTI)
==References==
*Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 21