Editing Acute Scrotum

See [https://www.auanet.org/meetings-and-education/for-medical-students/medical-students-curriculum/acute-scrotum AUA Medical Student Curriculum: 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==
*'''<span style="color:#ff0000">Differential diagnoses include (14):</span>[https://www.ncbi.nlm.nih.gov/books/NBK470335/]'''
*# '''<span style="color:#ff0000">Testicular appendage torsion'''
*# '''<span style="color:#ff0000">Acute epididymitis/epididymo-orchitis'''
*# '''<span style="color:#ff0000">Spermatic cord torsion'''
*# '''<span style="color:#ff0000">Strangulated/incarcerated inguinal hernia'''
*# '''<span style="color:#ff0000">Scrotal cellulitis'''
*# '''<span style="color:#ff0000">Fournier gangrene'''
*# '''<span style="color:#ff0000">Idiopathic scrotal edema'''
*# '''<span style="color:#ff0000">Intratesticular hematoma'''
*# '''<span style="color:#ff0000">Testicular rupture'''
*# '''<span style="color:#ff0000">Scrotal or testicular abscess'''
*# '''<span style="color:#ff0000">Varicocele'''
*# '''<span style="color:#ff0000">Testicular infarction'''
*# '''<span style="color:#ff0000">Testicular neoplasm'''
*# '''<span style="color:#ff0000">Henoch-Schonlein purpura'''
*'''<span style="color:#ff0000">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,'''
***'''<span style="color:#ff0000">Torsion of the appendix testis is typically most common after infancy and before puberty'''
***'''<span style="color:#ff0000">Epididymitis and spermatic cord torsion are most common in the perinatal and pubertal periods'''
**'''<span style="color:#ff0000">Torsion of an appendage and epididymitis are managed conservatively with limited consequence'''
**'''<span style="color:#ff0000">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 ===
==== Epidemiology ====
*'''<span style="color:#ff0000">May occur at any age'''
**'''<span style="color:#ff0000">Vast majority of cases occur after age 10 years with a peak at age 12-16 years'''
*Left-sided predominance

==== Risk Factors (3) ====
#'''<span style="color:#ff0000">“Bell-clapper deformity” wherein the tunica vaginalis abnormally fixes proximally on the cord, resulting in excess mobility of the testis'''
#'''<span style="color:#ff0000">Familial predisposition'''
#'''<span style="color:#ff0000">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
*'''<span style="color:#ff0000">Physical exam</span>'''
**'''<span style="color:#ff0000">Most common physical findings (4):</span>'''
**#'''<span style="color:#ff0000">Generalized testicular tenderness</span>'''
**#'''<span style="color:#ff0000">Abnormal (horizontal) orientation of the testis</span>'''
**#'''<span style="color:#ff0000">High-riding testis</span>''' from a foreshortened cord
**#'''<span style="color:#ff0000">Absent cremasteric/genitofemoral reflex</span>'''
**#*'''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.

===== Labs =====

* '''Urinalysis +/- culture'''
** Rule out infectious cause of acute scrotum
* '''CBC'''
** Rule out infectious cause of acute scrotum
[[File:43414588252 df2480a453 o.jpg|alt=Ultrasound with doppler demonstrating no flow to right testicle.|thumb|500x500px|Ultrasound with doppler demonstrating no flow to right testicle. [https://www.flickr.com/photos/iem-student/43414588252 Source]]]

===== Imaging =====
*'''Before the advent of reliable and rapid scrotal imaging, immediate scrotal exploration was routine'''
*'''<span style="color:#ff0000">Doppler Ultrasound'''
**'''<span style="color:#ff0000">Findings consistent with testicular torsion (2):'''
**#'''<span style="color:#ff0000">Reduced or absent Doppler color or waveforms'''
**#'''<span style="color:#ff0000">Parenchymal heterogeneity compared with the contralateral testis'''

==== Management ====
*'''<span style="color:#ff0000">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.'''

==== Option ====
*'''<span style="color:#ff0000">Orchiopexy'''
*'''Manual detorsion can be attempted. However, manual detorsion may not totally correct the rotation that has occurred and prompt exploration is still indicated'''

===== Orchiopexy =====
*'''Technique'''
**'''Equipment'''
***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.
**##Note that this method does not penetrate the blood-testis barrier with the suture needle and may reduce the risk of forming anti-sperm antibodies[https://pubmed.ncbi.nlm.nih.gov/23217129/]
**#'''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'''
*'''Post-operative follow-up'''
**Limit contact sports for 2 weeks or until pain free
**Perform wound check in 3-4 weeks
**'''Advise of risk to solitary testicle, consider'''
***'''Cup protector in high-risk activities (catcher in baseball team)'''
***'''Sperm banking in case other testicle is affected'''

==== 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 ===

==== Diagnosis and Evaluation ====

*Diagnosis requires a high index of suspicion unless the testis is noted to untwist
*'''Physical exam'''
**'''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'''

==== Management ====

*'''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==

=== Background ===

*Appendix testis
**From the müllerian duct
**Present in 76-83% of testes
*Appendix epididymis
**From the wolffian duct
**Present in 22-28% of testes

=== Epidemiology ===

*'''Peak age at occurrence is 7-12 years'''

=== Diagnosis and Evaluation ===
*'''<span style="color:#ff0000">History and Physical Exam'''
**'''<span style="color:#ff0000">Physical Exam'''
***'''<span style="color:#ff0000">“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'''
***'''Rarely demonstrates an abnormal appendage'''
****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
***'''Commonly shows hyperperfusion of the epididymis.'''

=== Management ===
*'''<span style="color:#ff0000">Observation'''
**Torsion of an appendage is a self-limited process; surgery is rarely indicated

==Epididymitis==
*'''Diagnosis and Evaluation'''
**'''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.'''
*Management
**Goal is to relieve inflammation and any associated infection
==References==
*Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 21
*Velasquez, James, Michael P. Boniface, and Michael Mohseni. "[https://www.ncbi.nlm.nih.gov/books/NBK470335/ Acute scrotum pain.]" (2017).