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Acute Scrotum: Difference between revisions

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See [https://www.auanet.org/meetings-and-education/for-medical-students/medical-students-curriculum/acute-scrotum AUA Medical Student Curriculum: Acute Scrotum]
== Definition ==
== Definition ==
*Acute scrotum refers any new onset of the following (or combination) of symptoms (3):
*Acute scrotum refers any new onset of the following (or combination) of symptoms (3):
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==Differential diagnosis==
==Differential diagnosis==
*'''<span style="color:#ff0000">Differential diagnoses include (14):</span>[https://www.ncbi.nlm.nih.gov/books/NBK470335/]'''
*'''<span style="color:#ff0000">Differential diagnoses include (14):</span>[https://www.ncbi.nlm.nih.gov/books/NBK470335/]'''
*# '''Testicular appendage torsion'''
*# '''<span style="color:#ff0000">Testicular appendage torsion'''
*# '''Acute epididymitis/epididymo-orchitis'''
*# '''<span style="color:#ff0000">Acute epididymitis/epididymo-orchitis'''
*# '''Spermatic cord torsion'''
*# '''<span style="color:#ff0000">Spermatic cord torsion'''
*# '''Strangulated/incarcerated inguinal hernia'''
*# '''<span style="color:#ff0000">Strangulated/incarcerated inguinal hernia'''
*# '''Scrotal cellulitis'''
*# '''<span style="color:#ff0000">Scrotal cellulitis'''
*# '''Fournier gangrene'''
*# '''<span style="color:#ff0000">Fournier gangrene'''
*# '''Idiopathic scrotal edema'''
*# '''<span style="color:#ff0000">Idiopathic scrotal edema'''
*# '''Intratesticular hematoma'''
*# '''<span style="color:#ff0000">Intratesticular hematoma'''
*# '''Testicular rupture'''
*# '''<span style="color:#ff0000">Testicular rupture'''
*# '''Scrotal or testicular abscess'''
*# '''<span style="color:#ff0000">Scrotal or testicular abscess'''
*# '''Varicocele'''
*# '''<span style="color:#ff0000">Varicocele'''
*# '''Testicular infarction'''
*# '''<span style="color:#ff0000">Testicular infarction'''
*# '''Testicular neoplasm'''
*# '''<span style="color:#ff0000">Testicular neoplasm'''
*# '''Henoch-Schonlein purpura'''
*# '''<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'''
*'''<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,'''
**'''Although all of these diseases can occur at any time during childhood,'''
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==== Risk Factors (3) ====
==== Risk Factors (3) ====
#'''<span style="color:#ff0000">Commonly attributed to excess mobility of the testis within a “bell-clapper deformity”, wherein the tunica vaginalis abnormally fixes proximally on the cord'''
#'''<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">Familial predisposition'''
#'''<span style="color:#ff0000">Cryptorchid testes'''
#'''<span style="color:#ff0000">Cryptorchid testes'''
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* '''CBC'''
* '''CBC'''
** Rule out infectious cause of acute scrotum
** 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 =====
===== Imaging =====
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==== Option ====
==== Option ====
*'''<span style="color:#ff0000">Orchiopexy'''
*'''<span style="color:#ff0000">Orchiopexy'''
*'''Manual detorsion can be attempted. However, manual detorsion may not totally correct the rotation that has occurred and that prompt exploration is still indicated'''
*'''Manual detorsion can be attempted. However, manual detorsion may not totally correct the rotation that has occurred and prompt exploration is still indicated'''


===== Orchiopexy =====
===== Orchiopexy =====
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**#'''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]
**#'''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'''
**#'''Apply dressing'''
*Post-operative follow-up
*'''Post-operative follow-up'''
**Limit contact sports for 2 weeks or until pain free
**Limit contact sports for 2 weeks or until pain free
**Perform wound check in 3-4 weeks
**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 ====
==== Prognosis ====
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==Torsion of the Appendix Testis and Epididymis==
==Torsion of the Appendix Testis and Epididymis==
=== Background ===
*Appendix testis
*Appendix testis
**From the müllerian duct
**From the müllerian duct
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**From the wolffian duct
**From the wolffian duct
**Present in 22-28% of testes
**Present in 22-28% of testes
*'''The peak age at occurrence is 7 to 12 years'''
 
=== 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'''
*'''Diagnosis and Evaluation'''
**'''History and Physical Exam'''
**'''Symptoms have a more insidious onset than torsion of the cord or an appendage''' but may be present rapidly
***'''Physical Exam'''
**'''The cremasteric reflex should be intact'''
****'''A “blue dot sign”, a discoloration at the upper pole of the testis representing the ischemic appendage, may be seen through stretched scrotal skin'''
**'''The majority of infants with epididymitis have sterile urine and apparently radiographically normal urinary tracts.'''
**'''Imaging'''
*Management
***'''US'''
**Goal is to relieve inflammation and any associated infection
****'''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==
==References==
*Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 21
*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).
*Velasquez, James, Michael P. Boniface, and Michael Mohseni. "[https://www.ncbi.nlm.nih.gov/books/NBK470335/ Acute scrotum pain.]" (2017).
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