ACUTE SCROTUM

The 5 Minute Urology Consult 3rd Ed.

Patrick T. Gomella, MD, MPH

Leonard G. Gomella, MD, FACS

BASICS

DESCRIPTION

• Acute pain and swelling in the scrotum is typically related to testicular pathology and is usually referred to as “acute scrotum” in the absence of obvious trauma.

• Occasionally pain from ureteral colic can be referred to the testicle but swelling is usually absent.

• Chronic testicular pain is referred to orchalgia.

• Testicular torsion is a major cause of the acute scrotum particularly in children and requires timely diagnosis and treatment to avoid testicular loss.

• In adults acute epididymo-orchitis is the most common cause of an acute scrotum.

• In children torsion of a testicular appendix or testicle are most common causes.

EPIDEMIOLOGY

Incidence

• Testicular torsion occurs most commonly in neonates and postpubertal boys and is more common on the left

– However in 1 series 39% of patients were reported to be in men >21 yr of age (1)

• Torsion of an appendix more common in prepubertal boys

• Approximately 600,000 cases of epididymitis/yr in US

Prevalence

Testicular torsion: 1:4,000 males <25 yr old

RISK FACTORS

• Testicular torsion

– Cryptorchidism

– Bell clapper deformity

• Epididymitis

– Unprotected sex in younger men

– Prostate disorders in older men

– Urinary tract instrumentation

– Anal insertive intercourse

Genetics

Testicular torsion reported in 10% of family members; may be autosomal or X-linked recessive; no specific genetic defects identified

PATHOPHYSIOLOGY

• Testicular torsion can be either intravaginal or extravaginal

– Intravaginal testicular torsion is twisting of the spermatic cord within the tunica vaginalis

Usually due to a so-called “bell clapper deformity”: A failure of normal posterior anchoring of the gubernaculum, epididymis and testis. Leaves the testis free to rotate within the tunica vaginalis of the scrotum much like the clapper inside of a bell (present in 12% of males)

– Extravaginal testicular torsion is twisting of both the spermatic cord and tunica vaginalis

• Perinatal: Extravaginal testicular torsion is usually the cause

• Appendix torsion is a result of vascular compromise may be related to pedunculated anatomy of the appendage

– Appendix testis 95% of appendix torsions

– Appendix epididymis torsion is less common

• Epididymitis

– Can present as acute or chronic epididymitis

Acute: Severe swelling, tenderness, rigors, high fevers

– Infectious causes

In men >35 yr of age, Chlamydia trachomatis and Neisseria gonorrhoeae (sexually transmitted infections) are the most common pathogens

In men >35 yr of age coliforms most common

Less common pathogens: Ureaplasma, TB, Brucella species; with HIV infection, Cytomegalovirus and Cryptococcus

– Less frequent causes include autoimmune diseases, vasculitis, trauma

– In a prepubertal boy epididymitis is almost always associated with a urinary tract anomaly

ASSOCIATED CONDITIONS

• Torsion

– Bell clapper deformity: 10–15% of males

– Cryptorchidism

• Epididymitis

– Other sexually transmitted infections

– Prostatic hypertrophy

GENERAL PREVENTION

• Torsion: Reduce testicular loss risk by

– Early diagnosis and treatment

– Community awareness about testis pain

– Elective bilateral orchidopexy for intermittent pain or contralateral orchidopexy at surgery for an episode of acute torsion

• Epididymitis

– Safe sex practices

DIAGNOSIS

HISTORY

• Rule out any traumatic insult to the groin area

– Some patients report minor trauma before presentation of torsion

• Sexual practice history

• Recent urinary tract instrumentation

• Testicular torsion

– The classic presentation is sudden hemiscrotal pain often awakening the patient from sleep

– Pain can radiate to the groin

– Nausea and/or vomiting can be present

– Movement tends to worsen the pain

– A history of intermittent testicular discomfort may be present suggesting past torsion and detorsion

• Appendix torsion

– Symptoms are similar to testicular torsion but not as severe

• Epididymitis

– Can present with acute: Fever, chills, rigors, or as chronic testicular/scrotal discomfort

– More likely to be associated with voiding complaints than torsion

PHYSICAL EXAM

• General

– Vital signs; low-grade fever with torsion, fever with UTI

– Presence of inguinal hernia

– Abdominal and flank tenderness

• GU exam

– Assess cremasteric reflex (2):

Stroke or pinch the skin of the upper thigh

Normal reflex is contraction of the cremaster muscle with elevation of the testis.

Absent reflex may aid in distinguishing testicular torsion from epididymitis/other causes of an acute scrotum where reflex is present

Phren sign (pain relief with elevation of testicle) is no longer considered accurate for diagnosis of torsion

• Testicular torsion

– Testicle may be high riding

– Very tender and may assume a transverse lie due to twisting of the cord

– The spermatic cord will not usually be palpable

– May be scrotal wall erythema and swelling

– Cremasteric reflex often absent

• Torsion appendix

– Pain may be localized to upper pole of testicle

– Cremasteric reflex usually present

– Blue dot sign: Rare, more likely in prepubertal boys;

Tender nodule with blue discoloration on the upper pole of the testis and more easily seen in light-skinned individuals

– In late findings scrotal swelling and reactive hydrocele may be present

• Epididymitis

– Cremasteric reflex usually present

– Acute epididymitis may have significant swelling and tenderness; with chronic epididymitis there is tenderness but usually no scrotal swelling

DIAGNOSTIC TESTS & INTERPRETATION

Lab

• Urinalysis

– White cells and positive leukocyte esterase

Suspect epididymitis or UTI

– Red blood cells suggest renal or ureteral source of pain (eg, stone)

– In cases of torsion UA usually negative

• Urine culture if epididymitis or UTI suspected

• Consider urethral swab if urethral discharge present: Culture and nucleic acid amplification testing for chlamydia and gonorrhea

Imaging

• Scrotal US with Doppler

– Intravaginal testicular torsion findings

– Usually shows decreased or absent arterial flow but may be normal

• Appendix torsion findings

– Normal exam most common

– Supratesticular complex mass without vascular flow may be present

• Epididymitis

– Enlarged epididymis reported as “epididymitis” often present

– Doppler flow normal or increased

Diagnostic Procedures/Surgery

In cases of testicular torsion, surgical exploration is usually diagnostic and therapeutic

Pathologic Findings

N/A

DIFFERENTIAL DIAGNOSIS

• Abscess or other infection such as Fournier gangrene

• Appendix torsion (appendix testis or epididymis testis)

– Most commonly seen in prepubertal boys

– Most common cause of acute scrotum in this age group

• Epididymitis due to UTI or STD: Rare or uncommon in pediatric age group; more likely in adult

• Fat necrosis of scrotal wall

• Henoch–Schönlein purpura

– Rash usually present

• Incarcerated inguinal hernia

• Orchitis: With the exception of mumps orchitis, isolated orchitis without epididymitis in adults is rare

• Referred pain: Urolithiasis or intra-abdominal process such as appendicitis

• Testicular infarction due to spermatic cord injury or thrombosis

• Testicular torsion: Most common in peripubertal boys but can occur at any age; less common than appendix torsion

• Testicular tumor: Usually painless but may have tenderness with trauma

• Trauma and possible testicular rupture: History suggestive; hematocele usually present

• Orchalgia; consider voiding dysfunction

TREATMENT

ALERT

Testicular torsion is a surgical emergency because the likelihood of testicular salvage diminishes with the duration of torsion.

GENERAL MEASURES

• Clinical history, exam, and diagnostic studies (urinalysis, Color Doppler Ultrasound) have a high degree of accuracy in making the diagnosis

• Emergent exploration indicated if evaluation suggests intravaginal testicular torsion or diagnosis is equivocal

• If torsion is present and surgery cannot be performed in a reasonable amount of time, manual detorsion should be considered

• Most cases of epididymitis can be treated on an outpatient basis

MEDICATION

First Line

• Epididymitis: Acute

– Ice, scrotal elevation, and NSAIDs with antipyretic for high temperature

– Younger male: Ceftriaxone (250 mg IM) with doxycycline (100 mg PO BID × 10 days).

– Older males: Ceftriaxone (250 mg IM) along with a 10-day course of fluoroquinolone for enteric organisms (ofloxacin 300 mg PO BID or levofloxacin (500 mg PO BID)

• Epididymitis: Chronic

– Scrotal elevation, avoid sexual and athletic activity, warm baths, and NSAIDs

• Appendix torsion: Ibuprofen to reduce inflammation and discomfort

• Testis torsion: Pain control may require opioids

Second Line

N/A

SURGERY/OTHER PROCEDURES

• Urgent scrotal exploration, bilateral fixation for extravaginal testicular torsion to avoid asynchronous contralateral torsion

• Manual detorsion: Use only if surgery is delayed >2 hr

– Testicle most often rotates medially during torsion

– Manual detorsion is accomplished by attempting to rotate the testicle laterally toward the thigh

– The twisting can range from 180–720 degrees such that multiple detorsion twists may be required

– However in up to 1/3 of cases, the torsion rotation can be lateral

– Successful detorsion still requires operative intervention and orchidopexy

– Hallmarks of successful manual detorsion include pain relief, testicle assuming a lower position in the scrotum, reorientation of the testicle from transverse lie to vertical positioning, restoration of Doppler blood flow

ADDITIONAL TREATMENT

Radiation Therapy

N/A

Additional Therapies

N/A

Complementary & Alternative Therapies

N/A

ONGOING CARE

PROGNOSIS

• In cases of testicular torsion 12 hr is considered the point at which the testis suffers irreversible damage

• Torsion surgery outcomes appear better in children than in adults

– Salvage rates in males <21 yr was 70% vs. those >21 yr who had a salvage rate of 41% (3)

Potential explanations: Time to presentation impacted salvage and patients over 21 yr of age had a greater degree of cord twisting than the younger patients

COMPLICATIONS

• Testicular torsion

– Testicular loss and or atrophy

– Infertility

• Appendix testis/epididymis torsion

– Usually none long term

• Epididymitis

– Scrotal abscess

– Urosepsis

– Chronic orchalgia

FOLLOW-UP

Patient Monitoring

Epididymitis due to culture-proven C. trachomatis or N. gonorrhoeae: refer sex partners for evaluation and treatment disease

Patient Resources

MedlinePlus: Testicular torsion http://www.nlm.nih.gov/medlineplus/ency/article/000517.htm

REFERENCES

1. Cummings JM, Boullier JA, Sekhon D, et al. Adult testicular torsion. J Urol. 2002;167(5):2109–2110.

2. Rabinowitz R. The importance of the cremasteric reflex in acute scrotal swelling in children. J Urol. 1984;132(1):89–90.

ADDITIONAL READING

Yu KJ, Wang TM, Chen HW, et al. The dilemma in the diagnosis of acute scrotum: Clinical clues for differentiating between testicular torsion and epididymo-orchitis. Chang Gung Med J. 2012;35(1):38–45.

See Also (Topic, Algorithm, Media)

• Acute Scrotum Algorithm