Acute Scrotum: Diagnosis and Signs

Acute Scrotum

• Acute scrotum involves acute pain in the scrotum and is a pediatric surgical emergency
• It can lead to testicular loss

Presentation

• Presentation of acute scrotum is diagnosed by pain which is the major feature
• Do not wait for swelling and redness to become present
• Lower abdominal pain can be associated with it
• Atypical presentations such as right flank pain can occur
• Patients may present a painful scrotum, with or without swelling and redness
• Sudden onset of scrotal pain present.
• This can progress to swelling and redness indicating the testis is necrotic
• Patients may also experience abdominal pain, nausea, and vomiting

Signs

• Tenderness of the testis is a sign
• A high-lying testis is a sign
• The testis may lie in a horizontal plane
• Absent cremasteric reflex is a very specific sign of acute scrotum

Testicular Torsion

• If history and examination suggest testicular torsion, emergent scrotal exploration is the next step
• Delaying exploration for Doppler US or nuclear scan wastes valuable time
• Take patient to the OR for emergent scrotal exploration and untwist the testis
• Untwist a left testis by turning clockwise and fix the contralateral testis
• Untwist a right testis by turning counterclockwise

Causes

• Torsion of appendages(pre-pubertal) is the most common cause
• Testicular torsion is the most serious cause, but it is rare
• Idiopathic scrotal edema can present
• Epididymo-orchitis is most common in post-pubertal boys
• Other conditions include incarcerated hernia, acute hydrocele, HSP, and trauma

Torsion of Appendages

• Embryological remnants of the mesonephric & mullerian duct system occur as tiny appendages of testis ranging from 2-10 mm long
• Examples include Appendix testes (hydatid of Morgagni), and appendix epididymitis:
• The peak age is 10-12 years
• Pain is localized to the upper part of the testis
• The pain has a more gradual onset, and the rest of the testis is not tender
• There is milder pain with testicular torsion
• A blue dot sign, the most specific sign, usually appears at the top of the testis

Testicular Torsion

• Occurs at an incidence 1:4000
• Has two peaks of perinatal peripubertal(14 years old)
• There is lower abdominal pain and vomiting
• Pain is Hemi-scrotal, severe, sudden onset and referred to lower abdomen
• Swollen and red hemi-scrotum appear
• It is a late sign and indicates ischemia

Idiopathic Scrotal Edema

• Peak age range of 4-5 years old.
• The scrotum has swelling and redness, there minimal pain
• It is usually bilateral; Samoan color is very pathognomonic
• The testis is tender upon palpation
• Cremasteric reflex is mostly absent(98%)
• The testis lies higher than the contralateral testis
• It may by horizontal in position

Diagnosis and Action

• Don't use Color Doppler US or Radionuclide scans
• Unless the diagnosis is clinically obvious
• When there is a high clinical suspicion of torsion do not investigate but intervene immediately.
• Emergent timing is critical, between 4-6 hours to avoid the risk of ischemia
• In case of doubt, explore
• Untwist(open book)& assess viability
• Fix the other side, it's likely to have the same condition if left without fixation
• In over 12 hours, it is likely to be non-viable(gangrenous)& need orchiectomy

Management

• Management of acute scrotum can be conservative with self-limiting presentation within 1-2 days Timing and Testicular Salvage:
• Less than 6 hours gives an 85-97% testicular salvage
• 6-12 hours gives 55-85%
• 12-24 hours 20-80%
• More than 24 gives less than 10%

Additional Notes

• Cord torsion can occur where the visceral layer of the tunica vaginalis completely covers the testis
• The testis thereby lies suspended within the parietal layer
• Commonly found in teenagers there is sudden onset of testicular pain and swelling and possibly minor trauma/previous partial torsion episodes
• A red, swollen hemi-scrotum is usually too tender to palpate
• Misdiagnosing the swelling as Epididymo-orchitis in teenagers can be detrimental
• Testis torsion is a surgical emergency, if the blood supply is not restored within 12 hours the testis will infarct and must be excised
• If at operation the testis is viable, suture it to the parietal tunica to prevent recurrence
• As the tunica abnormality is bilateral, the other testis must be fixed too