THE ACUTE SCROTUM

(MEDICAL STUDENTS LECTURE)

By; NK Dakum MBBS, MSc, FMCS, FWACS, FICS, DIP UROL(UK)

Consultant urologist/ Professor, JUTH/Unijos,

Visiting Professor, Bingham University, Karu.

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The Acute Scrotum-Definition

‘acute pain and/or swelling of the scrotum or its content’

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THE ACUTE SCROTUM-causes

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Aetiology of acute scrotum-JUTH-Dakum et al-2002

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TESTICULAR TORSION

• Definition-Twisting of the spermatic cord
• Aetiology
• Unknown
• Does not occur in normal fully descended testes
• There are predisposing anatomical anomalies and precipitating factors

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T Torsion- predisposing anatomical anomalies

• 1.Inversion of testis-horizontal lie or polar inversion
• 2.High investment of tunica vag (bell- clapper deformity)-B
• 3.Long mesochium-C
• 4. Maldescent
• These cause undue mobility of testes due to abnormal disposition
• (A=normal anatomy)

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T torsion: exciting factors

• Unknown
• Direction- Rt clockwise, lt anticlockwise
• 1 ½ to 5 ½ turns→venous obs, oedema, haemorrhage, arterial occlusion, gangrene, atrophy in 6 hrs.
• interstitial cells may survive infarction
• Usually intravaginal twist except in neonates and undescended testis
• Cremasteric contraction
• Straining at stool, heavy wt, coitus
• Trauma
• Idiopathic

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T Torsion: Cl Fxs- symptoms

• Neonatal to 25 yrs, but mainly between neonatal and 1yr, and 12-16yrs
• There may be history of antecedent trauma
• Vary with degree
• Pain- scrotal, groin. Ref lower abd and iliac fossae
• Vomiting, nausea
• Fever
• Urinary- dysuria, frequency- unusual

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T Torsion: Cl Fxs- signs

• Testis: swollen, firm tender, retracted(high riding). Elevation aggravates pain
• Cord- thickened
• Scrotum: later inflammed, oedematous
• +/- ↑T^o -37.2⁰C

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T Torsion: differentials

• Acute EO
• Strangulated ing hernia
• Trauma
• etc

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T Torsion:treatment

• 1^st hr- attempt untwisting
• Exploration
• Orchiopexy(Bilateral)
• Orchidectomy- gangrenous or infarcted
• Seen days/wks later and pain↓ ↓-observe

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T Torsion: prognosis

• Salvage rate: if operation done within
• 6hr=90-100%
• 12-24hrs=20-50%
• >24hrs=0-10%
• 70% apparently viable later atrophy and only 5% have normal sperm count
• Endocrine fxn unaffected

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Torsion of testicular appendages

• Similar fxs with testicular torsion
• May palpate appendix separately
• Testis may be normal
• Treatment by ligation and amputation or conservative if diagnosis certain

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Acute Epididymo-orchitis (EO)

• Primarily epididymitis
• Mode of infection-UTI, haematogenous, prostatectomy, reflux during straining, urethral instrumentation
• Young –gonococcal, chlamydia,e coli,staph, strep, prot
• Elderly- outflow obstruction

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Acute EO- Cl Fxs

• Pain-scrotal, groin,
• Scrotal swelling
• Fever, malaise
• Previous urethritis
• Scrotum-hot, inflammed,tender
• Epid-swollen, tender
• Testis-enlarged, tender. Elevation ↓pain
• 2^o hydrocoele

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Acute EO: Ix

• WBC ↑
• Urine m/c - pus cells, positive culture
• Urethral smear m/c/s

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Acute EO: Treatment

• Bed rest
• Scrotal support
• Antibiotics: levofloxacin,ciprofloxacin. For gc give ceftriaxone plus doxycycline (or azithromycin)
• Analgesics
• Alkalinise urine
• Liberal fluids
• I & D if suppurates
• Hydrocoele absorbs. ?tap residual

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Fourniers gangrene

• Acute, rapidly progressive and potentially life threatening necrotising fascitis involving the external genitalia and perineum
• aetiology
• Mixed aerobic, anaerobic infection
• Strep, staph E-coli, cl welchii, fusobacterium
• Subcut inflam→arteritis →gangrene →sloughing

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Fourniers

• Precipitating factor
• Minor injuries or procedures in perineum eg bruise, scratch, dilatation, inj anal fissure, I&D of periurethral abscess
• Majority have underlying pathology
• DM, HIV/AIDS,
• periurethral abscess,perianal sepsis
• Urethral stricture, local trauma, extravasation
• Alcoholism
• Children-may follow measles or chicken pox

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Fourniers

• 3 cardinal xtics (now doubted)
• Sudden onset
• Apparent good health
• No cause in > half pts (disproved now)

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Fourniers: Cl Fxs

• Painful tense scrotal swelling or cellulitis
• Fever, prostration, pallor
• Gangrene-progressive ,sharp border,foetid odour
• Skin may slough off leaving hanging testes
• No urinary difficulty except in those from extravasation

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Fourniers: treatment-1

• Resuscitation with IV fluids ( blood if needed)
• Antibiotics- for G-ve(gent or ceph), g+ve and anaerobic (metronidazole). Eg Ciproflox plus clindamycin or ceftriaxone.
• Analgesics,
• Debridement, hyperbaric oxygen

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Fourniers: treatment-2

• wound care-dressings, sitz bath. Dressing agents include N/Saline, Honey, povidone iodine, Sodium hypochlorite (Dakins Solution)
• Secondary suturing
• Reconstructive surgery-grafts, flaps, bury testes
• SPC if extravasation present

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Trauma: Scrotal injury

• Aetiology
• RTA,
• Gunshots,
• fights, etc
• Bites: Insect, human, animal
• Treatment:
• Debridement,
• antibiotics,
• anti-tetanus,
• analgesics,
• wound dressings

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Recent haematocoele

• From trauma( blow, needles), tumour
• Fxs: pain, tenderness, poor or absent transillumination
• Treatment: urgent operation
• Evacuate blood
• Hydrocoelectomy
• +/- orchiectomy if testis ruptured or tumour present

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Testicular tumour

• tumour→bleeding →haematocoele
• Treatment: orchiectomy, radioR, chemoR

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Recurrent funiculitis & EO

• Tropical
• Recurrent
• Filarial
• Treat with diethylcarbamazine 2mg/kg tds po x 2/7 or ivermectin 6mg stat

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Hydrocoele

• Hydrocele is an abnormal collection of serous fluid between visceral and parietal layers of tunica vaginalis

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Summary of staging of hydrocoele

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Clinical Presentations of hydrocoele

• Mostly asymptomatic
• Develops gradually
• Swelling of one or both hemiscrotum,
• Usually painless with associated vague sensation of heaviness
• Testis may not be palpable
• Fluctuant, smooth in consistency
• Transillumination test (may be positive)
• Mostly can get above the swelling
• Not reducible
• May coexist with inguinal hernia

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Complications of hydrocoele

• Infection
• Pyocele
• Hematoma
• Testicular atropy
• Herniation of hydrocele sac
• Rupture
• Impaired spermatogenesis

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Investigations of hydrocoele

• Basic laboratory investigations
• Haemoglobin, Packed Cell Volume
• urinalysis
• Random Blood Sugar
• HIV , Hepatitis screening in some centres
• Scrotal ultrasound (where available)
• U/E/Cr, clotting profile, etc if necessary

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Treatment of hydrocoele

• Hydrocoelectomy

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Strangulated hernia

• treat

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Idiopathic scrotal oedema

• 4-12yrs
• Scrotum very swollen and may extend to perineum, groin,penis
• BUT little pain or tenderness
• ?allergic. Occasionally eosinophilia
• Swelling subsides after about a day but may recur

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summary

• ‘acute painful swelling of the scrotum or its content’ ‘acute unilateral pains in the scrotal region and its contents’
• Torsion,EO, tumour,hernia important differentials
• Prompt exploration required in most cases
• Refer promptly if can’t handle

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Thank you!!!

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Food for thought

‘Character is both developed and revealed by tests, �and all of life is a test.’� -Rick Warren

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