Transcript Acute SCROTUM - luca cindolo

Acute SCROTUM
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Testicular torsion
Appendage torsion
Epidydimitis
Orchitis
Trauma
Tumor ?
Hernia ?
Testicular Anatomy
• The normal testis is oriented in the vertical
axis and the epididymis is above the superior
pole in the posterolateral position.
• Cremasteric reflex: Stroking/pinching the
inner thigh should result in elevation of > 0.5
cm of the ipsilateral testicle
Testicular Torsion
• Incidence 1:4000
• Only 50% salvageability w/ testicular loss from
either atrophy or ochiectomy
• Two peak periods: first year of life and at
puberty
• 10 times more likely in an undescended testis
Testicular Torsion
Most torsions due to bilateral anatomic
abnormality. Tunica vaginalis has a high
insertion about the spermatic cord.
Resultant bell-clapper deformity—testis dangles
in the scrotum and is mobile
Testicular Torsion: Pathophysiology
• Initially venous return is obstructed and then
venous thrombosis is followed by arterial
thrombosis
• Degree of obstruction is a function of the
degree of rotation
• Necrosis develops in testicle with complete
obstruction and infarction develops after
arterial thrombosis
Testicular Torsion
• Rapid swelling and edema of the testis and
scrotum, followed by scrotal erythema
• Damage proportional to duration/extent of
vascular obstruction
• Salvage rate of testis is 80-100% if pain lasts
less than 6 hours
• Pain > 24 hours is associated w/ testicular
infarction
Testicular Torsion
• 40% report a hx of similar pain that resolved
spontaneously in the past
• Often occurs after exertion or during sleep
• Typically no urinary symptoms
• Sudden onset of scrotal pain, but can be
inguinal or lower abdominal. May be constant
or intermittent. Not positional
• Nausea and Vomiting
Testicular Torsion
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Hemiscrotum is swollen, tender, firm
High-riding testis with a transverse lie is classic sign
Loss of cremasteric reflex – almost universal
May see the bell-clapper deformity, with horizontal
lie of the contralateral testicle
• Prehn’s sign: Relief of scrotal pain by elevating
testicle. NOT a reliable way to distinguish
epididymitis from torsion
Testicular Torsion: Diagnosis
• Doppler Ultrasononography now test of
choice for Dx of torsion. Sensitivity
comparable to radioisotope scans (86%100%) and greater specificity (100%).
Doppler U/S is more rapid and more
available than radioisotope scans.
Testicular Torsion: Management
• Immediate Urologic consultation for surgical
exploration and possible bilateral orchidopexy if
diagnosis is obvious
• Manual detorsion - Only a temporizing measure.
Endpoint for successful detorsion is pain relief.
• Most torsions occur lateral to medial, therefore
detorsion should be attempted in a medial to lateral
direction - “open the book” maneuver
• Imaging if diagnosis unclear, should NOT delay
exploration if high suspicion exists
Torsion of Appendage
• Torsion of appendages is more common than
testicular torsion
• Testicular and Epididymal appendages are vestigial
remnants of the wolffian and mullerian ducts
respectively
• Most frequent in preadolescent males 3-13,
appendix testis > epididymal appendix
• Cause unclear
• Twisting causes obstruction, edema and then painful
necrosis
Torsion of Appendage
• Discrete, painful testicular mass
• Symptoms less severe than torsion. No nausea,
vomiting, or fevers
• Transillumination of scrotum may reveal the
cyanotic appendage as a pathognomonic blue
dot
• U/S or Nuclear scintigraphy should reveal
normal to increased blood flow
Torsion of Appendage: Management
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Scrotal Support
Pelvic rest
Analgesia
Expect resolution of symptoms in 7-10 days
with degeneration of appendages
Epididymitis
• Average age 25 years
• Most common misdiagnosis for testicular torsion
• Rarely affects a prepubertal child without an
underlying urinary tract infection
• Result of retrograde ascent of urethral and bladder
pathogens
• Peritubular fibrosis may develop and occlude the
ductules, if bilateral may lead to sterility
Epididymitis
In men > 40, E. coli is the predominant
pathogen. Other coliform organisms,
Pseudomonas, and gram positive cocci.
Associated w/ underlying urologic pathology -Recent GU tract manipulation or bacterial
prostatitis.
In men <40, Chlamydia and N. gonorrhoeae
are the major pathogens
Epididymitis
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Gradual Scrotal pain, peaks over days
Low grade fever, average 38 degrees C
Cremasteric reflex usually preserved
Due to inflammatory nature of pain, may have some
transient pain relief from scrotal elevation
• Localized epididymal swelling initially, then may
progress to single, large testicular mass
• Urethral discharge and voiding symptoms may be
present
Epididymitis
• Pyuria and bacteriuria on U/A
• Urethral discharge should be examined for gram
stain and culture
• Leukocytosis between 10K-30K
• Torsion should not be excluded by pyuria, fever, or
dysuria. An equivocal exam demands Imaging. U/S
with increased or normal testicular blood flow is c/w
epididymitis
Epididymitis: Management
• Sexually acquired: Ceftriaxone 250 mg IM and
Doxycycline 100 mg PO bid x 10d. Treat sexual
partners.
• Nonsexually acquired: TMP-SMX or
Fluoroquinolone x 14d. Check urine C&S.
• Bed rest, scrotal support, analgesics, sitz
baths, and Urology follow up
Complications of Epididymitis
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Infertility - Sexually transmitted epididymitis
Abscess - Gonococcal epididymitis
Chronic epididymitis
U/S indicated if no response to medical
therapy
Orchitis
• Acute infection of the testis
• Rare without initial epididymitis. Consider testicular
tumor.
• Bacterial infection secondary to spread from
epididymitis of E. coli, Klebsiella, Pseudomonas
• Viral orchitis – Mumps. 4-6 days after onset of
parotitis usually. 50% of involved testes atrophy but
infertility rare
• Syphilis
• Treatment: Antibiotics for bacterial orchitis and local
scrotal measures for viral orchitis
Trauma
Testicular Tumor
• Testicular CA – Most common cause of
malignancy to afflict young men
• Average age of incidence 32
• DDx: Epididymitis and torsion
• Increased incidence with cryptorchidism in
bilateral testes
• Majority are Seminomas, then embryonal cell
CA and teratomas
Testicular Tumor
• Classic presentation – Painless, firm testicular mass
• Acute hemorrhage within the tumor can lead to
acute scrotal pain (10%)
• Ultrasound – Distinct Intratesticular Mass
• CXR if suspect Metastases
• Treatment: Immediate Urology referral. Radical
orchiectomy. Cisplatin chemotherapy and Radiation
for seminomas.