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Prof. A. Rajendran Additional Professor Department of General Surgery Stanley Medical College and Hospital Chennai. Scrotal Pain and Swelling. Outline. Embryology and anatomy Causes of Pain and Swelling Torsion, Epididymitis, Orchitis, Trauma History, Physical, Radiologic Exams, Labs - PowerPoint PPT Presentation
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SCROTAL PAIN AND SWELLING
Prof. A. Rajendran Additional ProfessorDepartment of General SurgeryStanley Medical College and Hospital Chennai
Outline
Embryology and anatomy Causes of Pain and Swelling
Torsion, Epididymitis, Orchitis, Trauma History, Physical, Radiologic Exams, Labs
Causes of Swelling Hydrocele, Varicocele, Spermatocele, Tumor,
Idiopathic
Embryology
Descent of testes at 32-40 wks gestation
Descends within processes vaginalis Outpouching of peritoneal cavity
Tunica vaginalis is potential space that remains after closure of process vaginalis
Anatomy Spermatic cord –testicular vessels, lymph,
vas deferens Epididymis - sperm formed in testicle and
undergo maturation, stored in lower portion Vas Deferens – muscular action propels sperm
up and out during ejaculation Gubernaculum – fixation point for testicle
to tunica vaginalis Tunica Vaginalis – potential space
Encompasses anterior 2/3’s of testicle Tunica albuginea is inner layer opposing testis
Anatomy – Nuts and Bolts
AnteriorPosterior
Causes of Pain and Swelling Pain
Testicular torsion Torsion of appendix testis Epididymitis Trauma Orchitis and Others
Swelling Hydrocele Varicocele Spermatocele Tumor
Torsion
Inadequate fixation of testes to tunica vagnialis at gubernaculum
Torsion around spermatic cord Venous compression to edema to ischemia
Epidemiology
Accounts for 30% of all acute scrotal swelling
Bimodal ages – neonatal (in utero) and pubertal ages 65% occur in ages 12-18yo
Incidence 1 in 4000 in males <25yo Increased incidence in puberty due to
inc weight of testes
Predisposing Anatomy
Bell-clapper deformity Testicle lacks normal attachment at vaginalis Increased mobility Tranverse lie of testes Typically bilateral Prevalence 1/125
Torsion: Clinical Presentation Abrupt onset of pain – usually
testicular, can be lower abdominal, inguinal Often < 12 hrs duration May follow exercise or minor trauma May awaken from sleep
Cremasteric contraction with nocturnal stimulation in REM
Up to 8% report testicular pain in past
Torsion: Examination
Edematous, tender, swollen Elevated from shortened spermatic cord
Horizontal lie common (PPV 80%) Reactive hydrocele may be present
Cremasteric reflex absent in nearly all (unreliable in <30mo old) (PPV 95%)
Prehn’s sign elevation relieves pain in epididymitis and not torsion is unreliable
Intermittent Torsion
Intermittent pain/swelling with rapid resolution (seconds to minutes)
Long intervals between symptoms PE: testes with horizontal lie, mobile
testes, bulkiness of spermatic cord (resolving edema)
Often evaluation is normal – if suspicious need GU followup
Diagnosis – “Time is Testicle” Ideally -- prompt clinical diagnosis Imaging
Color doppler – decreased intratesticular flow False + in large hydrocele, hematoma Sens 69-100% and Spec 77-100% Lower sensitivity in low flow pre-pubertal
testes Nuclear Technetium-99 radioisotope
scan Show testicular perfusion 30 min procedure time Sens and spec 97-100%
Acute torsion L testis Dec blood flow on L
Late torsion on R Inc blood flow around but dec flow w/in testis
Images - Torsion
Decreased echogenicity and size of right testicle
Nuclear medicine scan shows "rim sign“ =no flow to testicle and swelling
Management
Detorsion within 6hr = 100% viability Within 12-24 hrs = 20% viability After 24 hrs = 0% viability
Surgical detorsion and orchiopexy if viable Contralateral exploration and fixation if bell-
clapper deformity Orchiectomy if non-viable testicle Never delay surgery on assumption of
nonviability as prolonged symptoms can represent periods of intermittent torsion
Manual Detorsion
If presents before swelling Appropriate sedation In 2/3rds of cases testes torses medially, 1/3rd lateral Success if pain relief, testes lowers in scrotum Still need surgical fixation
Torsion: Special Considerations Adolescents may be embarrassed and
not seek care until late in course Torsion 10x more likely in undescended
testicle Suspicious if empty scrotum, inguinal
pain/swelling
Neonatal Torsion
70% prenatal, 30% post-natal Post-natal typically 7-10 days after birth Unrelated to gestation age, birth weight Post-natal presents in typical fashion
Doppler U/S and radionucleotide scans less accurate with low blood flow in neonates
Surgical intervention if post-natal Prenatal torsion presents with painless
testicular swelling, rare testicular viability Rare intervention in prenatal torsion
Torsion of Appendix Testis Appendix testis
Small vestigial structure, remnant of Mullerium duct Pedunculated, 0.3cm long
Other appendix structures
Prepubertal estrogen may enlarge appendix and cause torsion
Torsion of Appendix Testis Peak age 3-13 yo (prepubertal) Sudden onset, pain less severe Classically, pain more often in abd or
groin Non-tender testicle
Tender mass at superior or inferior pole May be gangrenous, “blue-dot” (21% of
cases) Normal cremasteric reflex, may have
hydrocele Inc or normal flow by doppler U/S
Torsion of Appendix Testis
Blue dot of gangrenous appendix testis
Torsion of Appendix Testis Management supportive
analgesics, scrotal support to relieve swelling
Surgery for persistent pain no need for contralateral exploration
Epididymitis
Inflammation of epididymis Subacute onset pain, swelling localized
to epididymis, duration of days With time swelling and pain less
localized Testis has normal vertical lie Systemic signs of infection
inc WBC and CRP, fever + in 95% Cremasteric reflex preserved Urinary complaints: discharge/dysuria
PPV 80%
Epididymitis
Scrotum has overlying erythema, edema in 60%
Normal vertical lie
Epididymitis
Sexually active males Chlamydia > N. gonorrhea > E. coli
Less commonly pseudomonas (elderly) and tuberculosis (renal TB)
Young boys, adolescents often post-infectious (adenovirus) or anatomic Reflux of sterile urine through vas into
epididymis 50-75% of prepubertal boys have anatomic
cause by imaging
Etiologies of Epididymitis
Epididymitis Diagnosis Leukocytosis on UA in ~40% of patients PCR Chlamydia + in 50%, GC + in 20% of
sexually active 95% febrile at presentation Doppler and Nuclear imaging show
increased flow If hx consistent with STD, CDC
recommends: Cx of urethral discharge, PCR for C and G Urine culture and UA Syphilis and HIV testing
Laboratory Adjuncts Studies of acute phase reactants: CRP, IL-1,
IL-6 Documented epididymitis have 4 fold increase in
CRP compared to testicular torsion PPV 94% and NPV 94% (inc 2 fold) Testicular tumor showed no increase in CRP
Doppler Epididymitis
Left Epididymitis Inc blood flow in and around left testis
Epididymitis Treatment
Sexually active treat with Ceftriaxone/Doxycycline or Ofloxacin
Pre-pubertal boys Treat for co-existing UTI if present Symptomatic tx with NASIDs, rest Referral all to GU for studies to rule out
VUR, post urethral valves, duplications Negative culture has 100% NPV for
anomaly
Orchitis
Inflammation/infection of testicle Swelling pain tenderness, erythema and
shininess to overlying skin
Spread from epididymitis, hematogenous, post-viral
Viral: Mumps, coxsackie, echovirus, parvovirus Bacterial: Brucellosis
Mumps Orchitis
Extremely rare if vaccinated 20-30% of pts with mumps, 70%
unilateral, rare before puberty Presents 4-6 days after mumps parotitis Impaired fertility in 15%, inc risk if
bilateral
Trauma
Result of testicular compression against the pubis bone, from direct blow, or straddle injuries
Extent depends on location of rupture Tunica albuginea ruptures (inner layer of
tuncia vaginalis) allows intratesticular hematoma to rupture into hematocele
Rupture of tunica vaginalis allow blood to collect under scrotal wall causing scrotal hematoma
Doppler often sufficient to assess extent
Surgery for uncertain dx, tunica albuginea rupture, compromised doppler flow
Testicular Hematoma
Blood as a filling defect in testis
Other Causes of Pain Incarcerated inguinal hernia Henoch-Schonlein Purpura
Vasculitis of testicular vessels Rarely presents with only scrotal pain
Referred pain Retrocecal appendix, urolithiasis, lumbar/sacral nerve
injury Non specific scrotal pain
Minimal pain, nl exam – return immediately for inc symptoms
Scrotal Swelling
Hydrocele Varicocele Spermatocele Testicular Cancer
Hydrocele
Fluid accumulation in potential space of tunica vaginalis May be primary from patent PV or secondary to torsion/epididymitis
Hydrocele
Transilluminating anterior cystic mass
Hydrocele
Getting above the swelling Fluctuation Trans illumination
Varicocele
Collection of dilated veins in pampiniform plexus surrounding spermatic cord More common on left side
R vein direct to IVC L vein acute angle to renal vein
~20% of all adolescent males
Varicocele
Often asymptomatic or c/o dull ache/fullness upon standing
Spermatic cord has ‘bag of worms’ appearance that increased with standing/valsalva
If prepubertal, rapidly enlarging, or persists in supine position rule out IVC obstruction
Most management conservatively Surgery if affected testis < unaffected testis
volume
Spermatocele
Painless sperm containing cyst of testis, epipdidymis Distinct mass from testis on exam Transilluminates Do not affect fertility Surgery for pain relief only
Epididymal cystFluid-filled swellings connected with the epididymis. If cyst contains clear fluid ,it is called epididymal cyst . However, if the fluid is grey opaque &contains few
spermatozoa, it is called spermatocele (after aspiration)Symptoms: Over age of 40 years Scrotal swelling (as if having a 3rd testis) Painless Often multiple, bilateral Enlarge slowly Doesn’t affect fertility (maybe after surgical removal)
O/E: Frequently bilateral Lies above & slightly behind the testes, the cord is
felt above it Cysts are not tender Elongated, measures from few millimeters to 5-10cm
diameter Smooth surface Testis can be felt separately Can “get above it Fluctuant, fluid thrill, dull to percussion Can’t be reduced Transilluminates if contains clear fluid i.e Epididymal
cyst (spermatocele; sometime depend on density of the fluid)
U/S Must be done to confirm your diagnosis & R/O testicular
tumore
spermatocele
Treatment:
None if asymptomatic But if large & interfere with walking:
• Aspiration may help• Excision for large cysts; this may affect
fertility of the testis
Acute Idiopathic Scrotal Edema Scrotal skin red and tender
underlying testis normal no hydrocele
Erythema extends off scrotum onto perineum Empiric tx, cause unknown
Antihistamine, steroids Resolves w/in 48-72hrs
Conclusions Clinical history and careful exam are key
factors in formulating accurate differential Imaging and labs useful adjuncts in unclear
cases U/S superior to nuclear imaging if time essential
TIME IS TESTICLE Early surgical intervention and GU involvement
Swelling without pain, usually less time sensitive diagnostically