Acute scrotal pain, tenderness, swelling Acute Scrotum Acute scrotal pain, tenderness, swelling

Differential Diagnosis of the Acute/Subacute Scrotum Torsion of the spermatic cord Torsion of the appendix testis Torsion of the appendix epidibymis Epididymitis Epididymo-orchitis Inguinal hernia Communicating hydrocele Hydrocele Hydrocele of the cord Trauma/insect bite Dermatologic lesions Inflammatory vasculitis (Henoch-Schonleiin purpura) Idiopathic scrotal edema Tumor Spermatocele Varicocele Nonurogenital pathology (e. g., adductor tendinitis)

Torsion of the spermatic cord Irreversible ischemic injury may begin as soon as 4 hrs 50% of men whose testes were detorsed less than 4 hrs had normal S/A Pts younger than 18 yrs were prone to testicular loss It is most common during adolescence (12-18yrs) The incidence is estimated to be 1 in 4000 male Pts less than 25 yrs.

Etiology Intravaginal torsion Bell-clapper deformity Added weight of the testis after puberty

Testicular Torsion Trauma Athletic activity Awakened from sleep Contraction of the cremasteric muscle

Presentation Acute onset of scrotal pain Some instance the onset appears to be more gradual Prior episode of sever, self limited scrotal pain and swelling Nausea, vomiting

Physical examination High-riding Transverse orientation Acute hydrocele or massive scrotal edema Absence of a cremasteric reflex (100%) Manual detorsion may not totally correct the rotation

Imaging Color doppler U.S: sensitivity 88.9%, specificity 98.5% Radionuclide imaging: sensitivity 90%, specificity 89%

Treatment When the diagnosis of torsion of the cord is suspected, prompt surgical exploration is warranted Sympathetic orchiopathy The contralateral testis must be fixed

Intermittent Torsion of the Spermatic Cord H/O prior episode of acute, self-limited scrotal pain, intermittent Elective scrotal exploration

Torsion of Testicular and Epididymal Appendages Hormonal stimulation Insidious onset, acute presentation Localized tenderness Blue dot sign Cremastric reflex should be present Radionuclide scan or color doppler (normal or increased flow)

Treatment When the diagnosis of a torsed appendage is confirmed clinically or by imaging, non operative management is suggested NSAIDs

Acute idiopathic scrotal edema Self-limited, unknown cause Not associated with scrotal erythema Minimal tenderness Pruritus Idiopath, allergic or chemical dermatitis, insect bites, trauma U. S, color doppler

Perinatal Torsion of the Spermatic Cord prenatally Immediate postnatally

Prenatal torsion Hard, non tender testis, fixed to the overlying scrotal skin at delivery Discolored skin by underlying hemorrhagic necrosis Extravaginal torsion Blind-ending spermatic cord (vanishing testis) Hard, non tender and fired to skin at birth don not merit surgical exploration, contralateral scrotal exploration has not been recommended

Postnatal torsion swelling, tenderness of the scrotum Extravaginal torsion, intravaginal torsion Prompt exploration Exploration of contralateral testis (17% bell clapper deformity)

Epididymitis Acute: pain, swelling and inflammation less than 6 wk Chronic Abscess, infraction, chronic pain, infertility

Etiology Sterile urine refluxing into the vas while the Pt strained against a closed external urethral sphincter (10%) STD organsm-N.gonorrhoeae, C.trachomatis (<35yr) Bacteriuria (>35yr) Homosexual; coliforms, H.influenzae Older men, pediatrics: bacteriuria Cryptorcoccus, brucellu, T. B Amiodarone

Diagnosis Swelling begin in the tail of the epididymis Indolent process 50% of men with G. C epididymitis did not have a urethral dischange Past H/O UTI, urethritis, urethral dischange,sexual activity, urethral cath, urinary tract surgery

Diagnosis The cremastric reflex should be present Pyuria, bacteriuiria or positive urine culture Urine culture may be sterile in 40% to 90% of pediatria Normal U/A dose not rule out epididymitis Most boy with a clinical diagnosis of epididymitis have sterile urine

Diagnosis Color Doppler sonography Radionuclide imaging

Radiographic imaging Sterile urine: U. S Positive culture: U. S, VCUG

Treatment Bed rest for 1-3 day Scrotal elevation NSAIDs STD related: ceftriaxone 250 mg IM + TCN 500mg Doxycycline 100 mg - Bacteriuria: (Levofloxacin or ofloxacin or systemic AB for 14-28 days) For 14-28 days