Dr. Mohamed Leithy MD. Urology

Dr. Mohamed Leithy MD. Urology
Acute Scrotum Dr. Mohamed Leithy MD. Urology “ Dr. Mohamed Leithy MD. Urology

We will address acute scrotum with: Testicular torsion Idiopathic scrotal oedema Testicular trauma Acute epididymorchitis Dr. Mohamed Leithy MD. Urology

Anatomy Review : Scrotal skin. The dartos muscle/fascia, which is contiguous with the Scarpa fascia of the abdomen, the Colles fascia of the perineum, and the dartos fascia of the penis. The external, middle, and internal spermatic fasciae The tunica vaginalis The tunica albuginea capsule like layer The seminiferous tubules of the testis. Dr. Mohamed Leithy MD. Urology

Blood supply to the testes: The testicular artery, rising from the aorta. The Cremasteric artery rising from inferior epigastric artery. The deferential artery rising from the superior vesical artery. These 3 vessels collateralize and anastomose in the spermatic cord and near the epididymes. Dr. Mohamed Leithy MD. Urology

Acute scrotum /Testicular torsion Background Testicular torsion is a true urologic emergency Delay in diagnosis and management can lead to loss of the testicle. It can occur at any age, including the prenatal and perinatal periods, commonly occurs in adolescent It is the most frequent cause of testicle loss . Salvage rate of % within 6 hours of pain; between 20% and 50% after 12 hours; and 0 to 10% viability greater than 24 hours Dr. Mohamed Leithy MD. Urology

Pathophysiology TV. attaches to the posterolateral surface of the testicle and allows for little mobility of the testicle within the scrotum The bell clapper deformity: an inappropriately high attachment of TV. It is present in approximately 12% of males The testicle can rotate freely on the spermatic cord within the tunica vaginalis (intravaginal testicular torsion). It causing venous occlusion and engorgement, with subsequent arterial ischemia causing infarction of the testicle. Dr. Mohamed Leithy MD. Urology

In the neonatal age group: the testicle frequently has not yet descended into the scrotum, where it becomes attached within TV Inadequate fusion of the testicle to the scrotal wall, moreover, typically occurs within the first 7-10 days of life This mobility of the testicle predisposes it to torsion (extravaginal testicular torsion). Torsion may be categorized as complete, incomplete, or transient. Dr. Mohamed Leithy MD. Urology

Causes * Congenital anomaly; bell clapper deformity * Undecided testicle * Sexual arousal and/or activity * Trauma * Exercise * Active Cremasteric reflex * Cold weather Dr. Mohamed Leithy MD. Urology

Diagnosis : History Torsion can occur with activity, be related to trauma in 4-8% of Or develop during sleep (0 Acute onset of unilateral scrotal pain (0 Scrotal swelling 0 Nausea and vomiting) 0 Abdominal pain :20-30%) 0 Fever:16%) 0 Urinary frequency :4%) Dr. Mohamed Leithy MD. Urology

Physical examination : 00) Difficult to perform, particularly in the case of an ill child 00) Painful testicle on palpation 00) Elevated in position when compared with the other side 00) Horizontal lie of the testicle 00) Enlargement and edema of the testicle and scrotum 00) Scrotal erythema 00) Ipsilateral loss of the cremasteric reflex 00) No relief of pain upon elevation of scrotum 00) Fever Dr. Mohamed Leithy MD. Urology

Imaging: Scrotal US: Scrotal wall Testis Epididymis Fluid collection Color Doppler US: Vascularity of testis and epididymis Dr. Mohamed Leithy MD. Urology

Doppler US scan Dr. Mohamed Leithy MD. Urology

Perinatal testicular torsion
Extravaginal torsion - Presents as newborn with asymptomatic testis mass Examination : hard ,nontender testis, mild scrotal redness Imaging: Color Doppler …. No blood flow to involved testis Management Orchiectomy with contralateral orchiopexy Dr. Mohamed Leithy MD. Urology

Perinatal Testicular Torsion
Dr. Mohamed Leithy MD. Urology

Asynchronous bilateral torsion
Dr. Mohamed Leithy MD. Urology

Neglected torsion Gangrene of the testis Dr. Mohamed Leithy MD. Urology

Site of torsion Preadolescent testicular torsion Dr. Mohamed Leithy MD. Urology

Torsion of testicular appendages
History - Less sever pain - Indolent onset - Fever, nausea, vomiting rare - Blue dot singe Management: Conservative or surgery Dr. Mohamed Leithy MD. Urology

Torsion appendix testis
Blue dot singe Dr. Mohamed Leithy MD. Urology

Acute idiopathic scrotal edema
Acute scrotum Acute idiopathic scrotal edema -Prepubertal age -Testis: palpable nontender Normal color Doppler Causes: Bug bite, allergic reaction, cellulitis Dr. Mohamed Leithy MD. Urology

US finding : significant scrotal wall subcutaneous edema Marked thickening of the subcutaneous tissues Increase in the vascularity of the scrotal skin and subcutaneous tissues. Management: Antihistamines Observation Dr. Mohamed Leithy MD. Urology

Acute scrotum :testicular trauma Ruptured testis Imaging-defect in tunica albuginea Hematocele Management: Surgical exploration TA.tear Dr. Mohamed Leithy MD. Urology

Ruptured Testis Dr. Mohamed Leithy MD. Urology

Scrotal and testicular injury Etiology Animal attacks Motor vehicle accidents sharp or high-velocity missiles Sports casualties Dr. Mohamed Leithy MD. Urology

Types of injury Avulsions Blunt injury Penetrating injury Dr. Mohamed Leithy MD. Urology

Scrotal examination: Must document all of the following elements: Location of swelling Skin ecchymosis - Extent and location Skin loss - Percent and integrity of remaining Exit and entry wounds Location and integrity of testis, epididymis An assessment for inguinal hernia Haematocele Dr. Mohamed Leithy MD. Urology

Imaging Studies: Color Doppler ultrasound imaging Hematomas, intratesticular and extra testicular Nonperfusion of the testis may indicate testicular torsion, vascular avulsion, or cord thrombosis and should be immediately explored. Retrograde urethrography: in suspected urethral injury CT scan In multisystem trauma, the abdominopelvic CT scan provides information regarding testis dislocation, anatomy of intratesticular structures, and some indication of perfusion. Dr. Mohamed Leithy MD. Urology

Medical therapy Antibiotics: First: Field-related avulsions or penetrations (farming, hunting, military) must be treated with clindamycin (900 mg IV/IM q8h) and high-dose penicillin to cover Clostridium and tetanus. Second Treatment of animal bites should cover Streptococcus species -amoxicillin/clavulanate Dr. Mohamed Leithy MD. Urology

Surgical therapy Scrotal avulsion Partial loss of the scrotum is managed by debridement, excision of any islands of remnant full-thickness scrotal wall, and primary closure with absorbable sutures. Complete scrotal loss requires skin grafting. Testicles should be pexed together and dependently to minimize motion and maximize graft take. Thigh pouches may be necessary with infected wounds until they are managed adequately to allow grafting Acute trauma without infection can be managed simply with dressings until the patient is available for definitive graft placement. Dr. Mohamed Leithy MD. Urology

Blunt trauma Salvage of a ruptured testis through debridement and primary closure of the tunica albuginea Epididymal avulsion or rupture often requires epididymectomy with surgical attention to preserving the internal spermatic artery because the vasal artery is obligated to ligation. Testis torsion should be managed by orchidopexy. Dislocation of the testis should be approached inguinally. Massive hemorrhage after minor injuries –suspect testis tumor When uncertain, inguinal exploration with early securing of the cord structures is a reasonable technique Dr. Mohamed Leithy MD. Urology

Penetrating trauma Require exploration With combined inguinal and scrotal approach. Bleeding is controlled with testis salvage . Complete vascular transection : immediate exploration, a microvascular reanastomosis. Skin should be debrided to bleeding edges Drains is mandatory as the demarcation of injury may be underestimated Dr. Mohamed Leithy MD. Urology

COMPLICATIONS Fournier gangrene. This synergistic infection of gram-negative and gram-positive anaerobes and aerobes requires aggressive debridement to prevent death, which occurs in 30% of patients. Testicular atrophy may follow testicular rupture or torsion but requires no additional treatment. . Dr. Mohamed Leithy MD. Urology

OUTCOME AND PROGNOSIS Long-term success with skin grafting for scrotal injury is excellent. 20% of patients require significant revisions or reconstructions, and these are routinely outpatient procedures. Testis viability is highly variable and is largely dependent on the extent of tissue devascularization. Dr. Mohamed Leithy MD. Urology

Acute scrotum: Epididymitis /Orchitis - Infrequently seen in prepubertal boys - Usually associated with UTI - In Sexually active males a STD due to Chlamydia -All cases associated with a UTI require further imaging study Management : Proper antibiotics Consider the causers of UTI Dr. Mohamed Leithy MD. Urology

Take home message Acute scrotum means Torsion Until Proven Otherwise No difference in Adult / Child Always consult Urologist Dr. Mohamed Leithy MD. Urology

Coming Soon ………… Congenital Obstructive Uropathy Urogenital Trauma Voiding Function and Dysfunction Nocturnal Enuresis Pediatric Urinary Stones Intersex and Ambiguous Genitalia Pediatric Urologic Oncology Pediatric UTI Dr. Mohamed Leithy MD. Urology

Thank you Dr. Leithy Dr. Mohamed Leithy MD. Urology

Dr. Mohamed Leithy MD. Urology

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