1. History
19-year-old male with acute right scrotal pain for the last 5 hours
No fever, dysuria, nausea and vomiting
No previous pain episodes
No history of trauma
Past history: Unremarkable

2. Physical exam T = 37.2, P = 72, BP = 105/74
Chest, abdomen, and extremities are all normal
Penis: Uncircumcised, no discharge or lesions
Left testis: Normal
Right scrotum: Swollen, erythematous and extremely tender

3. Exam

4. Laboratory
U/A: 5 WBC, 0 RBC, Mod. Bacteria
CBC: WBC 9.6, Hct 39

5. Differential Diagnosis
Spermatic cord torsion
Torsion of testicular appendage
Epididymitis / orchitis
Trauma
Malignancy
Idiopathic

6. Management Epididymitis - Antibiotics
Torsion of appendage - Observation
Torsion of cord - Exploration
Trauma - Exploration
Malignancy - Exploration

7. Imaging-Doppler Ultrasound

8. Management – Exploration
Bell-clapper

9. Management – Orchiopexy

10. Epididymitis/Orchitis
Etiology
Sexually active
N. Gonorrhea
Chylamidia
Ureaplasma urealyticum
Prepubertal
E. Coli

11. Infection: Management
STD
Azithromycin
Metronidazole
Prepubertal
Trim/sulfa
Cephalosporine

12. Torsion of Appendage

13. Torsion of Appendage
Observation (if you can be certain of the diagnosis)
Exploration if you can’t rule out spermatic cord torsion

14. Acute Scrotum – Summary
Spermatic cord torsion most common cause
Doppler ultrasound most accurate noninvasive imaging study
5% false negative
Suspect spermatic cord torsion
Immediate exploration

15. History 42-year-old white male w/ painful erection >6 hours
Past History: depression
Medications: trazadone

16. Exam
T = 37, P = 78, BP = 126/82
Penis: erect with tumescence of corpora cavernosa, soft glans and ventrum

17. Management Aspiration / Irrigation Phenylephrine Irrigation
Blood gas on aspirate
pH = 7.4, pO2 = 38
Phenylephrine Irrigation
Monitor patient (BP, pulse)

18. History 26-year-old white male suffered “crossbar” injury
Erection >5 hours
Past History: Negative

19. Exam T = 37, P = 78, BP = 126/82 Penis: erect
Aspirate - Bright red blood
pH = 7.0, pO2 = 86

20. High-flow Priapism History of trauma Diagnosis:
Duplex Doppler ultrasound
Arteriography
Management: Embolization