1. Scrotal Pain and Swelling
Prof. A. Rajendran
Additional Professor
Department of General Surgery
Stanley Medical College and Hospital
Chennai
Scrotal Pain and Swelling

2. 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

3. 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

4. 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

5. Anatomy – Nuts and Bolts
Posterior
Anterior

6. Causes of Pain and Swelling
Testicular torsion
Torsion of appendix testis
Epididymitis
Trauma
Orchitis and Others
Swelling
Hydrocele
Varicocele
Spermatocele
Tumor

7. Torsion
Inadequate fixation of testes to tunica vagnialis at gubernaculum
Torsion around spermatic cord
Venous compression to edema to ischemia

8. 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

9. Predisposing Anatomy Bell-clapper deformity Testicle lacks normal
attachment at vaginalis
Increased mobility
Tranverse lie of testes
Typically bilateral
Prevalence 1/125

10. 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

11. 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

12. 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

13. Diagnosis – “Time is Testicle”
Ideally -- prompt clinical diagnosis
Imaging
Color doppler – decreased intratesticular flow
False + in large hydrocele, hematoma
Sens % and Spec %
Lower sensitivity in low flow pre-pubertal testes
Nuclear Technetium-99 radioisotope scan
Show testicular perfusion
30 min procedure time
Sens and spec %

14. but dec flow w/in testis
Acute torsion L testis
Dec blood flow on L
Late torsion on R
Inc blood flow around
but dec flow w/in testis

15. Images - Torsion Decreased echogenicity and size of right testicle
Nuclear medicine scan
shows "rim sign“ =no flow
to testicle and swelling

16. Management Detorsion within 6hr = 100% viability
Within 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

17. 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

18. 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

19. 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

20. Torsion of Appendix Testis
Small vestigial structure,
remnant of Mullerium duct
Pedunculated, 0.3cm long
Other appendix structures
Prepubertal estrogen may
enlarge appendix and cause
torsion

21. 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

22. Torsion of Appendix Testis
Blue dot of gangrenous
appendix testis

23. Torsion of Appendix Testis
Management supportive
analgesics, scrotal support to relieve swelling
Surgery for persistent pain
no need for contralateral exploration

24. 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%

25. Epididymitis Scrotum has overlying erythema, edema in 60%
Normal vertical
lie

26. 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

27. Etiologies of Epididymitis

28. 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

29. 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

30. Doppler Epididymitis Left Epididymitis Inc blood flow in
and around left testis

31. 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

32. Orchitis Inflammation/infection of testicle Spread from epididymitis,
Swelling pain tenderness, erythema and shininess to overlying skin
Spread from epididymitis,
hematogenous, post-viral
Viral: Mumps, coxsackie,
echovirus, parvovirus
Bacterial: Brucellosis

33. 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

34. 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

35. Testicular Hematoma
Blood as a filling
defect in testis

36. 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

37. Scrotal Swelling
Hydrocele
Varicocele
Spermatocele
Testicular Cancer

38. Hydrocele Fluid accumulation in potential space of tunica vaginalis
May be primary from
patent PV or secondary
to torsion/epididymitis

39. Hydrocele
Transilluminating
anterior cystic
mass

40. Hydrocele
Getting above the swelling
Fluctuation
Trans illumination

41. 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

42. 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

43. Spermatocele Painless sperm containing cyst of testis, epipdidymis
Distinct mass from testis
on exam
Transilluminates
Do not affect fertility
Surgery for pain relief only

44. Epididymal cyst Fluid-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)

45. 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)

46. U/S Must be done to confirm your diagnosis & R/O testicular tumore
spermatocele

47. Treatment:
None if asymptomatic
But if large & interfere with walking:
Aspiration may help
Excision for large cysts; this may affect fertility of the testis

48. 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

49. 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