1. Acute Scrotal Pathology
Henry Yao
Pre-SET Urology Trainee
Royal Melbourne Hospital

2. Case History You are working in ED at night
It is 4am and you are tired + hungry
As you are about to go to get a snack
12 year old male presents with 2 hour history of pain in right side of scrotum

3. Question
What are your differential diagnoses?

4. Differential diganoses
Hydatid of Mortgagni (60%)
Testicular Torsion (30%)
Epididymo-orchitis (<5%)
Idiopathic scrotal oedema (<5%)

5. Question
What history questions would you ask?

6. Case History Scrotal pain came on over an hour Steadily getting worse
Vomited once
Some vague lower abdominal and back pain
No trauma to testicles
Two years ago had an STI rx with antibiotics
Stable girlfriend for 12 months

7. Question
What would you look for on examination?

8. Cresmateric Reflex

9. Testicular Torsion
Intravaginal vs Extravaginal

10. Testis Anatomy Paired solid viscera Oval shaped
Left lies slightly lower than right
Epididymis posteriorly
Vas deferens postero-medially
Tunica albuginea covering
Tunica vaginalis antero-laterally
Appendix of testis located in upper pole

11. Testis Anatomy Arterial supply Venous drainage Lymphatic supply
Testicular artery
Venous drainage
Pampiniform plexus
Lymphatic supply
Para-aortic nodes at origin of testicular artery (L2)
Nervous supply
T10 sympathetic supply (sensory follows this)

12. Presentation Most commonly age 12-18
Acute onset of severe testicular pain +/- swelling
On examination
Tender firm testicle
High riding testicle
Horizontal lie of testicle
Absent cremasteric reflex
No pain relief with elevation of testis
Thick or knotted spematic cord
Epididymis not posterior to the testis

13. Diagnosis Clinical suspicion
More likely when the onset of pain is acute and extremely intense
C.f. epididymitis more likely when onset of pain is gradual and progresses from mild to more intense
DO NOT WAIT FOR IMAGING if suspect torsion

14. Management
IMMEDIATE SURGICAL EXPLORATION if suspected testicular torsion
Most testicles remain viable if detorsed within 6 hours
Few testicles remain viable after > 24 hours of torsion

15. Surgical Exploration Median raphe incision
Cut through all layers to get to testis
Detorse the testis
Three point fixation to Dartos
Do the contralateral side

16. Imaging Doppler USS Nuclear testicular scan
Torsion: decrease blood flow
Epididymitis: increased blood flow
Nuclear testicular scan
Torsion: decrease uptake
Epididymitis: increased uptake of radiotracer activity

17. Hydatid of Mortgani Torsion of appendage Acute pain
Blue dot in upper pole
If in doubt  explore

18. Epididymo-orchitis Rare in childhood
Virtually never between 6 months and puberty
LUTS
Tender epididymis
Prehn’s sign
Dipstick and urine MCS
Rest, antibiotics, high fluid intake, alkalinisation of urine

19. Idiopathic Scrotal Oedema
Causes unknown: ?allergy, ?insect bites
Scrotum symmetrically swollen, pink and less painful c.f. other causes
Erythema spread beyond the scrotum
Scrotal skin hard but testis and epididymis not painful

20. Case 2 36 year old male Day 2 post vasectomy
Presents with painful scrotum

21. Question
What do you do?

22. Case History

23. Case History Vital signs Very tender scrotum Hardened scrotal skin
Tachycardia 110
Blood pressure 100/60
Very tender scrotum
Hardened scrotal skin
Spreading beyond scrotum

24. Question
What do you think is going on?

25. Fournier’s Gangrene
Necrotizing fascitiis of male genitalia and perineum
30% mortality
Rapidly progressive
Sources of bug from perianal region
Most common bug is E. coli but must also consider GPC and anaerobes

26. Fournier’s Gangrene Risk factors
T2DM
Alcohol
Other immunosuppressed patients
Spread across superficial fascial planes
Colles
Scarpa
Buck’s

27. Presentation
Painful swelling and induration of the penis, scrotum or perineum
Oedema spread beyond area of erythema
Eschar, necrosis, ecchymosis, crepitus are later signs
Foul odour
Fever
Diagnosis is clinical  don’t wait for imaging

29. Management Broad spectrum IV antibiotics – consult VIDS
Cover GP, GN and anaerobes
Immediate aggressive tissue debridement  cut down to normal tissue
Send tissue for MCS
May require flaps
(Consider hyperbaric oxygen therapy)

31. TGA Antibiotics

32. Questions

33. Acknowledgement
Dr. Kevin O’Connor (Urology Fellow)

34. Thank You for Your Attention