Acute Scrotum

ACUTE SCROTUM
BY
DR NGWOBIA P. AGWU
INTRODUCTION
 ACUTE SCROTAL CONDITIONS ARE
IMPORTANT UROLOGICAL EMERGENCIES:
 THOUGH OF LOW MORTALITY, BUT
GREAT MORBIDITY
 THE SCROTUM HOUSES THE TESTIS FOR
PROCREATION AND NORMAL SEXUAL
FUNCTION
INTRODUCTION contd
 DEFINITION:
PAINFUL AND OR SWELLING OF SCROTUM OR
CONTENTS PRESENTING ACUTELY OR
SUBACUTELY
 OFTEN ASSOCIATED WITH OEDEMATOUS
SCROTAL SKIN
 EMERGENCY SITUATION REQUIRING:
 ……….PROMPT EVALUATION
 ……. DIFFERENTIAL DIAGNOSIS
 …….. POTENTIALLY IMMEDIATE
……….SURGICAL
EXPLORATION
 A LONG LIST OF DIFFERENTIALS
 IMPERATIVE TO RULE OUT TORSION
ANATOMY OF SCROTUM AND ITS
CONTENTS
 CUTANEOUS FIBROMUSCULAR SAC
 CONTAINS TESTES AND ASSOCIATED
STRUCTURES
 CONSISTS OF 2 LAYERS;
1. HEAVILY PIGMENTED SKIN
2.DARTOS FASCIA
 SEPTUM DIVIDES IT INTO 2 COMPARTMENT
 SUPRFICIAL DARTOS DEVOID OF FAT AND IS
CONTINUOS WITH SCARPAS AND COLLES.
FASCIA
TESTIS
 OVAL ORGAN
 COVERED BY TUNICA ALBUGINEA
 POSTERIOR SURFACE- EPIDIDYMS
 VAS DEFERENCES ARISES FROM LOWER
POLE OF EPIDIDYMS, PASSES UPWARDS,
MEDIALLY AND BEHIND THE TESTIS
 TESTIS, EPIDIDYMS AND TUNICA LIE IN
THE SCROTUM
DIFFERENTIAL DIAGNOSIS OF ACUTE
SCROTUM
 1. TESTICULAR TORSION
 2.TORSION OF TESTICULAR APPENDAGE
 3. EPIDIDYMITIS
 4. ORCHITIS
 5.FOURNIER’S GANGRENE
 6. OBTRUCTED INGUINOSCROTAL HERNIA
 7.HYDROCOELE
 8. TESTICULAR TUMOR
 .9. IDIOPATHIC SCROTAL OEDEMA
 10. TRAUMA
 11. SCHONLEIN-HENOCH PURPURA
DIAGNOSIS
 HISTORY
1. AGE; TORSION COMMONER IN
NEONATES AND
POST-PUBERTALS
- S-H PURPURA, TORSION OF
APPENDAGE IN
PRPUBERTAL
- EPIDIDYMITIS IN POST-PUBERTALS
2. ONSET AND DURATION
-TORSION– ABRUPT, PAIN SEVERE
DIAGNOSIS, HISTORY
 MODERATE PAIN OVER FEW DAYS-
EPIDIDYMITIS AND APPENDICEAL
TORSION. PATIENT APPEARS
COMFORTABLE
 HX OF TRAUMA DOES NOT EXCLUDE
TORSION
 PAIN PERSISTING> I HOUR POST-
TRAUMA= RUPTURE OR TORSION
 PAIN RESOLVING PROMPTLY BUT APPEARING
GRADUALLY OVER DAYS- TRAUMATIC
EPIDIDYMITIS
 PREVOIUS HX OF SCROTAL PAINS
 UROLOGIC, SURGICAL HISTORY
 NEUROLOGIC PROBLEMS
 CONGENITAL GENITOURINARY
ABNORMALITIES
 URETHRAL INSTUMENTATION
 PHYSICAL EXAMINATION
1. INSPECTION
-DEGREE OF DISCOMFORT
-IS PATIENT AMBULANT OR WITH
DISCOMFORT
2.GENRAL ABD. EXAMINATION
-FLANK TENDERNESS
-BLADDER DISTENSION
-INGUINAL REGION
-SPERMATIC CORD FOR TENDERNESS
 3. GENITAL EXAMINATION
 HIGH RIDING TESTIS- TORSION
 CREMASTERIC REFLEX ; RARELY INTACT
IN TORSION
 TESTICULAR EXAMINATION: ANGELS
SIGN, PREHN’S SIGN
DIAGNOSTIC STUDIES
 URINALYSIS
 SCROTAL ULTRASONOGRAPHY
 COLOUR DOPPLER ULTRASONOGRAPHY

TREATMENT
 1. TESTICULAR TORSION
 AXIAL TWIST LEADING TO VENOUS
OBSTRUCTION, SECONADARY ARTERIAL
OCCLUSION, ISCHAEMIA, INFARCTION AND
GANGRENE
 TREATMENT IS URGENT SURGERY= SCROTAL
EXPLORATION, DETORSION AND
ORCHIDOPEXY, IPSIL+ CONTRALATERAL
 NON- VIABLE TESTIS- ORCHIDECTOMY
 2. ACUTE EPIDIDYMITIS/ORCHITIS
 ASSOCIATED MAINLY WITH N.S.U
 MAY BE DUE TO S.T.D, TRAUMA, SURGEY,
INSTRUMENTATION
 TREATMENT INCLUDES:
 BED REST
 SCROTAL ELEVATION
 ANALGESICS
 ANTIBIOTICS
 3. TORSION OF TESTICULAR APPENDAGE
 APPENDIX TESTIS( Mullerian duct ) AT
THE SUPERIOR PLOE, APPENDIX
EPIDIDYMIS( Wolfian duct)– HEAD OF
EPIDIDYMIS
 THESE PRODUCE TORSION BUT OF
SLOWER ONSET
 DOPPLER USS SHOWS INCREASED BLD
FLOW
 TREATMENT :
 BED REST
 SCROTAL ELEVATION
 NASIDS AND ANALGESICS HAVE BEEN
VERY EFFECTIVE
 NO ANTIBIOTICS IF URINE NORMAL
 4. TESTICULAR TRAUMA
 TESTIS USUALLY WELL PROTECTED
 BLUNT TRAUMA FROM BLOWS, KICKS, FALLING
ASTRIDE
 TRAUMA MAY FOLLOW SURGERY
 MINOR TRAUMA-ICE PACKS,SUPPORT
 EXPLORATION IF TESTIS IS BRUISED OR
SWOLLEN
 DECOMPRESSION OF TUNICA
 LACERATION OF TUNICA, LIGATE
BLEEDERS, DRAIN SCOTUM
 5. IDIOPATHIC SCROTAL OEDEMA
 XTRIZED BY RAPIDLY DEVELOPING
UNILATERAL SCROTAL OEDEMA
SPREADIN TO THE OPPOSITE SIDE, THEN
TO INGUINAL AND PERINEUM
 THERE IS DISCOMFORT NOT ACUTE PAIN
 TESTES ARE NON TENDER, NORMAL
 OEDEMA SUBSIDES IN 24-48HRS
 THERE MAY BE HX OF INSECT BITE,
MEDICATION
 TREATMENT: WARM SOAKS
 CLEANINESS
 MILD SEDATION WITH
ANTIHISTAMINES
 6. ACUTE HYDROCOELE
 USUALLY SECONDARY TO INFLAMMATION OF
TUNICA VAGINALIS
 MAY BE GONOCCAL OR COLIFORM, MAY
FOLLOW TORSION , STRANGULAED INGUINAL
HERNIA..
 DURING THE ACUTE STAGE, BEDREST,
ASPIRATION, SCROTAL ELEVATION
 LATER, HYDROCELECTOMY
 7.FOURNIER’S GANGRNE(
NECROTIZING PERINEAL FASCITIS)
 CONSERVATIVE ; HONEY DRESSING
 RADICAL EXCISION
 HYPERBARIC OXYGEN
 THAKS FOR LISTENING;
 YOUR QUERIES ARE WELCOME

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ACUTE SCROTUM

 COLOUR DOPPLER ULTRASONOGRAPHY

 YOUR QUERIES ARE WELCOME

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