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Acute Scrotum

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					Acute Scrotum




             Oren F. Miller, M.D.
                Pediatric Urology
Urologic Specialists of Oklahoma
                     July 5, 2006
Differential Diagnosis

 • Torsion of testis or appendages
 • Intrascrotal tumors
 • Infection/inflammation
    • epididymitis-orchitis
    • Fournier’s Gangrene
    • Mumps Orchitis
 • Systemic diseases
    • Idiopathic lymphedema
    • Henoch-Schonlein purpura
 • Trauma
 • Hernia / hydrocele
History and Physical

 • History
   • timing of onset: acute or insidious
     onset
   • associated symptoms or prior episodes
   • age at presentation
 • Physical
   • general appearance
   • lie of testes, scrotal skin, fluid
     collection,
   • testes or epididymis tender
   Acute Scrotum: Physical Exam

• Concentrate on the following:
  • Size, Location and Tenderness of Both Testes
  • Look for Tender, Firm, High Riding Testes +/-
    Surrounding Fluid
  • Lack of Transillumination
  • Scrotum is Edematous and Erythematous
  • Cremasteric Reflex Classically Absent
  • Examine for symptoms of disorders within the
    differential
Clinical criteria in acute scrotum

• Karmazyn, et al:
  • 172 children with testis torsion or other diagnoses
    (appendix torsion and epididymitis)
     • 41 with testis torsion and 131 other dx
     • 3 factors associated with testis torsion
         • Duration < 6 hours, absent or decreased cremasteric and
           diffuse testicular tenderness (score 0-3).
     • Children with a score of 0: no torsion
     • Children with a score of 3: 87% torsion
     • Ultrasound for score 1 & 2, surgery for score 3 and send
       home for score 0.


   B. Karmazyn, et al. Pediatr Radiol, 35: 302-310, 2005.
Laboratory

• Urinalysis: bacteria, WBC’s, crystals
  • may be present in torsion or tumors
  • commonly infected in epididymitis
• Obtain urine culture
• CBC may be helpful
• Radiographic studies
  • Ultrasonography vs Nuclear Scintigraphy
 Diagnostic Tests

• Ultrasonographic studies
  • Assesses blood flow of the testicular artery, reliable
  • Provides information on echotexture of the testes
    and surrounding tissues
  • Can find abnormalities such as hematoma, torsed
    appendix and hydrocele
  • Testicular torsion causes changes in echotexture
    over 24-48 hours with slow evolution of
    heterogeneous echotexture indicating necrosis.
  • Operator dependence: signal can be lost with cord
    compression over the pubic tubercle with the probe.
Testicular torsion
 Diagnostic Tests

• Nuclear Scintigraphy: uses
  technetium-99 tracer, documents
  testicular blood flow, false negatives may
  be caused by reactive scrotal hyperemia.
  A photon deficient area in the ipsilateral
  hemiscrota is almost pathognomic for
  torsion. Requires 1-2 hours. This study
  will fail to reveal a torsed testes that
  spontaneously detorses.
Testicular Torsion
Testicular Torsion

 •   The most urgent problem.
 •   High risk of loss due to infarction (90%)
 •   May have torsion of cord or appendages
 •   Neonatal and adolescence
     • more common in undescended testes due to
       absence of fixation
 • Extravaginal: exclusive to perinatal
 • Intravaginal: 90% of adolescent age
   group
 Testicular mesorchial attachments

• Normal Testis (A)
• Bell-Clapper Deformity(B)
• Mesenteric attachment
  between epididymis and
  testis (C)
• Torsion of Spermatic Cord
  (D)
• D same as C, with torsion
  of mesentery
Extravaginal Torsion
Intravaginal Torsion
Testicular Torsion

• History
  • Sudden onset of pain
  • Past history of similar pain in 50%
• Physical
  • Cremasteric reflex may be absent
  • Prehn’s sign: elevation of testes does not
    relieve pain
  • lateral testicular lie
Testicular Torsion

• Diagnosis
  • if certain : emergent surgery
  • if uncertain:
    • Nuclear scan: not done often depending on
      facility
    • Ultrasonography: documents blood flow
            PROVIDES ANATOMY
Left testicular torsion
Normal Testes
Testicular Torsion

• Refer Emergently!
  • < 6 hours, 90% salvage
  • > 24 hours, 100% loss and atrophy
• Attempt manual detorsion- outward
  • “ open the book “
• Some may be twisted 360, 720 or
  1440 degrees
Testicular Appendages

           Appendix testis




             Appendix epididymis
  Torsion of the Appendix Testis
• Usually a more gradual onset, pain moderately
  severe (but may be as severe as testicular
  torsion)
  • Localizes to the superior aspect of the testis
  • Testis is not hard
  • Scrotal erythema and a boggy epididymis are more
    indicative of a torsed appendix
• The classic blue dot sign indicates an
  infarcted appendix
• Reactive epididymitis is common
• If dx is in question, surgical exploration
Testicular Torsion
Results of Exploration

• One study (Sidler et al., 1997) of 199
  boys aged less than 13 years of age
  undergoing exploration reported 31%
  to have torsion of the testis, 31% to
  have torsion of the appendix, and 28%
  to have epididymo-orchitis. 6.5%
  were treated conservatively, and the
  rest had other causes.
Testes Tumors
Prepubertal testicular tumors

• Germ cell tumors         • Tumors of supporting tissues
   •   yolk sac               • fibroma
   •   teratoma               • leiomyoma
   •   teratocarcinoma        • hemangioma
   •   seminoma            • Lymphomas and leukemia's
• Gonadal stromal tumors   • Tumor-like lesions
   •   leydig cell            • epidermoid cyst
   •   sertoli cell           • hyperplastic CAH nodule
   •   granulosa cell      • Secondary tumors
   •   mixed               • Tumors of adnexa
• Gonadoblastoma
Paratesticular masses

 • Benign                • Malignant
   • Collections           • rhadomyosarcoma
      • varicocele
                           • liposarcomas
      • hydrocele
      • spermatocele       • leiomyosarcoma
   • Solid                 • malignant fibrous
      • adenomatoid          histiocytomas
      • melanotic
         neuroectoderm     • mesotheliomas
      • inflammatory       • plasmacytomas
         pseudotumors
      • hernias
      • polyorchidism
      • myxoma
Testicular Tumor

 • Bimodal Peak Age of Incidence
   • Age 2:
     • Yolk sac, Teratoma (benign), Leydig Cell
       (precocious puberty)
     • 60 - 75% germ cell
   • Age 18 - 30:
     • Seminoma, Embryonal
     • Commonly germ cell
 • Recurrent epididymitis or hydrocele
   may delay diagnosis
Pediatric Testis Tumors

• Incidence: 2-3/1,000,000 children
• 1% of all pediatric tumors
• Germ cell tumors 60-75% of pediatric
  testis tumors
  • vs. 95% of adult testis tumors
• majority of one histologic type
  • vs. mixed in 60% of adult testis tumors
Pediatric Testis Tumors

• Pediatric tumors more likely to be
  benign
  • testis sparing surgery considered
  • enucleation vs. radical orchiectomy
  • cosmetic, psychological and fertility issues
    considered
Pediatric Testis Tumors

     Yolk sac          63%
     Teratoma          16%
     Leydig cell       1.2%
     Sertoli cell      1.5%
     Gonadoblastoma    0.7%
     Epidermoid cyst   1.7%
     Gonadal stromal   3.2%
Physical Evaluation

 • Hydroceles found in 10% of tumors
   • may make palpation of testis difficult
 • Palpate a testicular mass vs.
   epididymal mass
   • testis tumor vs. spermatocele,
     varicocele, hydrocele
 • Lymphatics drain to
   retroperitoneum not inguinal region
   • unless scrotal extension or compromise
Laboratory Evaluation

• AFP: alpha-fetal protein
  • made in yolk sac, liver and GI tract
  • elevated in infants until 6-8 months / age
  • t 1/2 = 5 days
  • elevated in 90% of yolk sac
• HCG: human chorionic gonadotropin
  • not commonly found in pediatric tumors
Radiographic Evaluation




  Ultrasound: Most useful in distinguishing intra from extratesticular lesions.

  Testis CA usually hypoechoic. Sensitivity 95%, specificity 60%.
Infection/Inflammation
Epididymitis

• Most common acute scrotum post-
  pubertal
  • if presentation in prepubertal consider
    appendix testis torsion vs. congenital
    anomalies.
• Gradual onset of pain
• Fever in 40% of patients
• Dysuria in 50% of patients
• Urinalysis may show pyuria in 50%
Testicular Appendages

• Appendix testis - Hydatid of Morgagni
  • cranial remnant of mÜllerian system
  • Most common appendage for torsion
    (90%)
• Appendix epididymis
  • remnant of wolffian system
• Appendix of the vas
• Appendix of cord
Testicular Anatomy

           Appendix testis




             Appendix epididymis
Testicular Appendages

• Torsion of appendages rarely seen after
  puberty
• Presents with pain
• Physical
  • may develop scrotal swelling & erythema
  • “blue dot sign” seen early
  • Ultrasound required to rule out testis torsion
• Treat symptomatically
  • Be sure of early exam before swelling makes any
    further exam suspect!
Epididymitis

 • Confirm that torsion of testis
   does not exist
 • Treatment
   • scrotal elevation
   • Antibiotics considered: keflex, septra
 • Refer for persistence of
   pain/swelling.
Orchitis

• May be present with severe
  epididymitis
  • insufficient treatment may result in loss of
    testes
• Usually viral
• Associated with testes atrophy
Fournier’s Gangrene

 • Necrotizing fasciitis of the perineum
 • May ascend of fascial planes
   • Colles > Dartos > Scarpas
 • 20% to 50% Mortality Rate
 • Polymicrobial infection
   • Treat with Gent, Pen G and Flagyl
   • Debridement surgically
 • 20% to 30% related to GU source
Idiopathic Scrotal Edema

• Difficult to distinguish from
  torsion/tumor
• Ages 2 to 11
• Sudden onset, unilateral or bilateral
• Minimal tenderness, normal UA
• Normal gonads
• Self limiting process
  • conservative treatment
Henoch-Scholein Purpura

• Diffuse vasculitis involving:
  • skin, joints, GI tract and kidneys
  • hematuria and proteinuria
• Etiology unknown
  • complement / IgA involvement
  • 75% of patients < 7 years of age
• 33% have scrotal / testicular
  involvement
  • differentiate from torsion
HSP purpura
Filariasis: New Hebrides, 1942
Hernia/hydrocele
Hernia / Hydrocele

• Hydrocele: incomplete obliteration of
  the processus vaginalis
• Hernia: large opening of the processus
  vaginalis which may allow abdominal
  contents to enter scrotal sac.
• Neonatal hydrocele: 50% of newborns
  • most close by age 1
Scrotal Ultrasound




           Large left hydrocele
Testis Trauma
Testicular Trauma

• Most occur by blunt trauma
  • Penetrating trauma requires surgical
    repair
• Early exploration (<72 hours)
• Refer for definitive evaluation
• Suspect urethral injury if voiding
  symptoms
Diagnosis

• Blunt etiology
  • Examination
    • Hydrocele may make examination difficult
  • Ultrasound
    • Sensitive for testicular tunical disruption
  • Exploration
    • Within 72 hours if required
Results: Cass 1983
66 Blunt Testicular Ruptures

                Conservative   Early
#               23             43
Delayed (>4d) 11               0
Orchiectomy     5 (45%)        4 (9%)

Hospital stay   7.8 d          4.9 d
Diagnosis

• Penetrating etiology
  • Examination
    • Tunical vaginalis usually not disrupted.
  • Ultrasound
    • Not particularly informative
  • Exploration
    • Local repair in the ED vs. debridement in the
      main OR.
Ultrasound Diagnosis
Summary

• Refer emergently for any suspected
  torsion
  • young age, sudden onset, clean UA:
    torsion
  • older age, insidious onset, pyuria:
    epididymitis
  • older age, mass, clean UA: tumor
• Ultrasound to assist in diagnosis
• Exam patient!
• Call PedsUrology for any question

				
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