Chapter XIII.11 Acute Scrotum
Robert G. Carlile, MD
October 2013

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A 12 year old male presents with a chief complaint of acute onset of left scrotal pain 3 hours earlier, which awoke him from sleep. The pain is constant and does not change with position. There is no history of trauma. He has no dysuria, fever, chills, nausea, or vomiting.

Exam: He is afebrile in moderate distress secondary to left scrotal pain. The left hemiscrotum is mildly edematous and erythematous. The left testicle has a high transverse lie in the left hemiscrotum, with marked tenderness to palpation. The cremasteric reflex is absent on the left. The right hemiscrotum and testicle are normal on exam. The circumcised penis is normal, with no urethral discharge present.

Urinalysis is normal. An hour later, color Doppler ultrasound scanning of the scrotum demonstrates the absence of blood flow to the left testicle and epididymis. Normal blood flow to the right testicle is present. No testicular masses are noted.

An emergent urological consultation is obtained. Scrotal exploration, under anesthesia, reveals a 720 degree torsion of the left spermatic cord, an ischemic testicle, and a "bell-clapper" deformity. With detorsion, the left testicle's normal color returns. The left testicle is then fixed to the scrotal wall to prevent retorsion. The right testicle is also fixed to the scrotal wall. Postoperatively, his pain was markedly relieved with detorsion of the left testicle, and the remainder of his recovery is unremarkable.


The acute scrotum is a true urologic emergency. The window of opportunity to salvage a torsed, ischemic testicle is short. The testicular salvage rate approaches 100% if detorsion is performed within 6 hours of the start of the pain. However, the testicular salvage rate is only 20% if detorsion occurs greater than 12 hours after the onset of symptoms, and essentially no viability if detorsion is delayed greater than 24 hours (1). Acute scrotal swelling should be considered testicular torsion until proven otherwise.

Puberty is the most common age at which testicular torsion occurs, with the newborn period being the second most common. The incidence is 1 in 4000 males younger than 25 years (2).

Testicular torsion can be classified into two types, relative to the tunica vaginalis' relationship to the area of the spermatic cord that twists: extravaginal and intravaginal. Extravaginal torsions occur perinatally, during testicular descent and prior to testicular fixation in the scrotum (2). This incomplete fixation of the gubernaculum (the fibrous cord extending from the fetal testis to the fetal scrotum which occupies the potential inguinal canal and guides the testis in its descent) to the scrotal wall allows the entire testes and tunica vaginalis free rotation within the scrotum (2). The rotation of the cord is "extravaginal" because the rotation of the cord is proximal to the attachment of the tunica vaginalis that encloses the testes, and both the spermatic cord and the tunica vaginalis torse. These comprise 5% of all testicular torsions (3).

Intravaginal torsion occurs in the remaining 95% of all testicular torsions (3). The tunica vaginalis typically covers the testicle, creating a potential space around the testes. Normally, the tunical vaginalis attaches to the posterior surface of the testicle and allows for very little mobility of the testicle within the scrotum. A congenital inappropriately high attachment of the tunica vaginalis on the spermatic cord allows the testes to rotate freely on the cord, within the tunica vaginalis (intravaginal torsion). This is the "bell-clapper" deformity which is a horizontal lie of the testicle instead of the normal vertical lie. It is called a bell clapper deformity because the testicle resembles a horizontal oval hanging from a cord at its midpoint (like the clapper in a bell) as opposed to the normal testicle which resembles the letter "b" or "d" with the testicle positioned vertically attached to the cord on its side. This deformity, which is present in approximately 12% of males, is commonly bilateral, which places the contralateral testicle at risk for torsion also (2). As viewed from below, the testes rotate inward or medially during torsion; the right clockwise and the left counter clockwise.

The acute onset of severe testicular pain, sometimes with associated nausea and vomiting, is very suggestive of testicular torsion, especially in the adolescent. Fever and dysuria are not common in testicular torsion. Intermittent testicular torsion is suspected when brief episodes of acute testicular pain occur recurrently. Torsion of a testicular or epididymal appendage (appendix testis or appendix epididymis) usually presents in mid childhood with mild discomfort of a few days duration (2).

Epididymitis and/or orchitis, on the other hand, may be associated with fever, dysuria, and a more gradual onset of scrotal pain, usually over several days. A history of urethral strictures, posterior urethral valves, myelodysplasia with neurogenic bladder, and severe hypospadias with utricular enlargement may predispose to urinary tract infection, with secondary reflux into the ejaculatory ducts causing epididymitis (2). A history of scrotal pain and swelling associated with fever and parotid gland swelling suggest mumps orchitis. Inguinal hernia and/or hydroceles may present with similar symptoms to acute testicular torsion. A history of constipation or upper respiratory infection, both causing increases in intraabdominal pressure may be present. Henoch-Schonlein purpura, an uncommon cause of acute scrotal swelling (usually bilateral), is associated with a history of vasculitis and associated onset of a cutaneous purpuric scrotal rash (2).

Trauma, even minor, may be a cause of testicular pain and should be sought in the history (straddle injury, wrestling, sports). A history of trauma may suggest a traumatic etiology of pain and swelling, but this does not necessarily rule out the presence of testicular torsion.

The physical exam should be done in conjunction with the history taking. The level of distress is noted along with vital signs and examination of the abdomen. There should be a specific notation of the presence or absence of inguinal and scrotal swelling, urethral discharge, lacerations, scrotal or perineal ecchymoses or rashes, and lastly the appearance of the testes and area of pain and/or tenderness. The absence of a cremasteric reflex, in conjunction with testicular tenderness, is commonly associated with testicular torsion (4). This reflex is usually present in epididymitis. It is elicited by gently stroking the skin of the inner thigh: the presence of the cremasteric muscle results in movement of the testicle in the ipsilateral hemiscrotum.

Acute testicular torsion should be considered the leading diagnosis until it is ruled out. The acute onset of severe unilateral unrelenting pain, tenderness, high riding testicle, with absent cremasteric reflex and no change in pain in response to testicular elevation (Prehn's sign), highly suggest testicular torsion. In testicular torsion, the affected testicle may be more cephalad than normal and it may lie transversely (horizontally). A change in position is not seen in epididymitis or orchitis.

If one is able to palpate the testicle separate from the epididymis, one can distinguish between testicular torsion, epididymitis, and testicular appendage torsion. The affected testicle is exquisitely tender in testicular torsion, and the epididymis may not be palpable, but is also tender if palpable. In epididymitis, the testicle itself is not tender, but the epididymis is palpable and tender. Epididymitis has a more gradual onset, with tenderness being present. A cremasteric reflex is usually present, and the pain may be relieved with testicular elevation. Fever, pyuria, and dysuria may be present.

Torsion of a testicular appendage may present in a fashion similar to that of acute testicular torsion. The tenderness may be well localized to the upper part of the testes and a characteristic "blue dot" sign in the skin of the scrotum may be noted. This blue dot is due to venous congestion of the appendix testis of the torsed appendage.

Color Doppler ultrasound scanning has great utility in differentiating between the above diagnoses and ruling out testicular torsion in equivocal presentations (5). Absence of blood flow to the affected testicle is noted in testicular torsion, whereas increased blood flow is noted in epididymitis/orchitis. Flow to the testicle will be present in appendage torsion. Of course, these findings should be combined with the signs and symptoms, and not taken in isolation. Testicular anatomy is also visualized with ultrasound, helping to evaluate for testicular rupture, hematomas, and tumors. If scrotal ultrasonography is readily available, and especially if the diagnosis is questionable, ultrasonography of the testes is the single most useful adjunct to the history and physical exam in the diagnosis of torsion. One must remember that with a high degree of suspicion after history and physical exam, especially within the 6 hour window from the onset of symptoms, emergent surgical exploration is reasonable, and one should not wait for an ultrasound exam.

Nuclear testicular scans, CT or MRI, have essentially no role in the management of the acute scrotum today. CBC and urinalysis are helpful in evaluating infectious etiologies, but waiting for these results should not delay exploration if indicated, and a doppler testicular ultrasound can be done while awaiting the results. A hernia or hydrocele or varicocele can be distinguished on exam.

Acute testicular torsion requires emergent scrotal exploration, detorsion of the affected testicle, with orchiectomy if testicular ischemia and necrosis persists after detorsion, or testicular fixation if blood flow and testicular viability is restored with detorsion. In either case, the contralateral testicle should be explored and testicular fixation performed with permanent suture.

Epididymitis/orchitis can be treated with antibiotic and anti-inflammatory drugs. Occasionally "sepsis" may result from severe cases, requiring hospitalization with intravenous antibiotics. The majority can be treated with outpatient antibiotics. Activity should be limited. Any predisposing factors should be addressed.

Acute testicular appendage torsion may be observed, with analgesics/anti-inflammatory medications if the diagnosis is firm. No testicular fixation is necessary as these are not commonly associated with abnormalities of the attachments. If the diagnosis is in doubt, emergent scrotal exploration is indicated.

Trauma with rupture of the tunica albuginea of the testes requires exploration emergently, with debridement and repair. Penetrating injuries to the scrotum should be surgically explored as the risk of testicular injury is quite high. In blunt trauma, the incidence of testicular rupture varies widely. Scrotal ultrasonography is useful in these cases to determine the degree of testis injury, testicular rupture, and hematocoeles. Hematomas can be observed, with rest, cold packs, and analgesics. Henoch-Schonlein purpuric scrotal swelling may be managed medically. Neonatal torsion may require exploration, if the diagnosis is made early enough, but unfortunately, the majority are diagnosed too late for testicle viability. Hernias and hydroceles should be repaired, emergently if incarcerated, electively if not.

The salvageability of a testicle within 6 hours of torsion is very good. Greater than 6 hours is more worrisome, as noted above, but exploration should be performed to remove a necrotic testicle, even with a late presentation, as diminished fertility may result from leaving in an infarcted testicle (2).

In the acute scrotum presentation, a full range of scrotal pathology must be considered. Emergent scrotal exploration is indicated in cases with a high degree of suspicion for testicular torsion, as indicated by the history and physical exam, in testicular rupture, and in penetrating scrotal trauma. Ultrasound imaging is valuable in evaluating equivocal presentations of the acute scrotum.


Questions

1. What are the signs and symptoms that help to differentiate acute testicular torsion from epididymitis?

2. How is color Doppler ultrasound helpful in the differential diagnosis of acute scrotum?

3. What is the cremasteric Reflex? Prehn's sign? The blue dot sign? The bell clapper deformity?

4. What is the time frame most advantageous to restoring viability of a torsed testicle?

5. How is acute testicular torsion managed?

6. How is acute epididymitis managed?


References

1. Cimador M, DiPace MR, Castagnetti M, DeGrazia E. Predictors of testicular viability in testicular torsion. J Pediatr Urol. 2007 Oct;3(5)387:90.

2. Ringdahl E, Teague L. Testicular Torsion. Am Fam Physician 2006 Nov 15;74(10):1739-1743

3. John CM, Kooner G, Matthew DE, et al. Neonatal testicualr torsion -- a lost cause? Acta Paediatr 2008;97:502.

4. Trojian T, Lishnak T, Heiman D. Epididymitis and Orchitis: An Overview. Am Fam Physician. 2009 Apr 1;79(7):583-587.

5. Kapasi Z, Halliday S. Ultrasound in the diagnosis of testicular torsion. Emerg Med J 2005;22:559-560.


Answers to questions

1.In testicular torsion, there is acute onset of pain. Fever is typically absent. Cremasteric reflex absent. Scrotal lie may be transverse and cephalad compared to normal. Testicular elevation does not affect pain. Pyuria and dysuria are absent.

2. Blood flow to the testicles can be evaluated rapidly and the testicular anatomy can be assessed. Normal or increased blood flow is seen in epididymitis, while absent blood flow is indicative of torsion. Testicular rupture in trauma, can also be identified as can testicular tumors.

3. Cremasteric reflex: Gently stroking the medial thigh elicits spermatic cord cremasteric muscle contraction and testicular movement. Prehn's sign: elevation of the affected testicle may improve the pain in epididymitis. Blue dot sign: a torsed ischemic testicular appendage may appear as a blue dot through the scrotal skin. Bell clapper deformity: an incomplete tunica vaginalis attachment onto the testicle and epididymis, with the testicle being predisposed to rotate, and torse within the tunica vaginalis, more easily than if the normal posterior attachment of the tunica vaginalis to the testicle were present.

4. Detorsion within 6 hours of the onset of the torsion.

5. Acute scrotal exploration and testicular detorsion with bilateral testicular fixation (if the testicle was detorsed and salvageable).

6. Antibiotics for acute epididymitis.


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