Scrotal Pain and Swelling

1
Scrotal Pain and Swelling

• Jesse Sturm, MD
• December, 20, 2006

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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

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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 2/3s of testicle
• Tunica albuginea is inner layer opposing testis

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Anatomy Nuts and Bolts
Anterior
Posterior
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Causes of Pain and Swelling

• Pain
• 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

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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 lt25yo
• Increased incidence in puberty due to inc weight
  of testes

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Predisposing Anatomy

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

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Torsion Clinical Presentation

• Abrupt onset of pain usually testicular, can be
  lower abdominal, inguinal
• Often lt 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

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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 lt30mo old) (PPV 95)
• Prehns sign elevation relieves pain in
  epididymitis and not torsion is unreliable

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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

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Diagnosis Time is Testicle

• Ideally -- prompt clinical diagnosis
• Imaging
• Color doppler decreased intratesticular flow
• False in large hydrocele, hematoma
• Sens 69-100 and Spec 77-100
• Lower sensitivity in low flow pre-pubertal testes
• Nuclear Technetium-99 radioisotope scan
• Show testicular perfusion
• 30 min procedure time
• Sens and spec 97-100

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

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Images - Torsion

• Decreased echogenicity
• and size of right testicle
• Nuclear medicine scan
• shows "rim sign no flow
• to testicle and swelling

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Management

• Detorsion within 6hr 100 viability
• Within 12-24 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

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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

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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
• Adult Emergency Physicians accurate in bedside US
  diagnoses with sens of 95 and specificity of 94
  (missed 1 epididymitis, no torsion)
• Blavis M., Emergency Evaluation of Patients
  Presenting with A Cute Scrotum, Academy of
  Emergency Medicine. Jan 2001

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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

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Torsion of Appendix Testis

• Appendix testis
• Small vestigial structure,
• remnant of Mullerium duct
• Pedunculated, 0.3cm long
• Other appendix structures
• Prepubertal estrogen may
• enlarge appendix and cause
• torsion

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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

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Torsion of Appendix Testis

• Blue dot of gangrenous
• appendix testis

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Torsion of Appendix Testis

• Management supportive
• analgesics, scrotal support to relieve swelling
• Surgery for persistent pain
• no need for contralateral exploration

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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

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Epididymitis

• Scrotum has overlying erythema, edema in 60
• Normal vertical
• lie

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Epididymitis

• Sexually active males
• Chlamydia gt N. gonorrhea gt 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

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Etiologies of Epididymitis
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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

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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

Doehn C., Value of Acute Phase Proteins in the
Differential Diagnosis of A Cute Scrotum, Journal
of Urology. Feb 2001.
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Doppler Epididymitis

• Left Epididymitis
• Inc blood flow in
• and around left testis

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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

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Orchitis

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

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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

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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

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Testicular Hematoma

• Blood as a filling
• defect in testis

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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

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Scrotal Swelling

• Hydrocele
• Varicocele
• Spermatocele
• Testicular Cancer

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Hydrocele

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

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Hydrocele

• Transilluminating
• anterior cystic
• mass

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Hydrocele

• Mass increases in size during day or with crying
  and decreases at night if communicating
• If non-communicating and lt1 yo follow
• If communicating (enlarging), scrotum tense (may
  impair blood flow) requires repair
• Unlikely to close spontaneously and predisposes
  to hernia

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Varicocele

• Collection 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

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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 lt unaffected testis
  volume

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Spermatocele

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

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Testicular Cancer

• Most common solid tumor in 15-30 yo males
• 20 of all cancers in this group
• Painless mass
• Rapidly growing germ cell tumors may cause
  hemorrhage and infarction
• Present as firm mass
• Typically do not transilluminate
• Diagnostic imaging with U/S initially

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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

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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

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References

• Ciftci, AO. Clinical Predictors for Diff.
  Diagnosis of Acute Scrotum, European J. of Ped.
  Surgery. Oct 2004.
• Blavis M., Emergency Evaluation of Patients
  Presenting with Acute Scrotum, Academy of
  Emergency Medicine. Jan 2001
• Doehn C., Value of Acute Phase Proteins in the
  Differential Diagnosis of Acute Scrotum, Journal
  of Urology. Feb 2001.
• Kaplan G., Scrotal Swelling in Children.
  Pediatrics in Review. Sep 2000.
• Luzzi GA. Acute Epididymitis. BJU International.
  May 2001.
• Fleisher G, Ludwig S, Henretig F. Textbook of
  Pediatric Emergency Medicine. 2006.