The Acute Scrotum

The acute scrotum is a medical emergency. The acute scrotum is defined as

scrotal pain, swelling, and redness of acute onset.
The differential diagnosis includes torsion, infection, trauma, tumor, and rarer
causes (Table)

History-taking in the acute scrotum

Age
Past medical history
General symptoms
First local symptom: pain before swelling?
Pain: where? what kind? sudden onset?
Trauma
Prior surgery
Nausea and vomiting
Fever
Dysuria
Petechia
The patient should be asked about the exact temporal course of events, the
intensity of the pain, and, in particular, when the pain began.
Physical examination of the acute scrotum
Position and orientation of the testes (Brunzel sign = secondary high position of a
testis)
Size of the testes

 Cremasteric reflexes
Site of maximal tenderness
Color of the scrotum
Blue dot sign
Inguinal and abdominal examination

The scrotum should be inspected and a brief general physical examination

should be performed. The involved testis should be palpated, and its position, size,
and tenderness (if any) should be noted in comparison to the other side. The testis and
epididymis should be evaluated separately, if possible. Next, the inguinal canal and
the abdomen are palpated, and the cremasteric reflex is tested. The Ger and Prehn
signs are no longer relevant in everyday practice (the former is retraction of the
scrotal skin that may indicate testicular torsion in an early stage, and the latter is
improvement of pain when the affected testicle is supported against gravity).
Morphologically, an ultrasonographic study yields an estimate of testicular
volume and an assessment of the echo genicity and any pathological features of the
right and left testes in comparison to each other. For differential diagnosis, the study
should include a search for an enlarged epididymis, a hydatid, a hematoma, or a tumor
The ultrasonographic evaluation of testicular perfusion includes both the
arterial and the venous flow signals. The demonstration of central vessels in the
testicular parenchyma is important, as perfusion may be preserved in the periphery
and the outer coverings of the testis even in the presence of testicular torsion.

Theoretically, testicular perfusion could also be evaluated with magnetic

resonance imaging or scintigraphy, but these tests are of little value for the diagnostic
assessment of the acute scrotum in routine clinical practice because they are timeconsuming, expensive, and hard to obtain.
There is no single laboratory test that can exclude testicular torsion. A
reasonable laboratory profile to obtain in cases of suspected torsion consists of a
complete blood count (with differential, if indicated) and serum C-reactive protein
concentration. A urine sediment is needed to rule out urinary tract infection.
Torsion
Torsion of the spermatic cord is a true surgical emergency of the highest
order. Testicular torsion is a suddenly occurring rotation of a testis about its axis,
resulting in twisting of the spermatic cord. The venous drainage of the testis is choked
off and arterial perfusion is reduced, resulting in hemorrhagic infarction of the
parenchyma. Subsequently, perfusion of the testis is totally lost. Complete testicular
torsion, by definition, involves a full 360 rotation. Irreversible damage of the
testicular parenchyma can be seen after four hours of ischemia. The cause of
testicular torsion is thought to be an abnormal degree of mobility of the suspension of
the entire testis, or of the testis within its coverings, so that the testis can rotate about
its own axis during physical exercise, trauma, or a suddenly occurring cremasteric
reflex. Anatomical variants such as the bell-clapper anomaly, in which the
gubernaculum, testis, and epididymis are not anchored as they normally are,
predispose to testicular torsion. Supravaginal torsion (i.e., torsion occurring above the
tunica vaginalis) is more common in infants, while intravaginal torsion of the
spermatic cord is the usual variant occurring in adolescence and is much more
common overall.
Intravaginal torsion, or torsion of the cord within the space of the tunica
vaginalis, may result from lack of normal fixation of an appropriate portion of
the testis and epididymis to the fascial and muscular coverings that surround the
cord within the scrotum. In effect, the normally segmental area of the free space
between the parietal and visceral layers of the tunica vaginalis is expanded to
surround the testis and epididymis and extends proximally up the cord for a variable
distance. This creates an abnormally mobile testis that hangs freely within the tunica
space (a bell-clapper deformity) ( Fig. 127-9 ).

The classic manifestation of acute torsion of the spermatic cord is that of

an acute onset of scrotal pain, but in some instances the onset appears to be more
gradual, and in some boys the degree of pain is minimized. A large number of
boys with acute scrotal pain give a history of previous episodes of severe, selflimited scrotal pain and swelling. It is likely that these incidents represent previous
episodes of intermittent torsion of the cord with spontaneous detorsion. Nausea and
vomiting may accompany acute torsion, and some boys have pain referred to the
ipsilateral lower quadrant of the abdomen. Dysuria and other bladder symptoms are
usually absent.
The absence of a cremasteric reflex is a good indicator of torsion of the
cord. Rabinowitz (1984) found 100% correlation between absence of a cremasteric
reflex and the presence of torsion in 245 boys over a 7-year period.

When the diagnosis of torsion of the cord is suspected, prompt surgical

exploration is warranted. Although adjunctive tests are commonly used to aid in
the differential diagnosis of an acute scrotum, these tests are most appropriately
performed when their purpose is to confirm the absence of torsion of the cord in
cases in which surgical intervention is believed to be unnecessary. Doppler
examination of the cord and testis to determine whether blood flow is present was
once touted as a helpful diagnostic test, but false-positive and false-negative results
have led most examiners to abandon this technique. Color Doppler ultrasound
examination has become the adjunctive investigation of choice in many institutions
for the evaluation of both acute and chronic scrotal conditions. Color Doppler studies
allow an assessment of anatomy (e.g., presence of a hydrocele, swollen epididymis)
while determining the presence or absence of blood flow to the testis.
If the testis is to be preserved, it should be placed in the dartos pouch with
suture fixation. It has been shown experimentally that placing sutures through the
tunica albuginea of the testis can produce local injury to the testis, and therefore
fixation should be performed with fine, nonreactive, nonabsorbable sutures placed so
that they avoid superficial blood vessels on the surface of the testis ( Bellinger et al,
1989 ). When torsion of the spermatic cord is found, exploration of the
contralateral hemiscrotum must be carried out. In almost all cases a bell-clapper
deformity is found. The contralateral testis must be fixed to prevent subsequent
torsion.
Intermittent Torsion of the Spermatic Cord
A significant percentage of adolescents with acute torsion of the spermatic
cord give a history of previous episodes of acute, self-limited scrotal pain that
appear clinically to have been episodes of intermittent torsion with spontaneous
detorsion ( Stillwell and Kramer, 1986 ). It is not uncommon to be asked to evaluate
an adolescent for one or more episodes of acute scrotal pain that resolved
spontaneously, was severe in nature, and in many cases was associated with vomiting
or even a visit to the emergency room. At the time of evaluation the physical
examination will be normal. If suspicion is strong that episodes of intermittent torsion
and spontaneous detorsion have occurred, our experience has been that the finding of
a bell-clapper deformity at exploration can be expected. Elective scrotal exploration

should be undertaken, and scrotal fixation of both testes should be performed when
bell-clapper deformities are identified ( Eaton et al, 2005 ). The purpose of
prophylactic fixation of the testes is to prevent an episode of torsion that might lead to
testicular atrophy.
Torsion of the Testicular and Epididymal Appendages (Hydalid Torsion)
The appendix testis, a mllerian duct remnant, and the appendix epididymis, a
wolffian remnant, are prone to torsion in adolescence, presumably as a result of
hormonal stimulation, which increases their mass and makes them more likely to twist
on the small vascular pedicle on which they are based.
The symptoms associated with torsion of an appendage are extremely
variable, from an insidious onset of scrotal discomfort to an acute condition
identical to that seen with torsion of the cord.
When the diagnosis of torsion of an appendage is confirmed clinically or
by

imaging, nonoperative

management

allows most cases

to resolve

spontaneously. Limitation of activity, administration of nonsteroidal antiinflammatory agents, and observation permit most symptoms to subside as the acute
changes of ischemic necrosis resolve. In an occasional clinical situation, acute
exploration is performed because of suspicion of torsion of the cord, or delayed
exploration is performed because of failure of spontaneous resolution of the
inflammatory changes and discomfort. Simple excision of the twisted appendage in
these cases is therapeutic.
Infection
Epididymitis and orchitis
Epididymitis and orchitis are either viral or bacterial infections of the
epididymis and testis. Bacterial infec- tions are very rare in children, unlike in adults
(24, e34, e35). The symptoms of both conditions generally arise more slowly than
those of testicular torsion; unlike in testicular torsion, the testis is neither fixed nor in
a higher position (4). The cremasteric reflex is usually preserved. There may be
dysuria, indicating a concomitant urinary tract infection (4).

In these disease entities, scrotal ultrasonography reveals hyperemia with

increased vascularization, along with enlargement of the epididymis or testis (25, e3).
Low RI values may be seen (e5, e10). Further findings may include thickening of the
tuni- ca albuginea or an accompanying hydrocele (25, e5).
Urinalysis is an obligate part of the work-up of these infectious conditions (1,
2, e36). In cases of recurrent infection, extended diagnostic evaluation is indicated for
the exclusion of structural anomalies (the evaluation might include, for example, renal
ultrasonography, uroflowmetry, cystoscopy, and micturition cysto-urethrography) (1
3, e36). The symptomatic treatment of epididymitis and orchitis resembles that of
hydatid torsion. The need for antibiotic treatment (e.g. cefuroxime 100 mg/ kg/d) in
the absence of a demonstrated urinary tract infection is currently debated (e24).
Trauma
Blunt trauma can cause a hematocele or edema of the testis or scrotum (e5,
e37, e38). Ultra- sonographic imaging is needed to rule out post- traumatic torsion or
capsule rupture (e5, e38). The treatment is then decided upon individually in each
case.
Systemic disease
The acute scrotum as the initial manifestation of a systemic disease is a
challenge for differential diagnosis. When the scrotum is involved in Henoch
Schnlein purpura, the epididymis and testis are often enlarged (e39, e40). Physical
examin- ation reveals the pathognomonic petechiae on the calves. Both leukemia and
lymphoma can also present with scrotal involvement as their initial manifestation. In
such cases, the ultrasonographic findings are generally not definitive, but laboratory
tests reveal the diagnosis.
Other diseases
Incarcerated inguinal hernia can cause testicular ische- mia, sometimes
presenting highly acutely. A thick swelling in the area of the inguinal canal points to
the diagnosis. Here, too, ultrasonography is a useful aid in differential diagnosis,
complementary to the physical examination. If complete reposition is not possible,

immediate surgery is indicated.

Acute idiopathic scrotal edema and emphysema is an entity in which the
scrotum becomes swollen for unknown reasons (e41e43) (Figure 5). The testes are
not involved. The marked swelling makes diag- nosis by palpation impossible; the
condition can only be diagnosed with ultrasonographic imaging.
Acute abdominal inflammation or infection (e.g., appendicitis) can also
present with the clinical pic- ture of an acute scrotum. In such cases, the physical
examination, laboratory tests, and ultrasonography usually suffice to establish the
diagnosis (e44).
Testicular tumors are generally painless. Intratumo- ral hemorrhage can,
however, present with an acute scrotum (e45). Ultrasonography reveals the tumor
mass (e5). Germ-cell tumor markers should be determined (alpha-fetoprotein, HCG).
Overview
The acute scrotum is a medical emergency because any unnecessary delay can
bring about irreversible damage to the testicular parenchyma. The percentage of
patients with an acute scrotum who need emergen- cy scrotal exploration because of
testicular torsion is probably less than 20%. It is, therefore, of vital importance to
identify the patients who do not need surgery by use of the appropriate diagnostic
procedures. A standardized diagnostic approach is recommended in which Doppler
ultrasonography plays a central role (Figure 6). The treatment is decided upon on the
basis of the findings of the physical examination and Doppler ultrasonography, as
soon as these have been performed. Whenever any question remains as to the central
perfusion of the testis, emergency surgical exploration is the treatment of choice.
When in doubt, explore! (e46)