THE ACUTE

SCROTUM
Urology for Medical Students
THINGS YOU SHOULD KNOW
AS A JUNIOR DOCTOR
There are multiple causes
for acute scrotal pain
and it is often difficult to
differentiate them

Acute testicular torsion is a

urological emergency

Do not delay surgical

referral exploration for
unnecessary investigations
TOPIC OUTLINE

Causes Trauma

Ischaemia . Referred pain

Infection Other
 CAUSES

Testicular Referred
Ischaemia Infection Other
Trauma pain
Epididymitis Varicocoele
Torsion of testis Rupture Nerve root pain

Hydrocoele
Epididymo-orchitis

Spermatocoele
Contusion or
Torsion of appendage Orchitis Retrocaecal appendicitis
Haematoma
Strangulated inguinal
hernia

Fornier’s Gangrene
Heinrech-Scholein
purpura (HSP) vasculitis
Testicular infarction Haematocoele Urinary stone
Cellulitis Testicular tumour (rapidly
growing/necrotic)
ANATOMY OF TORSION
 Types  Structures
 << Intravaginal  Testis
 twisted spermatic cord within  Appendix epididymis
tunica vaginalis
 Appendix testis
 Extravaginal >>
 twisted spermatic cord AND
tunica vaginalis (in neonates)
RISK FACTORS
 Bell-Clapper deformity
 Undescended testis

Bell-Clapper Deformity (blue is tunica vaginalis)

SURGERY

Immediate
exploration

Detorsion

Fixation OR
Orchidectomy
TESTIS/EPIDYDIMIS INFECTION
 Bacterial
 UTI  younger/older patients
 usually gram negative bacteria

 STD  sexually active patients

 Chlamydia trachomatis
 Neisseria gonorrhoeae

 Viral
 Mumps
INVESTIGATIONS
 Urine cultures
 Urinary STD screen in sexually active
 Doppler ultrasound
 (Bloods + blood cultures) Doppler ultrasound

Microscopy of E. coli
TREATMENT
 Analgaesia & scrotal support
 Urinary tract source (for 14 days) – empirical
 Trimethoprim 300mg PO daily
 OR cephalexin 500mg PO QID
 OR augmentin 1tab PO BD

 Sexually active young men – empirical

 Ceftriaxone 500mg IV
 AND Azithromycin 1g PO stat
 AND Doxycycline 100mg PO BD (14 days)

 If not improving exclude abscess

 Ensure urine clear at end of antibiotics with U/A
FOURNIER’S GANGRENE
 Necrotising fasciitis of genitalia & perineum
 High mortality (30%)
 Rapidly progressing
 Risk factors – Diabetic, Immunocompromised, Alcoholic
 Treatment
 Rapid surgical debridement
 Supportive care & broad spectrum antibiotics
 Hypobaric oxygen
TRAUMA
 Testicular Rupture
 Requires prompt surgical repair
 Can only be seen on US in 20% - go by clinical suspicion

 Testicular Contusion/Intratesticular Haematoma

 Hypoechoic or haetrogenous area on ultrasound
 Usually explored because rupture cannot be excluded.
 Then managed symptomatically:
 Analgaesia
 Scrotal support & elevation

 Ensure resolution on follow-up ultrasound  could be a testicular carcinoma!

REFERRED PAIN
 Retrocaecal appendicitis
 Urinary stones
 Nerve root pain
OTHER CAUSES
 Varicocoele
 Hydrocoele
 Spermatocoele

 Strangulated inguinal hernia

 Heinrech-Scholein purpura (HSP) vasculitis

 Testicular tumour (rapidly growing/necrotic)