Scrotal Pain and Swelling

1. Scrotal Pain and Swelling Jesse Sturm, MD December, 20, 2006

2. 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

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

5. Anatomy – Nuts and Bolts Posterior Anterior

6. 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

8. 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 <25yo • Increased incidence in puberty due to inc weight of testes

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

10. Torsion: Clinical Presentation • Abrupt onset of pain – usually testicular, can be lower abdominal, inguinal • Often < 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

11. 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 <30mo old) (PPV 95%) • Prehn’s sign elevation relieves pain in epididymitis and not torsion is unreliable

12. 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

13. 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%

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

15. Images - Torsion • Decreased echogenicity and size of right testicle • Nuclear medicine scan shows "rim sign“ =no flow to testicle and swelling

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. Torsion of Appendix Testis Blue dot of gangrenous appendix testis

23. Torsion of Appendix Testis • Management supportive • analgesics, scrotal support to relieve swelling • Surgery for persistent pain • no need for contralateral exploration

24. 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%

25. Epididymitis • Scrotum has overlying erythema, edema in 60% • Normal vertical lie

26. Epididymitis • Sexually active males • Chlamydia > N. gonorrhea > 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

27. Etiologies of Epididymitis

28. 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

29. 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.

30. Doppler Epididymitis • Left Epididymitis • Inc blood flow in and around left testis

31. 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

32. 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

33. 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

34. 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

35. Testicular Hematoma • Blood as a filling defect in testis

36. 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

37. Scrotal Swelling • Hydrocele • Varicocele • Spermatocele • Testicular Cancer

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

39. Hydrocele • Transilluminating anterior cystic mass

40. Hydrocele • Mass increases in size during day or with crying and decreases at night if communicating • If non-communicating and <1 yo follow • If communicating (enlarging), scrotum tense (may impair blood flow) requires repair • Unlikely to close spontaneously and predisposes to hernia

41. 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

42. 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 < unaffected testis volume

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

44. 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

45. 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

46. 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

47. 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.