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The acute scrotum


Essentials

  • 1

    Torsion is the most time-critical diagnosis in acute scrotal pain.

  • 2

    Early surgery is mandatory if the diagnosis is strongly suspected. No investigation should delay surgery.

  • 3

    Colour Doppler ultrasound is helpful and is best used when testicular ischaemia must be excluded in an inflammatory mass or in an older patient.

  • 4

    Torsion of an appendage can be diagnosed clinically by finding a small blue lump in the scrotal sac (with normal scrotum and non-tender testes) and can be managed non-operatively.

  • 5

    Epididymo-orchitis is rare in adolescence and torsion should be suspected. Colour Doppler ultrasound may be used to exclude torsion if suspicion remains.

  • 6

    Masses found on ultrasound should be followed up, as traumatic injury can bring attention to an undiscovered tumour.

  • 7

    Ultrasound is unreliable in diagnosing testicular rupture.

  • 8

    Early surgery in scrotal trauma allows diagnosis and treatment of rupture as well as early evacuation of other haematomas with shorter inpatient stays and less pain.

Torsion of the Spermatic Cord (Testicle)

Torsion is a twisting not of the testicle but of the spermatic cord, which then interferes with the vascularity of the testicle, ultimately leading to infarction.

Aetiology

The normal postero-lateral testicular anchoring to the scrotal sac is missing due to an enlarged tunica vaginalis, which surrounds the whole of the testes and epididymis. The testis floats freely like a clapper inside a bell. Contraction of the cremaster causes the testes to be rotated, thereby twisting the cord.

Pathology

The twisting of the cord causes obstruction of the lymphatic and venous outflows, leading to venous engorgement; eventually it occludes the arterial inflow. Damage depends on the degree of torsion. Less than one turn (360 degrees) may partially occlude flow, whereas two or more turns (720 degrees) may occlude arterial flow completely, with necrosis occurring in less than 2 hours.

Classical clinical presentation

  • There is a sudden onset of severe scrotal or abdominal pain. Between one-third and one-half of patients have had previous episodes of acute scrotal pain.

  • Patient presents with pallor and vomiting.

  • The testis is tender and riding high in the scrotum.

  • There is loss of the cremasteric reflex; also scrotal oedema, testicular swelling tenderness and retraction.

  • There are no irritative voiding symptoms.

  • Systemic signs such as fever are usually absent.

  • Urinalysis is normal.

Van Glabeke studied over 500 children who had mandatory exploration and found that these clinical signs had false-negative rates of 10% to 40% and false-positive rates of 30% to 70%.

Intermittent torsion of the testis

This is a syndrome of recurrent acute scrotal pain, usually lasting less than 2 hours, which resolves spontaneously. Some of these cases show evidence of torsion on later exploration.

Differential diagnosis of acute testicular pain

The differential diagnoses to consider in acute testicular pain are listed in Box 10.2.1 .

Box 10.2.1
Differential diagnosis of acute testicular pain

  • Epididymo-orchitis

  • Strangulated hernia

  • Haematocoele

  • Hydrocoele

  • Testicular tumour

  • Henoch-Schönlein purpura in children

  • Idiopathic scrotal oedema

Traps in the clinical diagnosis

There are many potential pitfalls in the clinical diagnosis of the acute scrotum :

  • Age: The abnormality is present for life, so the torsion could potentially occur at any age. In those under 18 years of age, an acutely painful scrotum should always be considered to be torsion. It is most common in adolescence, with less than 4% of torsions in men over age 30. The increase in sexually transmitted diseases among teenagers may confuse the diagnosis. There is an old surgical aphorism that says, ‘When do you diagnose epididymo-orchitis in a teenager? Answer: After you have fixed the torsion’.

  • Pain: In 25% of cases pain is not sudden in onset, nor is it necessarily severe. However, some patients with epididymo-orchitis (EDO) do have severe pain.

  • Localization: Some patients may have no scrotal pain but may have all their pain referred to the lower abdomen or inguinal area. The scrotum must always be examined in males with lower abdominal pain.

  • Abnormal position of testis: this is seen only if rotation of 360 degrees or greater occurs.

  • Previous repair: Torsion can occur in a testis that has previously been fixed, especially if absorbable sutures have been used.

  • Dysuria: Irritative voiding symptoms rarely occur with torsion and suggests infection.

  • Fever: Temperatures above 102°F have been noted in up to 15% of torsion patients.

  • Clinical findings remain misleading and none can reliably exclude the diagnosis of torsion.

Investigations

Surgical exploration of the scrotum

This is the investigation of choice where the diagnosis of torsion is likely; it also maximizes the chance of saving the testis. Delaying the diagnosis is ‘castration by neglect’. Surgical exploration requires only a skin incision and has no major complications.

Low rates of torsion diagnosed at operation have led to interest in other tests to predict torsion preoperatively.

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