Prof. A. Rajendran Additional Professor Department of General Surgery Stanley Medical College and Hospital Chennai.

SCROTAL PAIN AND SWELLING

Prof. A. Rajendran Additional ProfessorDepartment of General SurgeryStanley Medical College and Hospital Chennai

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

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

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

Anatomy – Nuts and Bolts

AnteriorPosterior

Causes of Pain and Swelling Pain

Testicular torsion Torsion of appendix testis Epididymitis Trauma Orchitis and Others

Swelling Hydrocele Varicocele Spermatocele Tumor

Torsion

Inadequate fixation of testes to tunica vagnialis at gubernaculum

Torsion around spermatic cord Venous compression to edema to ischemia

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

Predisposing Anatomy

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

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

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

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

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%

Acute torsion L testis Dec blood flow on L

Late torsion on R Inc blood flow around but dec flow w/in testis

Images - Torsion

Decreased echogenicity and size of right testicle

Nuclear medicine scan shows "rim sign“ =no flow to testicle and swelling

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

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

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

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

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

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

Torsion of Appendix Testis

Blue dot of gangrenous

appendix testis

Torsion of Appendix Testis Management supportive

analgesics, scrotal support to relieve swelling

Surgery for persistent pain no need for contralateral exploration

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%

Epididymitis

Scrotum has overlying erythema, edema in 60%

Normal vertical lie

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

Etiologies of Epididymitis

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

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

Doppler Epididymitis

Left Epididymitis Inc blood flow in and around left testis

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

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

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

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

Testicular Hematoma

Blood as a filling defect in testis

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

Scrotal Swelling

Hydrocele Varicocele Spermatocele Testicular Cancer

Hydrocele

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

Hydrocele

Transilluminating anterior cystic mass

Hydrocele

Getting above the swelling Fluctuation Trans illumination

Varicocele

Collection of 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

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

Spermatocele

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

Epididymal cyst

Fluid-filled swellings connected with the epididymis. If cyst contains clear fluid ,it is called epididymal cyst . However, if the fluid is grey opaque &contains few

spermatozoa, it is called spermatocele (after aspiration)Symptoms: Over age of 40 years Scrotal swelling (as if having a 3rd testis) Painless Often multiple, bilateral Enlarge slowly Doesn’t affect fertility (maybe after surgical removal)

O/E: Frequently bilateral Lies above & slightly behind the testes, the cord is

felt above it Cysts are not tender Elongated, measures from few millimeters to 5-10cm

diameter Smooth surface Testis can be felt separately Can “get above it Fluctuant, fluid thrill, dull to percussion Can’t be reduced Transilluminates if contains clear fluid i.e Epididymal

cyst (spermatocele; sometime depend on density of the fluid)

U/S

Must be done to confirm your diagnosis & R/O testicular tumore

spermatocele

Treatment:

None if asymptomatic But if large & interfere with walking:

• Aspiration may help• Excision for large cysts; this may affect

fertility of the testis

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

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