(1)
Introduction
Acute scrotal swelling poses one of the more
challenging clinical dilemmas in medicine. Distinguishing benign
conditions from the acute scrotum is the key to managing these
patients. The acute scrotum can be defined as any condition of the
scrotum or intrascrotal contents requiring emergent medical or
surgical intervention. Although rarely fatal, acute scrotal pathology
can result in testicle infarction and necrosis, testicular atrophy,
infertility, persistent testalgia, and significant morbidity.
The correct diagnosis of the acute scrotum is not
always obvious, but a thorough history, physical exam, and use of
basic laboratory studies can aid in distinguishing benign from
surgical conditions. However, patients may present with an atypical
history and physical exam. They may often delay presenting for help
until far into the course of the illness when the physical exam is
obscured by scrotal edema. Patient discomfort may limit obtaining a
thorough physical exam. Ultimately, the most important question to be
addressed is whether the testicle is adequately perfused.
(2)
Differential Diagnosis
The differential diagnosis of acute scrotal
swelling can be divided most easily into painful and painless
categories. The sources of painful scrotal swelling include
testicular torsion, torsion of a testicular appendage, epididymitis,
orchitis, an incarcerated hernia, an infarcted germ cell tumor,
scrotal cellulitis and fasciitis, and post-traumatic causes. Painless
etiologies for acute scrotal swelling may include hernias,
varicocoeles, hydrocoeles, spermatocoeles, epididymal cysts, and germ
cell tumors of the testis.
(3)
Presentation
Testicular torsion may occur at any age and is
the diagnosis that must be excluded when a patient presents with an
acutely swollen scrotum. The patient will often describe the
paroxysmal onset of sharp, debilitating pain in the scrotum. Most
often there is no inciting event and the patient may describe being
awakened at night with the pain. The testicle may be described as
high riding in the scrotum with associated scrotal erythema and
edema. Often there are no associated irritative voiding symptoms,
burning on urination, or urethral discharge. If the patient presents
early in the course of the torsion, the exam will often confirm the
diagnosis. The testis is frequently firm to hard, fixed to the dartos
and scrotal wall. The testicle may be exquisitely tender, but this is
not universal. It may be high riding in the scrotum. The ipsilateral
cremasteric reflex is almost universally absent, but if the
contralateral reflex is missing, the significance of the finding is
less helpful. The spermatic cord will be foreshortened and
thickened. The epididymis may assume a medial, lateral, or anterior
position. Because of venous congestion, the testis is usually larger
than the unaffected side. Urinalysis and culture is typically normal
in the early course of testicle torsion. The diagnosis of torsion is
often confirmed with Doppler ultrasound. The absence of blood flow
within the testicle is diagnostic. Ultrasound of a recently detorsed
testicle may show an enlarged testicle with increased blood flow
throughout. The key to torsion of the testicle is recognizing the
presence of the torsion and immediate referral for surgical orchiopexy.
The testicle must have its blood supply returned within 6 hours to
avoid permanent damage. If the patient is suspected to have torsion
of the testicle, emergent referral to the nearest
facility with a surgeon capable of performing an orchiopexy is
mandatory.
(4)
Manual Detorsion: Open the Book
Manual detorsion of the testicle may be attempted
as a temporizing measure. Detorsion is most frequently successful
when the testicle is rotated toward the respective outer thigh. The
physician should rotate the testicle outward as if opening a book
(clockwise with the right hand, counter clockwise with the left). The
testicle may need to be rotated more than 360 degrees. Successful
detorsion is characterized by significant relief of the patient’s
symptoms. The patient still must be referred for emergent surgical
exploration and orchiopexy.
(5)
Torsion of a
Testicular Appendage
Torsion of a testicular appendage can
mimic testicular torsion, but the symptoms are often not as severe.
In patients with thin scrotal skin, the torsed appendage may present
with a visible “blue dot” at the pole of the testicle. Tenderness is
usually isolated to that area and the testis is usually neither
enlarged nor tender. The epididymis is in the correct anatomic
position. There may be impressive scrotal swelling if the patient has
delayed seeking medical attention. Urinalysis and culture are
generally normal early in course of the disease. Ultrasound may be
required if the diagnosis is in question. No surgery is required.
The treatment is supportive with anti-inflammatory medications,
scrotal elevation, cold packs, and rest.
(6)
Epididymitis
Epididymitis occurs more frequently than
testicular torsion as males grow beyond adolescence. Most patients
will describe the gradual onset of increasingly intense pain in the
testicle and scrotum for some period of time before presentation. The
pain may, however, have an acute onset, thus leading to the difficulty
distinguishing this from torsion of the testicle. Pain with
epididymitis may radiate along the spermatic cord to the lower abdomen
and may even reach the flank. The patient may describe having burning
on urination, irritative voiding symptoms, and a urethral discharge.
On physical exam, the epididymis is exquisitely tender, often
enlarged, and scrotal edema may be present. As the disease
progresses, the epididymis may no longer be distinguishable from the
testis, the cord may become thickened, and the patient may develop a
reactive hydrocoele. The pain may be diminished with elevation of the
testicle (Prehn’s sign). Laboratory studies may help to confirm the
diagnosis. A CBC may show leukocytosis with a left shift. Urinalysis
will typically show pyuria, hematuria, and bacteriuria. Urine culture
may grow coliform bacteria, neisseria species, or chlamydia. It is
always necessary to see these patients back to document full
resolution of the symptoms. Although rare, patients with testicular
tumors may present with a reactive epididymitis as the only finding on
exam. Two to 4 weeks of appropriate antibiotic therapy should be
enough time for an epididymitis to resolve.
(7)
Epididymo-orchitis
Severe epididymitis can progress to
epididymo-orchitis, an infection of the entire testicle. These
patients are at significant risk for complications, such as testicular
necrosis, abscess formation, eventual testicular atrophy, infertility,
and testalgia. Etiologies for orchitis in addition to progression of
epididymitis include mumps orchitis, tuberculous orchitis,
granulomatous orchitis, and syphilitic gummas. If the patient is
suspected to have an epididymo-orchitis and it resolves completely
with antibiotics, no referral is necessary. However, referral to a
urologist or infectious diseases specialist is warranted if the
orchitis does not respond to initial management.
One note of extreme importance is to remember
that epididymitis is extremely rare in childhood. Any child who
presents with acute scrotal pain has torsion until proved otherwise.
(8)
Incarcerated Hernia
Incarcerated hernias can present as an etiology
of acute, painful, scrotal swelling. The history is usually
consistent with a hernia, the testicle exam is usually unimpressive,
the urinalysis typically normal and there is usually no associated
voiding symptoms. Nausea and vomiting, a change in bowel habits, and
abdominal distension may help to suggest the diagnosis. The abdominal
exam will generally confirm the diagnosis. Immediate surgical
referral is required if the hernia cannot be reduced.
(9)
Fournier’s Gangrene
Fournier’s gangrene is a very uncommon infection
of the skin and fascia of the scrotum and perineal tissues. It occurs
most frequently in middle aged patients and is usually associated with
obesity and diabetes. It is rapidly progressive and requires quick
intervention and radical surgical debridement for treatment. The
mortality rate has been reported as high as 75 percent, even despite
antibiotics and aggressive surgical resection of the necrotic
tissues. Although it would be uncommon to see this disease in the
general military population, it is not out of the realm of
possibilities to see this process in contaminated wounds in a
forward-deployed operational setting. The initial treatment is
multiple broad-spectrum antibiotics and immediate evacuation to the
nearest surgical facility.
(10)
Testicular Tumors
The most common solid tumor in males between the
ages of fifteen and forty is a germ cell tumor of the testicle. While
most testicular tumors will present with a painless nodule found on
palpation of the testis, occasionally a patient will present with
testicular pain and swelling due to necrosis from the tumor outgrowing
its blood supply. The pain may be acute in onset, can be associated
with scrotal skin changes and edema, but generally the spermatic cord
will be normal and the epididymis is normally positioned and nontender.
Often the diagnosis of the solid, intratesticular mass is made on
ultrasound. The treatment is immediate radical surgery to remove the
entire testicle and spermatic cord. Referral or evacuation at the
earliest safe opportunity to a surgical facility capable of performing
the surgery is mandatory. These tumors can progress rapidly and
patients can die within days after diagnosis if treatment is delayed.
(11)
Varicocoele
A varicocoele is a collection of dilated veins
within the spermatic cord. The exam will reveal a thickened spermatic
cord that will engorge with valsalva. The testicle is normal, but
with a longstanding varicocoele, especially in an adolescent, atrophy
of the testicle may be noted. Approximately fifteen percent of the
population will have a varicocoele and most commonly they will present
on the left side. If the patient has a right sided varicocoele or one
which does not go away with supine positioning, a CT scan of the
abdomen and pelvis is needed to rule out a retroperitoneal process
causing compression of the venous system. No therapy is required for
a varicocoele, unless the patient has progressive atrophy of the
testicle. Varicocoeles have been associated with an increased rate of
infertility; however, a causal relationship does not exist. Routine
referral to a urologist for evaluation is warranted if this becomes an
issue for the patient.
(12)
Spermatocoeles,
Epididymal Cysts, and Hydocoeles
Spermatocoeles and epididymal cysts are cystic
dilations of the epididymis and accessory structures of the testicle.
They commonly present as a newly discovered soft mass along the pole
of the testicle or the epididymis. They typically transilluminate,
have a cystic consistency by palpation, and the remainder of the
testicle exam is normal. These are self-limited processes and no
surgery is required. A routine ultrasound can be performed to confirm
the diagnosis.
Hydrocoeles are another major source of painless
scrotal swelling. A hydrocoele is a collection of fluid within the
tunica vaginalis surrounding the testicle and cord. The mass will
transilluminate easily and may compress or reduce on exam. It may
communicate with the abdominal cavity. The acute onset of a
hydrocoele requires an ultrasound to confirm the absence of a
testicular neoplasm. While this is unlikely, hydrocoeles rarely occur
spontaneously as one ages. No therapy is needed for the hydrocoele
unless it becomes so large as to become burdensome for the patient.
(13)
Summary
Acute scrotal swelling has many etiologies, some
of which can have disastrous consequences if not diagnosed and treated
properly. However, a thorough history and physical will often help
distinguish between benign conditions and the acute scrotum. The
general consideration with all scrotal swelling is assessing whether
the testicle is adequately perfused. When this is in doubt, an
ultrasound of the scrotum will answer this question. A prompt
diagnosis is often required, especially if torsion of the testicle is
considered likely.
Submitted by CAPT M. Melanie Haluszka, MC,
USN, LCDR Brian K. Auge, MC, USN, and LT Timothy F. Donahue, MC, USNR,
National Naval Medical Center, Bethesda (1999). |