Michal Sut and CJ Shukla
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling (Table 4.1). A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention.
Torsion of testicular appendage
Strangulated inguinoscrotal hernia, with or without associated testicular ischaemia
Acute on chronic conditions
Testicular tumour with infection, bleeding or ischaemia
Scrotal/testicular haematoma or haematocoele
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion is a true emergency and an organ-threatening condition. ‘Missed torsion’ may have a significant impact on the patient (e.g. psychosexual, behavioural, hormonal, reproductive), as well as potentially on the clinician (medicolegal). Despite widespread awareness of the condition, the ability to differentiate testicular torsion from other scrotal emergencies could still be improved. Testicular ischaemia leads to irreversible loss of reproductive germinal tissue within hours of onset. It is therefore of paramount importance to assess these patients without delay.
There is a bimodal distribution of testicular torsion with peak incidences in infants and again in young adolescents (age 7–15 years), although presentation can be at any age, including very rarely in men over 40. The pathophysiology is secondary to twisting/torsion of the spermatic cord within (intravaginal) or including (extravaginal torsion) the tunica vaginalis. Extravaginal torsion tends to occur in newborn boys and is much less common than intravaginal torsion. Torsion of the testis and spermatic cord results in impaired venous return, congestion and oedema, leading to reduced arterial blood flow, ischaemia and eventually infarction of testicular tissue.
At the initial assessment patients report a sudden onset of pain. The pain may wake them from sleep, or start after strenuous exercise, minor trauma to the genitals or sexual activity. In general, a gradual onset of pain is atypical for torsion and other diagnoses should be strongly considered.
Previous episodes of similar pain with spontaneous resolution is occasionally reported and may suggest intermittent testicular torsion. In this scenario, the testis torts and detorts without causing irreversible ischaemia. This group of patients are at risk of a progression to complete torsion and should have their testis fixed urgently.
A familial history of a father or brother with proven testicular torsion may be present, as an anatomical variant of a bell-clapper abnormality can be hereditary.
•Inspection: patients with testicular torsion are in significant pain that is worse on movement. This is particularly noticeable when the patient attempts to walk, often with a wide-based, slow gait. We suggest examination of the scrotum both in standing and lying positions. When the patient is upright, the affected testis is high-riding and may appear swollen. It is useful to confirm with the patient whether or not this is his normal anatomy. The overlying scrotal skin can be erythematous.
•Palpation: this is undertaken with the patient in the supine position. Typically, the testis is mildly enlarged but may feel firm and slightly irregular; this is the result of the aforementioned vascular engorgement. The torted testis is tender and the cord structures are often difficult/impossible to palpate. Patients may present much later, after several days, and at that stage the pain may have resolved due to testicular infarction.
Diagnosis of testicular torsion is a clinical one and any tests should be done only under the proviso they do not delay surgical exploration in cases of suspected torsion. They are generally useful to confirm a suspected alternative diagnosis such as epididymo-orchitis. If there is diagnostic uncertainty, surgical exploration is the only infallible diagnostic test.
Doppler ultrasound may show absent blood flow to the testis but in cases of torsion with less than a 360° twist, some blood flow may still be apparent; therefore, ultrasound cannot be relied upon to accurately exclude a torsion.
Laboratory tests may be normal or report mild white cell count (WCC) and C-reactive protein (CRP) elevation corresponding with tissue ischaemia within the testis.
Testicular torsion is managed with scrotal exploration and bilateral fixation of both testes if viable. In cases of an infarcted non-viable testis, this should be excised (orchidectomy) and the contralateral testis fixed (orchidopexy). Where there is questionable testicular viability, the testis should be detorted and wrapped in a warm saline-soaked swab for 15 minutes before re-evaluating.
If the attending doctor is concerned about testicular torsion, they should immediately notify the appropriate team (urology, paediatric surgery or general surgery) and start preparing the patient for theatre (ensure the patient is ‘nil by mouth’, check bloods, give intravenous [IV] fluids and analgesia).
Torsion of testicular appendage (torted hydatid of Morgagni)
This uncommon condition is a result of a twist of a vestigial remnant of the Müllerian duct or Wolffian duct (Figure 4.1) at the upper pole of the testis.
Figure 4.1 The locations of the testicular appendages. The appendix testis is a remnant of the Müllerian duct, whereas the epididymal appendix is a remnant of the Wolffian duct.
•Pain also develops rapidly in a similar fashion to testicular torsion.
•The severity of pain is usually less; however, this is subjective and may not reliably distinguish between this and testicular torsion.
•Usually affects younger children (pre-pubertal), making the clinical history more difficult to obtain and somewhat less reliable.
•Inspection typically reveals a discoloured, ischaemic appendage of the testis which, in Caucasians, can be seen through thin scrotal skin as a ‘blue dot sign’ (Figure 4.2) associated with the upper pole of the testis.
•Palpation may be difficult, especially in younger patients, but if possible, then elicited tenderness is usually confined to the upper pole of the affected testis, rather than throughout the testis.
Figure 4.2 Blue dot sign. Torted hydatid of Morgagni of the left hemiscrotum. (Illustration by Dr O. Kenyon.)
As for testicular torsion.
If there is any doubt about the diagnosis, scrotal exploration should be done to exclude testicular torsion. If a confident diagnosis can be made, conservative management with regular pain relief can be embarked upon. However, scrotal exploration and excision of the torted appendix should be considered as this will firstly confirm the diagnosis and, secondly, alleviate the pain more rapidly than expectant management.
Epididymo-orchitis is an infective process affecting the testis (orchitis), epididymis (epididymitis) or both (epididymo-orchitis).
The aetiology varies between age groups. In young, sexually active men, sexually-transmitted infections (STIs) due to chlamydia or gonorrhoea are the most likely causes, while in older men ascending Gram-negative infections, predominantly with Escherichia coli from the urinary tract, on a background of poor bladder emptying is the more common cause. This is not absolute, and a detailed sexual history is still necessary. Rarely, and especially if appropriately-treated infection does not resolve and certain risk factors are present (immunosuppression, travel to endemic areas, bacillus Calmette–Guérin [BCG] treatment for bladder cancer), tuberculosis-related epididymitis and orchitis should be excluded.
Gradually increasing pain and swelling of the hemiscrotum with or without associated fevers is typically reported. It is important to enquire about sexual behaviour, lower urinary tract symptoms (LUTS), previous episodes and risk factors for tuberculosis (TB) as this will guide appropriate management.
•Typically, the affected hemiscrotum looks markedly enlarged and erythematous, but changes may spread and involve the contralateral testis. It is crucial to inspect the entire scrotal skin, including the perineal aspect in order not to miss any areas of skin necrosis that may suggest the development of Fournier’s gangrene (see page 88).
•Palpate and percuss the suprapubic area to assess for a distended urinary bladder.
•Rectal examination of the prostate looking for an enlarged gland due to benign prostatic enlargement (BPE) causing bladder outlet obstruction (BOO) and for prostatitis or prostatic abscess.
•Record vital signs and in the case of hospital admission monitor patients on a regular basis, looking for any signs of systemic inflammatory response (SIRS) and to assess the response to treatment.
•WCC and CRP should be tested to assess severity of the infection.
•Urine dipstick may reveal a background urinary tract infection (UTI), in which case mid-stream urine (MSU) samples should be sent for culture and sensitivity. In younger patients (<35 years of age) or older patients with a risk of STIs, urinary polymerase chain reaction (PCR) tests for chlamydia and gonorrhoea tests are also necessary prior to treatment.
•A post-void residual (PVR) bladder scan to assess for adequate bladder emptying.
•Scrotal ultrasound scanning (USS) should be done acutely to exclude a collection or an abscess, or if there is any doubt about the diagnosis, e.g. tumour or missed torsion. A follow-up scan should also be considered to look for resolution of the changes and exclude underlying testicular malignancy that may present as an infective episode (Figures 4.3, 4.4).
Figure 4.3 Colour Doppler ultrasound image showing a normal testicle with a thickened epididymis lying posteriorly, with increased vascularity in keeping with epididymitis.
Figure 4.4 Longitudinal ultrasound image of the right testicle with power Doppler showing a heterogeneous testicle with significant increased vascularity and an adjacent loculated hydrocoele, in keeping with orchitis with a secondary hydrocoele.
Antibiotics should be given orally or IV depending on the severity of infection. In the case of significant sepsis, aminoglycosides in the form of gentamicin could be combined with either broad-spectrum penicillins (e.g. co-amoxiclav) or fluoroquinolones (e.g. ciprofloxacin, ofloxacin).
Oral antibiotics are given empirically according to the most likely pathogenic organism and local policy. Therefore, young, sexually active men should be treated with fluoroquinolones with activity against Chlamydia trachomatis (e.g. ofloxacin or levofloxacin); alternatively, doxycycline 100mg twice-daily for two weeks. If a STI is not suspected, co-amoxiclav or ciprofloxacin could be given. In suspected TB, the infectious disease/microbiology team should be consulted.
A urinary catheter should be considered if bladder emptying is significantly affected (PVR >300ml). Any recurrent UTIs and LUTS should be managed accordingly in the outpatient setting after resolution of infection.
A collection of pus within the deep layers of the scrotum is termed correctly as a scrotal abscess.
Not infrequently, superficial infections within hair follicles or primary perineal abscesses with some scrotal skin involvement are also labelled the same. The significance of a correct diagnosis relates to the fact that the latter should be managed by colorectal or general surgeons. Scrotal abscesses almost exclusively develop on the background of other infective conditions (e.g. epididymo-orchitis, UTI, urine extravasation due to urethral stricture disease).
Patients usually report gradually increasing swelling and pain that develop on the background of another condition, usually epididymo-orchitis. Febrile episodes related to SIRS are not uncommon, and like other abscesses there may be swinging fevers. Patient-related risk factors include diabetes mellitus, immunodeficiency and poor bladder emptying.
Generalised swelling and tenderness associated with erythema can be seen on the ipsilateral side. Commonly, fluctuance can be palpated over the area where the collection is nearest to scrotal skin. It is very important to exclude the presence of necrotising infection by carefully inspecting the skin for any signs of necrosis or skin crepitus. The testis is usually easily palpable and may be found lying normally in the scrotum but is commonly irregular and warm due to the underlying infection.
•Inflammatory markers (WCC, CRP) are commonly elevated.
•Scrotal USS confirms an underlying collection, which may have characteristics of purulent fluid and may also identify underlying pathology (Figure 4.5).
Immediate management constitutes broad-spectrum antibiotic cover. Fluid resuscitation and pain relief should be considered and bladder catheterisation might be required if PVR volumes are high.
In most cases, surgical exploration and drainage of the abscess is indicated. A trial of conservative management may be an option in selected cases presenting early with small abscesses and no clinical signs of septicaemia. However, this is only acceptable as an inpatient where regular re-examination of the scrotum is done and vital signs as well as inflammatory markers are monitored. In such cases, progression or lack of improvement requires surgical exploration and drainage of the collection. In cases of associated skin necrosis or suspected Fournier’s gangrene, the overlying skin and superficial fascia may also require debridement (see page 88). Orchidectomy is rarely required.
Figure 4.5 Ultrasound images of the testicle in grey scale (a) and power Doppler (b) showing a well-defined hypoechoic avascular testicular abscess (arrow).
A hydrocoele is an abnormal accumulation of serous fluid around a testicle, also termed a ‘hydrocoele testis’.
The space between the tunica albuginea casing of the testis and its surrounding fascia is physiologically filled with a small amount of yellow straw fluid within the tunica vaginalis, a coelomic sac derivative, which allows smooth traction between both surfaces. As a result of some insult (e.g. minor trauma, infection), the amount of fluid can increase significantly. It can in rare circumstances present acutely, either as a result of infection within a pre-existing hydrocoele, or as an acute hydrocoele secondary to epididymo-orchitis.
Due to the pathophysiological mechanisms explained above, presentation may be related to a new onset of scrotal swelling or infection of a chronic swelling. In the first scenario, symptoms of epididymo-orchitis may be present or minor trauma may be reported by the patient. Alternatively, patients may complain of an asymptomatic hydrocoele increasing in size, becoming tender or warm, which may or may not be associated with systemic upset.
Hemi-scrotal swelling should be smooth and fluctuant to varying degrees depending on the pressure within the sac. It is possible to palpate above the swelling, which differentiates it from an inguinoscrotal hernia. In a case of infected hydrocoele the hemi-scrotum may feel warm and tender. Typically the swelling transilluminates when a pen-torch light is applied, although this sign may be lost due to turbidity of infected hydrocoele fluid. The testis is often not palpable as a separate entity to the fluid swelling.
•Inflammatory markers in the form of WCC and CRP should be checked if an infection is suspected.
•USS of the scrotum is utilised to differentiate between a simple hydrocoele, infected hydrocoele and scrotal abscess. It may also report underlying epididymo-orchitis. Fluid turbidity and the presence of septations is usually noted in an infected hydrocoele as opposed to a simple hydrocoele (Figure 4.6).
Figure 4.6 Power Doppler ultrasound images showing normal vascularity in the right testicle (a) and infarcted left testicle (b). The left testis is enlarged and heterogeneous with no blood flow and a surrounding echogenic loculated hydrocoele.
A reactive hydrocoele is not a true emergency and is not treated as such. Treatment of underlying epididymo-orchitis might alleviate the size of the swelling. Alternatively, elective repair of the hydrocoele may be performed.
An infected hydrocoele may be treated conservatively with either oral or IV antibiotics according to the severity of infection. Broad-spectrum antibiotics in the form of co-amoxiclav or fluoroquinolones (e.g. ciprofloxacin, ofloxacin) can be administered orally (also, see local microbiology guidelines). In cases of more severe infection, for any of the above conditions, antibiotics may be used IV with the addition of gentamicin, according to hospital guidelines.
If an infected hydrocoele fails to respond to conservative treatment, or in severe infections with systemic upset, drainage in the operating theatre is indicated. Patients should be counselled on the possibility of an orchidectomy if the underlying testis has necrosed from an abscess.
A scrotal haematoma is a collection of blood within the scrotum.
This may be secondary to trauma, or iatrogenic as a result of elective procedures such as hydrocoele repair or vasectomy. Blood may collect in specific anatomic layers and this will determine the necessity for treatment and outcomes. Blood may collect within the tunica vaginalis, known as a haematocoele (this is where hydrocoele fluid accumulates), between the testis and scrotal wall (following hydrocoele surgery) or within the muscular layers of the scrotal wall.
The patient may report a previous direct blow to the genital area or a recent scrotal surgical procedure. Spontaneous bleeding happens very rarely, although it can present in the age extremes in relation to systemic diseases (e.g. Henoch–Schönlein purpura, bleeding diathesis) or anticoagulation (warfarin), which can be elicited during history taking.
The hemi-scrotum is usually uniformly enlarged, bruised and depending on the size of the haematoma, might be tense. The swelling is typically mildly tender, and in cases of infected collection it may be warm. Severe tenderness is usually due to an underlying pathology, e.g. testis rupture from trauma, infection, etc.
Laboratory tests including FBC, CRP and clotting screen should be done in the first instance. Although extremely unlikely, checking haemoglobin (Hb) will confirm whether blood loss is significant. If there is a significant drop in Hb, suspect blood loss from the operation (on table) or post-operatively (e.g. bleeding from the testicular artery which can retract into the abdomen following an inguinal orchidectomy). In cases of infected haematoma, one would expect an elevated WCC and CRP. A clotting screen will be deranged in haematological diseases.
Scrotal USS is the examination of choice to confirm the presence of echodense fluid in the scrotum. The role of USS is also to rule out features of infection as well as assessing testicular integrity in trauma cases.
•Most commonly, conservative management is sufficient with prophylactic oral antibiotics to prevent infection. Co-amoxiclav for 7–10 days is appropriate. Even minor haematomas take weeks to reabsorb and the patient should be advised of this on discharge. More significant haematomas causing pain/discomfort from the distension can be drained surgically.
•In cases of trauma leading to testicular injury, or signs of infected haematoma, scrotal exploration should be undertaken as an emergency procedure.
•Any spontaneous bleeding related to an underlying systemic disorder should have the background problem addressed by the appropriate team.
•Testicular torsion is a urological emergency.
•Suspected torsion should be assessed rapidly as patients should reach the operating theatre within 6 hours of symptom onset.
•Previous episodes of similar short-lived pain and a family history of proven testicular torsion may be reported in the history.
•Sudden onset and significant testicular pain are usually present; consider an alternative diagnosis otherwise.
•The typical examination findings of torsion is a unilateral high-riding and swollen testis, tender to palpation throughout.
•With the exception of suspected torsion (when exploration should not be delayed), ultrasound is the investigation of choice for most scrotal pathology.