Thread: Acute Scrotal Swelling - Diagnosis and Treatment of the Acute Scrotum

Acute Scrotal Swelling - Diagnosis and Treatment of the Acute Scrotum

Testicular torsion must be considered in any patient who complains of acute scrotal pain and swelling. Torsion of the testis is a surgical emergency because the likelihood of testicular salvage decreases as the duration of torsion increases. Conditions that may mimic testicular torsion, such as torsion of a testicular appendage, epididymitis, trauma, hernia, hydrocele, varicocele and Schönlein-Henoch purpura, generally do not require immediate surgical intervention. The cause of an acute scrotum can usually be established based on a careful history, a thorough physical examination and appropriate diagnostic tests. The onset, character and severity of symptoms must be determined.

The physical examination should include inspection and palpation of the abdomen, testis, epididymis, scrotum and inguinal region. Urinalysis should always be performed, but scrotal imaging is necessary only when the diagnosis remains unclear. Once the correct diagnosis is established, treatment is usually straightforward.


Testicular pain or swelling, often referred to as the acute scrotum, can have a number of causes. Testicular torsion represents a surgical emergency because the likelihood of testicular salvage diminishes with the duration of torsion. Therefore, the family physician must act quickly to identify or exclude this condition in any patient who presents with an acute scrotum. This article reviews an approach to the diagnosis and treatment of the acute scrotum (Figure 1).

Illustrations of Pain In Testicle



The male reproductive structures include the penis, the scrotum, the seminal vesicles and the prostate.

History

The history and physical examination can significantly narrow the differential diagnosis of an acute scrotum, if not establish the exact cause. None of the conditions responsible for acute scrotal pain or swelling has a single pathognomonic finding, but the combined background information and physical findings frequently suggest the correct diagnosis

A history of trauma does not exclude the diagnosis of testicular torsion. Scrotal trauma incurred during sports activities or rough, boisterous play often causes severe pain of short duration. Pain that persists for more than one hour after scrotal trauma is not normal and merits investigation to rule out testicular rupture or acute torsion. Pain that resolves promptly after scrotal trauma only to recur gradually a few days later suggests traumatic epididymitis.

Anatomy of the Normal Testies and Spermatic cord

Information should always be obtained about prior occurrence of pain. When asked, many patients with torsion describe previous episodes of similar pain that lasted only a short time and resolved spontaneously. Acute on-and-off pain suggests intermittent torsion with spontaneous detorsion.

Finally, a general urologic and surgical history should be obtained. Neurologic problems, congenital genitourinary anomalies and urethral instrumentation can predispose patients to urinary tract infections and thus epididymitis.

Physical Examination

The physician can often assess the severity of pain by observing the patient before beginning the physical examination. Is the patient writhing in pain or lying comfortably? Does he talk with friends or family? Is he able to ambulate without discomfort?

A general abdominal examination should be performed, with particular attention given to flank tenderness and bladder distention. Next the inguinal regions should be examined for obvious hernias and any swelling or erythema. The spermatic cord in the groin may be tender in a patient with epididymitis but typically is not tender in a patient with testicular torsion.

The genital examination begins with inspection of the scrotum. The two sides should be assessed for discrepancies in size, degree of swelling, presence and location of erythema, thickening of the skin and position of the testis. Unilateral swelling without skin changes suggests the presence of a hernia or hydrocele.

The duration of symptoms is also relevant. A high-riding testis with an abnormal (transverse) lie may suggest torsion, but this diagnosis is unlikely if pain has been present for over 12 hours and the scrotum has a normal appearance. In both epididymitis and testicular torsion, the affected hemiscrotum typically displays significant erythema and swelling after 24 hours.

The cremasteric reflex should always be assessed. This reflex is elicited by stroking or gently pinching the skin of the upper inner thigh while observing the scrotum. A normal response is contraction of the cremasteric muscles on the ipsilateral side with unilateral elevation of the testis. One study1 found that the cremasteric reflex was intact in 100 percent of boys 30 months to 12 years of age but was not consistently normal in infants and teenagers. The cremasteric reflex is rarely intact in patients with testicular torsion but is usually present in patients with torsion of a testicular appendix.

A thorough testicular examination requires a knowledge of testicular landmarks. An illustration of normal anatomy of the testis is presented in Figure 2. The testis is best examined by grasping it between the thumb and the first two digits. The epididymis should be palpable as a soft, smooth ridge posterolateral to the testis. The testes are normally the same size.

In early torsion, the entire testis is swollen and tender, and is larger than the unaffected testis (Figure 3). Tenderness limited to the upper pole suggests torsion of a testicular appendage, especially when a hard, tender nodule is palpable in this region. A small bluish discoloration, known as the "blue dot sign," may be visible through the skin in the upper pole. This sign is virtually pathognomonic for appendiceal torsion when tenderness is also present.

In early epididymitis, the epididymis exhibits tenderness and induration, but the testis itself is not tender. Swelling to the degree that the epididymis is no longer palpable can indicate torsion if the symptoms have been present for only a few hours. With both appendiceal torsion and epididymitis, loss of testicular landmarks occurs later in the clinical course.

The testis may be elevated to elicit Prehn's sign. Lack of pain relief (negative sign) may contribute to the diagnosis of testicular torsion.

If torsion is suspected, manual detorsion can be attempted by rotating the testis away from the midline. Dramatic resolution of pain as a result of this maneuver confirms the diagnosis of torsion and eliminates the need for urgent surgical exploration. However, the patient should still be referred for elective orchiopexy.

Testicular torsion

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