Scrotal pain: evaluation and management

Scrotal pain is a common complaint in a urological practice. Its diagnosis can prove challenging in both acute and chronic forms and requires a thorough and complete history and physical examination. This article discusses the evaluation and management of several entities of scrotal pain, including testicular torsion, epididymitis, postvasectomy pain, varicocele, and chronic orchialgia.

A nationwide epidemiological study of testicular torsion in Korea

Testicular torsion is a surgical emergency in the field of urology. Knowledge of the epidemiology and pathophysiology is significant to an urologist. However, the epidemiology of testicular torsion in Korea has not been studied. We performed a nationwide epidemiological study to improve knowledge of the epidemiology of testicular torsion. From 2006-2011, the Korean Urologic Association began the patient registry service. The annual number of patients with testicular torsion from 2006 to 2011 were 225, 250, 271, 277, 345, and 210, respectively. The overall incidence of testicular torsion in males was 1.1 per 100,000; However, the incidence in men less than 25 yr old was 2.9 per 100,000. Adolescents showed the highest incidence. Total testicular salvage rate was 75.7% in this survey. There was no geographic difference of testicular salvage rate. Minimizing the possibility of orchiectomy for testicular torsion is important to improve public awareness to expedite presentation and provider education to improve diagnosis and surgery.

Perinatal testicular torsion and medicolegal considerations

Perinatal testicular torsion (PTT) is a very complex condition because of rarity of presentation and diagnostic and therapeutic difficulties. In presence of perinatal testicular torsion, the involvement of contralateral testis can be present also in absence of other indications which suggest the bilateral involvement; therefore, occurrences supported by literature do not exclude the use of surgery to avoid the risk of omitted or delayed diagnosis. The data on possible recovery of these testicles are not satisfactory, and treatment consists of an observational approach ("wait-and-see") or an interventional approach. The hypothesis of randomized clinical trials seems impracticable because of rarity of disease. The authors present a case of PTT, analyzing injuries due to clinical and surgical management of these patients, according to medicolegal profile. The delayed diagnosis and the choice of an incorrect therapeutic approach can compromise the position of healthcare professionals, defective in terms of skill, prudence and diligence. Endocrine insufficiency is an unfortunate event. The analysis of literature seems to support, because of high risk, a surgical approach aimed not only at resolution of unilateral pathology or prevention of a relapse, but also at prevention of contralateral testicular torsion.

Omental infarct in a hernia: an unusual cause of paediatric acute scrotum

We report a case of paediatric acute scrotum due to segmental haemorrhagic infarct of the omentum secondary to strangulation in the left inguinal hernia in a toddler as initial presentation after hernia being noticed by mother once earlier. A 4-year-old boy with non-traumatic acute left scrotum who had a history of left inguinal swelling once earlier presented with massively swollen, painful and discoloured left hemiscrotum extending into the groin simulating acute testicular torsion. Interestingly, there was a segmental omental infarct which precipitated the emergency and had ipsilateral testicular ascent and atrophy as long-term sequelae. Strangulated segmental omental infarct is a rare cause of acute abdomen/scrotum in children. Omentum is a very rare content of inguinal hernia in a toddler and infarct is exceptional. The diagnosis is usually not established before surgery in children. It should be included in the differential diagnoses of acute scrotum, especially in patients with untreated inguinal hernia.

Testicular torsion: diagnosis, evaluation, and management

Testicular torsion is a twisting of the spermatic cord and its contents and is a surgical emergency affecting 3.8 per 100,000 males younger than 18 years annually. It accounts for 10% to 15% of acute scrotal disease in children, and results in an orchiectomy rate of 42% in boys undergoing surgery for testicular torsion. Prompt recognition and treatment are necessary for testicular salvage, and torsion must be excluded in all patients who present with acute scrotum. Testicular torsion is a clinical diagnosis, and patients typically present with severe acute unilateral scrotal pain, nausea, and vomiting. Physical examination may reveal a high-riding testicle with an absent cremasteric reflex. If history and physical examination suggest torsion, immediate surgical exploration is indicated and should not be postponed to perform imaging studies. There is typically a four- to eight-hour window before permanent ischemic damage occurs. Delay in treatment may be associated with decreased fertility, or may necessitate orchiectomy.

[The role of dynamic contrast-enhanced magnetic resonance imaging in diagnosis of torsion of the testicular appendix : a case report]

A 7-year-old male presented to our hospital with pain and swelling in the right scrotum for 9 days. On physical examination a swollen right scrotum was noted and right side cremasteric reflex disappeared. Ultrasound examination showed enlarged right testis and epididymis. Subsequent dynamic contrast enhanced magnetic resonance imaging (MRI) showed a 7 mm area of high signal intensity anterior to the right testis on coronal imaging of T2-weighted. Subtraction MRI revealed testicular perfusion and a nonenhanced mass was also identified anterior to the right testis. These findings indicated a diagnosis of torsion of the testicular appendix. We performed excision of the torsed appendage.

Intravital microscopic evaluation of cremasteric microcirculation in experimental testicular torsion

AIM

Although absent cremasteric reflex is a significant clinical finding for testicular torsion (TT), there is limited information about microcirculation of the cremasteric muscle (CM) after TT. This experimental study was performed to evaluate CM microcirculation by intravital microscopy after TT.

MATERIALS AND METHODS

Twelve Wistar rats were allocated into two equal groups: control (CG) and torsion (TG). After anesthetization of the CG rats, the CM flap was dissected through a left ventral inguinal incision with its vascular pedicle. In TG rats, TT was performed by rotating left testicles 720(°) in clockwise direction for 1 h. Then, the CM flap was dissected as in CG, and was placed under an intravital microscope. Vessel diameters, functional capillary perfusion and leukocyte activation in post-capillary venules were measured and evaluated statistically.

RESULTS

There was a significant decrease in vessel diameter in TG compared to CG (p < 0.05). The median of perfused capillaries in CG and TG was 13 (11.75-14.30) and 5.5 (4.75-7.25), respectively (p < 0.05). Number of granulocytes (rolling, sticking, transmigrated) was greater in TG than CG (p < 0.05).

CONCLUSION

Intravital microscopic evaluation of CM after TT showed decrease in vessel diameter and number of perfused capillaries, and increase in granulocyte activation. Clinical, electrophysiological alterations in CM after TT can be explained by deterioration of microcirculation of CM.

Torsion of an epididymal cyst: a case report and review of the literature

Torsion of an epididymal cyst (EC) on its pedicle is an extremely rare condition that resembles acute testicular torsion. Herein, a boy with EC torsion managed surgically is presented and discussed in light of the relevant literature. The presented child is probably the fourth case of pediatric EC torsion, and to our knowledge, the first report of a child who was known to have EC and was followed conservatively until the occurrence of EC torsion.

Acute scrotal pain

BACKGROUND

Acute scrotal pain, once diagnosed, can be treated appropriately with either conservative or surgical measures. The complexity lies in the use of history, clinical examination and investigations in a restricted time frame, to identify the appropriate management path.

OBJECTIVE

To evaluate the literature regarding important and common differentials of acute scrotal pain with the intent to enable primary care doctors to appropriately assess and manage the acutely painful scrotum.

DISCUSSION

Since there is no single feature in the history, examination or investigation that is pathognomonic in diagnosing acute scrotal pain, the triad together is pivotal in its clinical evaluation. If there is any suspicion of testicular torsion, a prompt referral to a surgeon with relevant experience or to the emergency department may salvage the testis. Epididymitis and torsion of the appendix testis may be managed conservatively once testicular torsion has been ruled out.

Torsion of spermatic cord in children: a review

The current opinion on spermatic cord torsion is discussed in this review, with special attention to natural history, value of diagnostic tools, evidence for surgical management, outcome and management of atypical forms of torsion.

Managing epididymo-orchitis in general practice

Epididymitis and orchitis normally co-exist with isolated epididymitis being more common than an isolated orchitis. Epididymo-orchitis (EO) can be acute (less than 6 weeks' duration), sub-acute, or chronic if persisting for more than three months and typically presents with testicular pain and swelling. Sexually transmitted infection (STI) is the most common cause in younger men and urinary tract pathogens are the more common culprits in older men. The most common pathogens in the under 35s are N gonorrhoeae and C trachomatis and E coli is the most common cause of acute epididymitis in the over 35s. Acute testicular torsion is the most important differential diagnosis of acute testicular pain especially in younger men. If there is any suspicion of testicular torsion, the patient should be referred to secondary care immediately as surgery is required within four to six hours. Patients who are in severe pain or systemically unwell should be referred for analgesia, IV antibiotics and hydration. Examination of a patient with acute EO classically reveals a swollen, tender testis with swelling of the epididymis which starts at the lower pole and moves up towards the head of the epididymis at the upper pole of the testes. UTI in men is often associated with bladder outflow obstruction. So it is important to examine the bdomen for a palpable bladder and to perform a digital rectal exam to check for BPH, prostate cancer, constipation and prostatitis which can also cause EO.

Critical urologic skills and procedures in the emergency department

The evaluation and management of genitourinary emergencies is a fundamental component of the training and practice of emergency physicians. Urologic procedures are common in the emergency room. Emergency physicians play a vital role in the initial evaluation and treatment because delays in management can lead to permanent damage. This article discusses the most common urologic procedures in which emergency physicians must be proficient for rapid intervention to preserve function and avoid complications. An overview of each procedure is discussed as well as indications, contraindications, equipment, technique, and potential complications.

Case series on testicular torsion: an educational emergency for sub-Saharan Africa

Testicular torsion remains a common surgical emergency of adolescent males presenting with sudden onset of intense scrotal pain in Africa. While the magnitude of testicular torsion is not known it has been identified as a cause of male infertility. Testicular loss in Africa is directly related to delay in surgery and the referral patterns at the point of first contact with health workers. This paper sets out to demonstrate the importance of the patient's age in the diagnosis of testicular torsion. A surgical audit was made of patients records collected over the last 30 years, for presentation of testicular related symptoms and analyzed to identify changes in the patterns of diagnosis over time and in different countries. There were 305 records found, for patients with an age range of 9-56 years. There were 195/305 (64%) with orchitis and 110/305 (36%) with testicular torsion. Testicular torsion is more common under the age of 18 years while orchitis was more common after 18 years of age (rho = -0.834, p value > 0.001 one tailed). This paper supports the development of educational interventions that promote the use of age in a simple diagnostic rule of the thumb for communities and lower cadre health workers in low resource settings.

[Acute scrotal pain]

The onset of the pain, tenderness and swelling in the scrotal content is a common complaint in the urological outpatient. A child with those symptoms should be looked on as an emergency sign requiring emergency surgical exploration as a testicular torsion. Testicular torsion represents a surgical emergency because the likelihood of testicular salvage diminishes with the duration of torsion. Therefore, we must act quickly to identify this condition in any patient who presents with an acute scrotum. The history, physical examination and patient age can provide important clues as to the exact cause of acute scrotal pain. Age is a key factor since many conditions responsible for acute scrotum commonly occur in certain age groups. Moreover, imaging is used more routinely to identify accurate diagnosis.

Testicular torsion: a 15-year single-centre clinical and histological analysis

AIM

This study reviewed the demographic, epidemiological and clinical factors of boys seen at a single centre who underwent surgical exploration for testicular torsion.

METHODS

Retrospective single-centre review of boys with testicular torsion between 1996 and 2011 was made.

RESULTS

Testicular torsion (right n = 43, left n = 60, bilateral n = 1) was identified in 104 boys between 0 and 18 years. Ten newborns presented with 11 intrauterine torsions. Nine torsions presented in undescended inguinal testes (one intrauterine). In 94 boys with descended testes, presentation included pain (76%), scrotal swelling (65%) and abdominal symptoms (22%). Ultrasonography was performed in 85 patients with false-negative results in 4 (4.7%). Orchiectomy was performed during initial exploration in 41, with significantly higher rates of orchiectomies in patients with late (>6 h) versus patients with early referrals (<6 h) (56% vs. 9.1%). Histological evaluation was carried out in 68 testes, with 43 resected testes demonstrating haemorrhagic necrosis. In 25 biopsied testes, histology revealed acute parenchymal bleeding (n = 14), onset of parenchymal infarction (n = 8), orchitis (n = 1) and normal tissue (n = 2). Eighty-two patients were followed up with pathological findings in four patients: testicular atrophies requiring orchiectomy (n = 2), testicular autolysis (n = 1) and small testicular vein thrombosis (n = 1).

CONCLUSION

Chances of testicular salvage after torsion are higher if patients present early. The majority of patients presenting late (>6 h) require orchiectomy owing to testicular necrosis.

[Testicular torsion: a tricky diagnosis]

In common urological practice, testicular torsion is one of the most serious emergencies. Consequences can be devastating for the patient, both physically and psychologically. The primary care physician should be able to quickly identify the pathology and refer immediately the patient to a center with surgical facilities. Rapid diagnosis provides the best chances to save the patient's testicle, which may suffer irreversible damage as soon as 6 hours after the onset of the symptoms. History and clinical examination remain the cornerstones of the diagnosis, and are often sufficient to select patients who need surgical exploration. If time allows it, Doppler Ultrasound can often help distinguish torsion from other scrotal conditions, but cannot be considered as a 100% diagnostic tool.

[Bilateral intrauterine testicular torsion in a newborn]

Bilateral intrauterine testicular torsion is a rare condition associated with a low salvage rate of the testes. Due to variable symptoms it is difficult to rapidly find the correct diagnosis. Here, we report on a newborn with bilateral livid swelling of the scrotum for which a bilateral orchiectomy was carried out. Histological investigation of the specimens confirmed bilateral hemorrhagic infarction. The management of bilateral intrauterine testicular torsion is still controversial. Immediate surgical intervention is still considered to be the treatment approach of choice to salvage the testes.

History and physical examination findings predictive of testicular torsion: an attempt to promote clinical diagnosis by house staff

OBJECTIVE

To standardize the history and physical examination of boys who present with acute scrotum and identify parameters that best predict testicular torsion.

MATERIALS AND METHODS

Over a 5-month period, a standardized history and physical examination form with 22 items was used for all boys presenting with scrotal pain. Management decisions for radiological evaluation and surgical intervention were based on the results. Data were statistically analyzed in correlation with the eventual diagnosis.

RESULTS

Of the 79 boys evaluated, 8 (10.1%) had testicular torsion. On univariate analysis, age, worsening pain, nausea/vomiting, severe pain at rest, absence of ipsilateral cremaster reflex, abnormal testicular position and scrotal skin changes were statistically predictive of torsion. After multivariate analysis and adjusting for confounding effect of other co-existing variables, absence of ipsilateral cremaster reflex (P < 0.001), nausea/vomiting (P < 0.05) and scrotal skin changes (P < 0.001) were the only consistent predictive factors of testicular torsion.

CONCLUSION

An accurate history and physical examination of boys with acute scrotum should be primary in deciding upon further radiographic or surgical evaluation. While several forces have led to less consistent overnight resident staffing, consistent and reliable clinical evaluation of the acute scrotum using a standardized approach should reduce error, improve patient care and potentially reduce health care costs.