Acute Scrotum

Acute scrotum is defined as the sudden onset of painful and/or swollen clinical condition of the scrotum. Accurate history and physical examination can often determine the cause. Conditions may or may not require surgical intervention and can be confined to scrotal structures or referred from other sources.

Layers of the Scrotum

1. Skin
2. Dartos Muscle
3. External Spermatic Fascia
4. Cremaster Muscle and Fascia
5. Internal Spermatic Fascia
6. Tunica Vaginalis

Contents of the Scrotum

1. Testes
   • Encased in the tunica albuginea
2. Epididymis
3. Distal Spermatic Cord

Spermatic Cord Components

1. Vas Deferens
2. Blood Vessels
   • Testicular Artery
   • Cremasteric Artery
   • Artery to the Vas Deferens
3. Venous Drainage
   • Pampiniform Plexus
4. Lymphatics
5. Autonomic Nerves

Vascular Supply

1. Testicular Arteries
   • Arise from the abdominal aorta
2. Venous Drainage
   • Pampiniform Plexus to Testicular Veins

Key Anatomical Landmarks

1. Scrotal Septum
2. Tunica Albuginea
3. Inguinal Ring (Deep and Superficial)

Scrotal Skin and Muscle

• Unstriated dartos muscle merges with Colles fascia posteriorly and superficial fascia (Scarpa's) anteriorly.
• Deep to the dartos muscle are the external and internal spermatic fasciae, which are extensions of the superficial fascia of the abdominal wall.
• Scrotum can be subject to edema in cardiac or renal failure or hypoproteinemia and lymphoedema due to its dependent position.
• Temperature within the scrotal sac is 1°C to 2°C lower than body temperature, necessary for testis growth and function.

Testis and Epididymis

• Testes are paired ovoid structures housed in the scrotum with a vertical long axis.
• Epididymis is attached to the posterolateral part of the testis; the tunica vaginalis is anterior and along the sides.
• Normal testis is fixed within the tunica and does not twist.
• Lymphatic drainage to para-aortic lymph nodes, with potential metastasis to the neck and mediastinum.
• Left testicular vein drains into the left renal vein; left renal carcinoma may present as a left varicocele.
• Nerve supply from the abdominal aortic and renal sympathetic plexuses (T10-T12) and pelvic plexus.

Spermatic Cord

• Contains structures running to and from the testis and suspends the testis in the scrotum.
• Begins at the deep inguinal ring, passes through the inguinal canal, exits at the superficial inguinal ring, and ends in the scrotum.
• Includes ductus deferens, testicular artery, pampiniform plexus (testicular vein), and genital branch of the genitofemoral nerve.

Incidence varies.

Study by Mbibu et al.: 178 patients over 18 years (1978-1997) showed 50% had testicular torsion with a mean age of 23 years. Torsion more common in the cold harmattan season (October-March). Salvage rate of torted testes was 52%. Inguinoscrotal hernia caused testicular infarction in 10%. Epididymo-orchitis found in 12% of suspected torsion cases. 13% presented with scrotal gangrene (Fournier's gangrene), which did not result in testicular loss.

• Testicular torsion
• Epididymo-orchitis
• Torsion of epididymal and testicular appendages
• Incarcerated inguinal hernia
• Idiopathic scrotal edema
• Acute hydrocele
• Henoch-Schonlein purpura
• Tumours
• Trauma
• Scrotal (Fournier's) gangrene
• Symptomatic varicocele

Causes of Acute Scrotal Pain and Swelling

• Ischemia:
  • Torsion of the testis (synonymous with torsion of the spermatic cord)
    • Intravaginal; extravaginal (prenatal or neonatal)
  • Appendiceal torsion, testis, or epididymis
  • Testicular infarction due to other vascular insult (cord injury, thrombosis, sickle cell)
• Trauma:
  • Testicular rupture
  • Intratesticular hematoma, testicular contusion
  • Hematocele
• Infectious conditions:
  • Acute epididymitis
  • Acute epididymo-orchitis
  • Acute orchitis
  • Insect bites
  • Abscess (intratesticular, intravaginal, scrotal cutaneous cysts)
  • Gangrenous infections (Fournier's gangrene)
• Inflammatory conditions:
  • Henoch-Schonlein purpura (HSP) vasculitis of scrotal wall
  • Fat necrosis, scrotal wall
• Hernia:
  • Incarcerated, strangulated inguinal hernia, with or without associated testicular ischemia
• Acute on chronic events:
  • Spermatocele, rupture or hemorrhage
  • Hydrocele, rupture, hemorrhage, or infection
  • Testicular tumor with rupture, hemorrhage, infarction, or infection
  • Varicocele

• A twist of the spermatic cord resulting in the strangulation of the blood supply to the testis and epididymis. If left untreated, the blood supply ceases and the testicle dies.
• A testicular salvage rate of 100% if untwisted within 6 hours of the torsion taking place compared with approximately 20% if surgery is delayed for 24 hours.
• Torsion is usually in a clockwise direction in the right testis and anticlockwise in the left.
• There may be half to five and a half turns.
• It leads to venous obstruction, oedema, haemorrhage and finally arterial occlusion, infarction, and atrophy of the testis if it is unrelieved in 6 hours.
• Interstitial cells may survive the infarction.
• Torsion is nearly always intravaginal except in the neonate or undescended testis where it is extravaginal.

Epidemiology

• Most frequently between the ages of 10 and 30 (peak incidence 13-15 years of age), but any age group may be affected.

Predisposing factors

• Inversion of the testis
• Abnormally high attachment of the tunica vaginalis - the bell-clapper deformity
• Undescended testis
• Separation of the epididymis from the body of the testis
• Trauma
• Straining on stool, lifting of heavy weight and rigorous sexual activity

Management - History

• Seen in neonatal period to about 25, but mainly between the neonatal period and one year and 12-16 years
• Sudden onset of severe pain in the hemiscrotum, sometimes waking the patient from sleep
• Pain may radiate to the groin, loin, or epigastrium
• Sometimes a history of minor trauma to the testis
• Some patients report previous episodes with spontaneous resolution of the pain
• Patient feels nauseated and may vomit
• Patient may have a slight fever

Physical examination

• Acutely ill-looking patient, sweating +/- febrile
• The testis is usually very swollen and very tender to touch
• It may be high riding
• May be in a horizontal position due to twisting of the cord
• Cremasteric reflex is usually, but not always, absent (positive Rabinowitz sign)
• Elevation of the involved testicle does not ameliorate the symptoms (negative Prehn’s sign)
• In the neonate, the scrotum at birth is swollen, firm, and bluish or red

Investigation

• The diagnosis is clinical and if in doubt, it is better to explore the testis.
• Imaging investigations are done to rule out other differentials and should not delay surgical exploration.
• Color Doppler USS - reduced arterial blood flow in the testicular artery
• Radionuclide scanning (reduced radioisotope uptake)

Treatment

• Scrotal exploration should be undertaken as a matter of urgency through a scrotal incision.
• Orchidopexy is the goal: if the testis is viable, the cord is untwisted and the testis is fixed using a non-absorbable suture between the tunica vaginalis and tunica albuginea in two places.
• The contralateral testis is also fixed.
• If the testis is not viable, after due consent has been taken, it should be removed - orchidectomy and the contralateral testis fixed.

Differential diagnosis

• Epididymo-orchitis
• Torsion of testicular appendage
• Mumps orchitis
• Idiopathic scrotal edema

Prognosis

• Exploration within 6 hours, salvage rate is 80%
• At 10 hours, 20%
• After 24 hours, almost 0%

• Small polypoid appendages are often found attached to the testis or epididymis and are either Mullerian or Wolffian duct remnants.
• Similar to testicular torsion, torsion of the appendix testis or appendix epididymis can also present with the acute onset of scrotal pain and swelling.
• However, the testis is palpable and has a normal lie.
• Before scrotal swelling develops, it may be possible to palpate the twisted appendage as a 3-5cm tender lump near the upper pole of the testis.

If the torsed appendage is ecchymotic, it can usually be seen through the skin and represents the "blue-dot sign." Doppler ultrasound will demonstrate a normally perfused testis, often with hypervascularity in the area of the appendage.

In many cases, a clear distinction from testicular torsion is not possible and exploration is needed.

Treatment consists of excision of the Appendix.

Inflammatory condition of the epididymis and testis usually caused by a bacterial infection.

Etiology / Pathophysiology

• Infection reaches the epididymis via the vas from a primary infection of the urethra, prostate, or seminal vesicle. As a general rule, infection is of genital origin in young sexually active men, while in older men, more likely a urinary infection.
• In sexually active men aged <35 years, the infective organism is commonly N. gonorrhoeae, C. trachomatis, or coliform bacteria.
• In older men and children, the infective organisms are usually common uropathogens (E. coli), M. tuberculosis.

Management - History

• Scrotal pain that may radiate to the groin and lower abdomen
• Testicular swelling
• Fever

Physical examination

• Erythema of the scrotal skin
• Thickening of the spermatic cord
• Reactive hydrocele
• Evidence of an underlying associated infection (urethral discharge, symptoms of urethritis, cystitis, or prostatitis)
• Positive Prehn’s sign

Investigations

• FBC
• E/U/Cr
• CRP
• Blood cultures (if systemically unwell)
• Urine dipstick +/- culture
• Urethral swab/culture of any urethral discharge
• Scrotal USS

Treatment

• Bed rest
• Analgesia
• Scrotal elevation
• Empirical antibiotics (according to local microbiology guidelines) until culture sensitivities are available

Differential diagnosis

• Testicular torsion
• Torsion of testicular appendage
• Mumps orchitis

Complications

• Testicular abscess formation (requiring incision and drainage)
• Infarction of the testis
• Chronic testicular pain and infection
• Infertility

• Acute, rapidly progressing, and potentially life-threatening necrotizing fasciitis of the genitalia and perineum
• Caused by synergistic and opportunistic infection due to both aerobic and anaerobic organisms including Staphylococcus, microaerophilic hemolytic streptococcus, E. coli, Klebsiella, Fusobacterium, Clostridium welchii, and Bacteroides from the patient
• The aerobes reduce the oxygen tension which enables the anaerobes to thrive
• An accompanying thrombosis of the small subcutaneous vessels leads to necrosis of the overlying skin

Can occur in children and adults.

• Majority are caused by underlying problems like DM, alcoholism, immunosuppression, perianal sepsis, periurethral abscess, urethral stricture/stone, paraphimosis, local trauma, instrumentation, and periurethral extravasation of urine
• In children, it may follow an attack of measles

Clinical features

• Start as sudden painful, tense swelling of the scrotum
• Or cellulitis adjacent to the portal entry of the bacteria
• Local crepitation in some
• Gangrene
• Fever, seriously ill
• Progressive gangrene with a sharp border of healthy tissue
• Fetid odor due to dead tissue and organism
• Gangrene involves whole scrotal thickness which is sloughed off exposing the testes which is unaffected
• May spread to penile skin, anterior abdominal wall, and the thighs
• Preceding urinary difficulty in those that result from urine extravasation

Investigations

• Diagnosis is primarily clinical
• Due to systemic illness: FBC, E/U/Cr, wound swab, urinalysis, urine culture and sensitivity
• FGSI (Fournier’s gangrene severity index) - clinical and laboratory parameters to aid risk stratification and prognosis at the time of admission
  • Parameters are: temperature, heart rate, respiratory rate, serum sodium, potassium, creatinine, and bicarbonate levels, hematocrit, and leukocyte counts
  • Degree of deviation of each parameter is 0-4
  • Overall FGSI > 9 indicates a poor prognosis
• Imaging studies (USG, CT, MRI) may be needed to determine the extent of disease or underlying cause

Treatment

• Urological emergency
• Multimodal approach involving hemodynamic stabilization, broad-spectrum antibiotics, and surgical debridement

• This can be blunt or penetrating.
• Injuries can range from simple bruising, significant intratesticular hematoma, rupture of the tunica albuginea with a very significant collection of blood in the tunica vaginalis (hematocele), to testicular rupture.
• Following blunt injury, the physical examination findings may include swelling, tenderness, or ecchymosis.
• If one can clearly palpate the testis and it is entirely normal to palpation, rupture is unlikely. If there is significant scrotal wall thickening from edema or hematoma, testicular palpation may be difficult or impossible, and scrotal ultrasonography can determine the degree of testicular injury.
• In addition to demonstrating a break in the continuity of the tunica albuginea or evidence of extruded parenchyma, ultrasound evidence of a marked loss of internal homogeneity of the testis is highly predictive of testicular rupture and warrants surgical exploration.
• Treatment is to repair the tunica albuginea and preserve the testis and in some occasions, orchidectomy is necessary.

• An acute inguinal hernia may also present as an acute scrotum. In this case, pain and swelling involve both the scrotal and the groin area.
• An incarcerated inguinal hernia involves bowel that is obstructed, it's not reducible and no cough impulse. It is a surgical emergency.
• Treatment is herniotomy or herniorrhaphy.

• Hydrocele is an abnormal collection of serous fluid in the tunica vaginalis or a patent processus vaginalis.
• A vaginal hydrocele can be primary or secondary.
• Hydrocele of a patent processus vaginalis is always primary and congenital.
• Secondary vaginal hydrocele can be due to acute or chronic epididymitis or tumor of the testis.

• It collects rapidly in most patients and may be serous, turbid, or frankly purulent. And when the underlying cause is malignant testis, the fluid is serous or bloodstained.
• There may be painful swelling of the epididymis and scrotum preceded by urethritis.
• The fluid should be tapped and examined.

Treatment

• Tapping
• Hydrocelectomy
• Eversion of the sac
• Lord's operation
• Aspiration and Injection of sclerosant

• It is an abnormal dilatation, elongation, and tortuosity of the pampiniform venous plexus that run along the spermatic cord and drain the testis. It is seen in 15% of normal males and approximately 40% of men with infertility.
• Common etiological factors include high venous pressure in the left internal spermatic vein (90%), the nutcracker phenomenon, obstruction of the left renal vein.

Clinical features

• Clinically manifest at the time of puberty. It is seen commonly in adolescents or young men complaining of infertility.
• Complaint of swelling or dragging pain in the scrotum.
• In over 90% of patients, it is the left veins that are affected.
• When the patient stands erect, the affected hemi-scrotum, usually the left, hangs lower because the elongation of the veins tends to lengthen the cord.
• On palpating the cord between the thumb and index finger at the neck of the scrotum, the affected veins feel like a bag of worms.
• When the patient lies down, the veins empty and the worm-like feeling disappears.
• The testis on the affected side may be smaller and softer than the contralateral unaffected one.

Clinical grading system

• Divides varicoceles into 3 grades:
  1. Small (grade 1) varicoceles are only palpable during a Valsalva manoeuvre.
  2. Moderate (grade 2) varicoceles are palpable without the need for the Valsalva manoeuvre.
  3. Large (grade 3) varicoceles are both visible and palpable.

Investigation and treatment

• Diagnosis of varicocele may be confirmed by the use of Doppler ultrasound which shows venous reflux in the pampiniform plexus or by scrotal thermography.
• In patients complaining of subfertility, the semen analysis is done; it is usually subnormal.
• Treatment is varicolectomy.
• Complications of varicolectomy include hydrocele formation (2-5%), testicular artery injury, and recurrence (10%). Surgical approaches that utilize lymphatic-sparing techniques have a lower rate of hydrocele formation.

• Henoch-Schonlein purpura (HSP) is an immune-mediated systemic vasculitis generally found in children.
• Scrotal and testicular manifestations associated with HSP are rare.
• Common testicular manifestations of HSP include epididymitis, orchitis, and spermatic cord complications. Symptoms of scrotal involvement associated with HSP typically include clinical manifestations of HSP as well as scrotal pain, redness, and swelling.

The disease is self-limiting and treatment is usually supportive; steroids can also be given. Appropriate treatment of the complications should also be done.

• Testicular tumours have an incidence among Caucasians of 2.5-3/100,000 and account for 1% of male tumours. It is less commonly encountered in Negroes, Africans, and Asians.
• About 10% of them arise in undescended testes. A quarter of males with bilateral undescent who develop a tumour in one testis will develop a tumour in the second.
• They are of various types (modified WHO classification 2004).

Germ Cell Tumours

• Precursor lesions - Intratubular germ cell neoplasia (ITGCN) or carcinoma in situ
• Tumours of one histological type:
  1. Seminoma (Variant: Seminoma with syncytiotrophoblastic cells)
  2. Spermatocytic seminoma (Variant: Spermatocytc seminoma with sarcoma)
• Non-seminomatous germ cell tumours (NSGCT)
  1. Embryonal cancer
  2. Yolk sac tumour
  3. Polyembryoma
  4. Trophoblastic tumours (Choriocarcinoma)
     • Pure
     • Mixed
     • Placental site trophoblastic tumour
  5. Teratoma
     • Mature
     • Dermoid cyst
     • Teratoma with malignant areas
• Tumours of more than one histological type (mixed forms)
  • Embryonal carcinoma and teratoma
  • Teratoma and seminoma
  • Choriocarcinoma and teratoma embryonal carcinoma
  • Other combinations

Non Germ Cell Tumours

• Sex Cord/Gonadal Stromal Tumours
  1. Leydig cell tumours
  2. Sertoli cell tumours
  3. Granulosa cell tumours
     1. Adult-type
     2. Juvenile-type
  4. Tumours of thecoma/fibroma group
  5. Incompletely differentiated tumours
  6. Mixed forms
• Tumours containing both germ cell and sex cord/stromal elements
  1. Gonadoblastoma
  2. Mixed germ cell-sex cord/gonadal stromal tumours
• Miscellaneous tumours
  1. Carcinoid tumour
  2. Tumours of ovarian epithelial types
• Lymphoid and Haematopoietic Tumours
  1. Lymphoma
  2. Plasmacytoma
  3. Leukaemia

Spread

Testicular tumours metastasize via the bloodstream to the lungs and other sites and via the lymphatics to the para-aortic, mediastinal, and supraclavicular lymph nodes.

Clinical Features

• Enlarged painless or heavy testis (80% of patients).
• A secondary hydrocele.
• Acute pain due to bleeding and simulating acute epididymo-orchitis.
• Metastases.
• Endocrinopathy.

Examination

• There is a firm or hard non-tender testicular swelling which may have a smooth (seminoma) or bosselated (teratoma) surface.
• If there is a secondary hydrocele, it is only moderate in size. If its presence, however, impairs full examination of the testis, scrotal ultrasound to evaluate the testis is warranted.
• There may be a midline upper abdominal mass of lymph nodes and/or supraclavicular lymphadenopathy, occasionally with normal or atrophic testis.
• The lungs are examined for metastases.

Investigations

• Scrotal ultrasound: It is useful (in doubtful cases) in separating testicular from extra testicular swellings. On ultrasonography, a typical germ cell tumour is hypoechoic.
• Other imaging tests:
  1. Chest X-ray and CT scan will reveal pulmonary or mediastinal node metastases.
  2. Abdomino-pelvic CT scan will detect retroperitoneal node or liver metastases.
• Serum tumour markers: beta-human chorionic gonadotorophin (hCG), alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH).
• Serum tumour markers should be obtained at diagnosis, after orchidectomy, and during the monitoring of treatment response.
• Differentials include hematocele and epididymo-orchitis.
• Staging is with the TNM classification.

Treatment

• Radical Inguinal Orchidectomy: This is the first part of treatment. It establishes the histologic diagnosis and the extent of tumour spread within the testis (primary T stage). Radical orchidectomy alone is curative in the majority of patients with Stage I disease (80-85% of seminomas and 70-80% of NSGCTS).
• Very rarely, a patient may present with life-threatening metastasis for which primary chemotherapy is initiated upfront, followed by delayed orchidectomy after clinical stabilization.

Post-orchidectomy Treatment

This depends on the type of tumour, stage of the disease, and the prognosis of patients with metastatic GCT, using the IGCCCG classification. Due to the effect of the modalities of treatment (i.e., chemotherapy, radiation, retroperitoneal lymph node dissection (RPLND)) on fertility, men who are undecided or are planning future paternity should be counseled to undergo sperm cryopreservation (if facilities are available) before treatment is started.

• A full range of scrotal pathology must be considered in acute scrotum cases.
• Several conditions that result in acute scrotum require surgical exploration, making this a very time-sensitive condition.
• A high value is placed on the history, physical examination, and ultrasound imaging for acute scrotum diagnoses.