ACUTE SCROTUM

BY DR NGWOBIA P. AGWU

INTRODUCTION
ACUTE SCROTAL CONDITIONS ARE IMPORTANT UROLOGICAL EMERGENCIES: THOUGH OF LOW MORTALITY, BUT GREAT MORBIDITY THE SCROTUM HOUSES THE TESTIS FOR PROCREATION AND NORMAL SEXUAL FUNCTION

INTRODUCTION contd
DEFINITION: PAINFUL AND OR SWELLING OF SCROTUM OR CONTENTS PRESENTING ACUTELY OR SUBACUTELY OFTEN ASSOCIATED WITH OEDEMATOUS SCROTAL SKIN

EMERGENCY SITUATION REQUIRING: .PROMPT EVALUATION . DIFFERENTIAL DIAGNOSIS .. POTENTIALLY IMMEDIATE .SURGICAL EXPLORATION A LONG LIST OF DIFFERENTIALS IMPERATIVE TO RULE OUT TORSION

ANATOMY OF SCROTUM AND ITS CONTENTS

CONSISTS OF 2 LAYERS; 1. HEAVILY PIGMENTED SKIN 2.DARTOS FASCIA SEPTUM DIVIDES IT INTO 2 COMPARTMENT SUPRFICIAL DARTOS DEVOID OF FAT AND IS CONTINUOS WITH SCARPAS AND COLLES. FASCIA

CUTANEOUS FIBROMUSCULAR SAC CONTAINS TESTES AND ASSOCIATED STRUCTURES

TESTIS
OVAL ORGAN COVERED BY TUNICA ALBUGINEA POSTERIOR SURFACE- EPIDIDYMS VAS DEFERENCES ARISES FROM LOWER POLE OF EPIDIDYMS, PASSES UPWARDS, MEDIALLY AND BEHIND THE TESTIS TESTIS, EPIDIDYMS AND TUNICA LIE IN THE SCROTUM

DIFFERENTIAL DIAGNOSIS OF ACUTE SCROTUM

1. TESTICULAR TORSION 2.TORSION OF TESTICULAR APPENDAGE 3. EPIDIDYMITIS 4. ORCHITIS 5.FOURNIERS GANGRENE 6. OBTRUCTED INGUINOSCROTAL HERNIA 7.HYDROCOELE 8. TESTICULAR TUMOR .9. IDIOPATHIC SCROTAL OEDEMA 10. TRAUMA 11. SCHONLEIN-HENOCH PURPURA

DIAGNOSIS
HISTORY 1. AGE; TORSION COMMONER IN NEONATES AND POST-PUBERTALS - S-H PURPURA, TORSION OF APPENDAGE IN PRPUBERTAL - EPIDIDYMITIS IN POST-PUBERTALS 2. ONSET AND DURATION -TORSION ABRUPT, PAIN SEVERE

DIAGNOSIS, HISTORY
MODERATE PAIN OVER FEW DAYSEPIDIDYMITIS AND APPENDICEAL TORSION. PATIENT APPEARS COMFORTABLE HX OF TRAUMA DOES NOT EXCLUDE TORSION PAIN PERSISTING> I HOUR POSTTRAUMA= RUPTURE OR TORSION

PAIN RESOLVING PROMPTLY BUT APPEARING GRADUALLY OVER DAYS- TRAUMATIC EPIDIDYMITIS PREVOIUS HX OF SCROTAL PAINS UROLOGIC, SURGICAL HISTORY NEUROLOGIC PROBLEMS CONGENITAL GENITOURINARY ABNORMALITIES URETHRAL INSTUMENTATION

PHYSICAL EXAMINATION 1. INSPECTION -DEGREE OF DISCOMFORT -IS PATIENT AMBULANT OR WITH DISCOMFORT 2.GENRAL ABD. EXAMINATION -FLANK TENDERNESS -BLADDER DISTENSION -INGUINAL REGION -SPERMATIC CORD FOR TENDERNESS

3. GENITAL EXAMINATION HIGH RIDING TESTIS- TORSION CREMASTERIC REFLEX ; RARELY INTACT IN TORSION TESTICULAR EXAMINATION: ANGELS SIGN, PREHNS SIGN

DIAGNOSTIC STUDIES

URINALYSIS SCROTAL ULTRASONOGRAPHY COLOUR DOPPLER ULTRASONOGRAPHY

TREATMENT
1. TESTICULAR TORSION AXIAL TWIST LEADING TO VENOUS OBSTRUCTION, SECONADARY ARTERIAL OCCLUSION, ISCHAEMIA, INFARCTION AND GANGRENE TREATMENT IS URGENT SURGERY= SCROTAL EXPLORATION, DETORSION AND ORCHIDOPEXY, IPSIL+ CONTRALATERAL NON- VIABLE TESTIS- ORCHIDECTOMY

2. ACUTE EPIDIDYMITIS/ORCHITIS ASSOCIATED MAINLY WITH N.S.U MAY BE DUE TO S.T.D, TRAUMA, SURGEY, INSTRUMENTATION TREATMENT INCLUDES: BED REST SCROTAL ELEVATION ANALGESICS ANTIBIOTICS

3. TORSION OF TESTICULAR APPENDAGE APPENDIX TESTIS( Mullerian duct ) AT THE SUPERIOR PLOE, APPENDIX EPIDIDYMIS( Wolfian duct) HEAD OF EPIDIDYMIS THESE PRODUCE TORSION BUT OF SLOWER ONSET

DOPPLER USS SHOWS INCREASED BLD FLOW TREATMENT : BED REST SCROTAL ELEVATION NASIDS AND ANALGESICS HAVE BEEN VERY EFFECTIVE NO ANTIBIOTICS IF URINE NORMAL

4. TESTICULAR TRAUMA TESTIS USUALLY WELL PROTECTED BLUNT TRAUMA FROM BLOWS, KICKS, FALLING ASTRIDE TRAUMA MAY FOLLOW SURGERY MINOR TRAUMA-ICE PACKS,SUPPORT EXPLORATION IF TESTIS IS BRUISED OR SWOLLEN

DECOMPRESSION OF TUNICA LACERATION OF TUNICA, LIGATE BLEEDERS, DRAIN SCOTUM

5. IDIOPATHIC SCROTAL OEDEMA XTRIZED BY RAPIDLY DEVELOPING UNILATERAL SCROTAL OEDEMA SPREADIN TO THE OPPOSITE SIDE, THEN TO INGUINAL AND PERINEUM THERE IS DISCOMFORT NOT ACUTE PAIN TESTES ARE NON TENDER, NORMAL

OEDEMA SUBSIDES IN 24-48HRS THERE MAY BE HX OF INSECT BITE, MEDICATION TREATMENT: WARM SOAKS CLEANINESS MILD SEDATION WITH ANTIHISTAMINES

6. ACUTE HYDROCOELE USUALLY SECONDARY TO INFLAMMATION OF TUNICA VAGINALIS MAY BE GONOCCAL OR COLIFORM, MAY FOLLOW TORSION , STRANGULAED INGUINAL HERNIA.. DURING THE ACUTE STAGE, BEDREST, ASPIRATION, SCROTAL ELEVATION LATER, HYDROCELECTOMY

7.FOURNIERS GANGRNE( NECROTIZING PERINEAL FASCITIS) CONSERVATIVE ; HONEY DRESSING RADICAL EXCISION HYPERBARIC OXYGEN

THAKS FOR LISTENING;

YOUR QUERIES ARE WELCOME