Scrotal Pain and Swelling

Jesse Sturm, MD
December, 20, 2006

Outline
Embryology and anatomy
Causes of Pain and Swelling
Torsion, Epididymitis, Orchitis, Trauma
History, Physical, Radiologic Exams, Labs

Causes of Swelling
Hydrocele, Varicocele, Spermatocele, Tumor,
Idiopathic

Embryology
Descent of testes at 32-40 wks gestation
Descends within processes vaginalis
Outpouching of peritoneal cavity
Tunica vaginalis is potential space that remains
after closure of process vaginalis

Anatomy
Spermatic cord testicular vessels, lymph, vas
deferens
Epididymis - sperm formed in testicle and undergo
maturation, stored in lower portion
Vas Deferens muscular action propels sperm up and
out during ejaculation

Gubernaculum fixation point for testicle to

tunica vaginalis
Tunica Vaginalis potential space
Encompasses anterior 2/3s of testicle
Tunica albuginea is inner layer opposing testis

Anatomy Nuts and Bolts

Posterior

Anterior

Causes of Pain and Swelling

Pain

Testicular torsion
Torsion of appendix testis
Epididymitis
Trauma
Orchitis and Others

Swelling

Hydrocele
Varicocele
Spermatocele
Tumor

Torsion
Inadequate fixation of testes to tunica vagnialis
at gubernaculum
Torsion around spermatic cord
Venous compression to edema to ischemia

Epidemiology
Accounts for 30% of all acute scrotal swelling
Bimodal ages neonatal (in utero) and pubertal
ages
65% occur in ages 12-18yo

Incidence 1 in 4000 in males <25yo

Increased incidence in puberty due to inc weight
of testes

Predisposing Anatomy
Bell-clapper deformity
Testicle lacks normal
attachment at vaginalis
Increased mobility
Tranverse lie of testes
Typically bilateral
Prevalence 1/125

Torsion: Clinical Presentation

Abrupt onset of pain usually testicular, can be
lower abdominal, inguinal
Often < 12 hrs duration
May follow exercise or minor trauma
May awaken from sleep
Cremasteric contraction with nocturnal stimulation
in REM

Up to 8% report testicular pain in past

Torsion: Examination
Edematous, tender, swollen
Elevated from shortened spermatic cord
Horizontal lie common (PPV 80%)
Reactive hydrocele may be present

Cremasteric reflex absent in nearly all

(unreliable in <30mo old) (PPV 95%)
Prehns sign elevation relieves pain in
epididymitis and not torsion is unreliable

Intermittent Torsion
Intermittent pain/swelling with rapid resolution
(seconds to minutes)
Long intervals between symptoms
PE: testes with horizontal lie, mobile testes,
bulkiness of spermatic cord (resolving edema)
Often evaluation is normal if suspicious need
GU followup

Diagnosis Time is Testicle

Ideally -- prompt clinical diagnosis
Imaging
Color doppler decreased intratesticular flow
False + in large hydrocele, hematoma
Sens 69-100% and Spec 77-100%
Lower sensitivity in low flow pre-pubertal testes

Nuclear Technetium-99 radioisotope scan

Show testicular perfusion
30 min procedure time
Sens and spec 97-100%

 Acute torsion L testis

Dec blood flow on L

Late torsion on R
Inc blood flow around
but dec flow w/in testis

Images - Torsion
Decreased echogenicity
and size of right testicle

Nuclear medicine scan

shows "rim sign =no flow
to testicle and swelling

Management
Detorsion within 6hr = 100% viability
Within 12-24 hrs = 20% viability
After 24 hrs = 0% viability

Surgical detorsion and orchiopexy if viable

Contralateral exploration and fixation if bell-clapper
deformity

Orchiectomy if non-viable testicle

Never delay surgery on assumption of nonviability
as prolonged symptoms can represent periods of
intermittent torsion

Manual Detorsion
If presents before swelling
Appropriate sedation
In 2/3rds of cases testes
torses medially, 1/3rd lateral
Success if pain relief, testes
lowers in scrotum
Still need surgical fixation

Torsion: Special Considerations

Adolescents may be embarrassed and not seek
care until late in course
Torsion 10x more likely in undescended testicle
Suspicious if empty scrotum, inguinal pain/swelling

Adult Emergency Physicians accurate in bedside

US diagnoses with sens of 95% and specificity
of 94% (missed 1 epididymitis, no torsion)
Blavis M., Emergency Evaluation of Patients Presenting with A Cute Scrotum, Academy of Emergency Medicine.
Jan 2001

Neonatal Torsion

70% prenatal, 30% post-natal

Post-natal typically 7-10 days after birth
Unrelated to gestation age, birth weight
Post-natal presents in typical fashion
Doppler U/S and radionucleotide scans less accurate
with low blood flow in neonates
Surgical intervention if post-natal

Prenatal torsion presents with painless testicular

swelling, rare testicular viability
Rare intervention in prenatal torsion

Torsion of Appendix Testis

Appendix testis
Small vestigial structure,
remnant of Mullerium duct
Pedunculated, 0.3cm long

Other appendix structures

Prepubertal estrogen may
enlarge appendix and cause
torsion

Torsion of Appendix Testis

Peak age 3-13 yo (prepubertal)

Sudden onset, pain less severe
Classically, pain more often in abd or groin
Non-tender testicle
Tender mass at superior or inferior pole
May be gangrenous, blue-dot (21% of cases)
Normal cremasteric reflex, may have hydrocele
Inc or normal flow by doppler U/S

Torsion of Appendix Testis

Blue dot of gangrenous

appendix testis

Torsion of Appendix Testis

Management supportive
analgesics, scrotal support to relieve swelling

Surgery for persistent pain

no need for contralateral exploration

Epididymitis
Inflammation of epididymis
Subacute onset pain, swelling localized to
epididymis, duration of days
With time swelling and pain less localized
Testis has normal vertical lie
Systemic signs of infection
inc WBC and CRP, fever + in 95%

Cremasteric reflex preserved

Urinary complaints: discharge/dysuria PPV 80%

Epididymitis
Scrotum has overlying erythema, edema in 60%
Normal vertical
lie

Epididymitis
Sexually active males
Chlamydia > N. gonorrhea > E. coli
Less commonly pseudomonas (elderly) and
tuberculosis (renal TB)
Young boys, adolescents often post-infectious
(adenovirus) or anatomic
Reflux of sterile urine through vas into epididymis
50-75% of prepubertal boys have anatomic cause by
imaging

Etiologies of Epididymitis

Epididymitis Diagnosis
Leukocytosis on UA in ~40% of patients
PCR Chlamydia + in 50%, GC + in 20% of
sexually active
95% febrile at presentation
Doppler and Nuclear imaging show increased flow
If hx consistent with STD, CDC recommends:
Cx of urethral discharge, PCR for C and G
Urine culture and UA
Syphilis and HIV testing

Laboratory Adjuncts
Studies of acute phase reactants: CRP, IL-1, IL-6
Documented epididymitis have 4 fold increase in CRP
compared to testicular torsion
PPV 94% and NPV 94% (inc 2 fold)
Testicular tumor showed no increase in CRP

Doehn C., Value of Acute Phase Proteins in the Differential Diagnosis of A Cute Scrotum, Journal of Urology. Feb 2001.

Doppler Epididymitis
Left Epididymitis
Inc blood flow in
and around left testis

Epididymitis Treatment
Sexually active treat with
Ceftriaxone/Doxycycline or Ofloxacin
Pre-pubertal boys
Treat for co-existing UTI if present
Symptomatic tx with NASIDs, rest
Referral all to GU for studies to rule out VUR,
post urethral valves, duplications
Negative culture has 100% NPV for anomaly

Orchitis
Inflammation/infection of testicle
Swelling pain tenderness, erythema and shininess to
overlying skin

Spread from epididymitis,

hematogenous, post-viral
Viral: Mumps, coxsackie,
echovirus, parvovirus
Bacterial: Brucellosis

Mumps Orchitis
Extremely rare if vaccinated
20-30% of pts with mumps, 70% unilateral, rare
before puberty
Presents 4-6 days after mumps parotitis
Impaired fertility in 15%, inc risk if bilateral

Trauma
Result of testicular compression against the
pubis bone, from direct blow, or straddle injuries
Extent depends on location of rupture
Tunica albuginea ruptures (inner layer of tuncia
vaginalis) allows intratesticular hematoma to rupture
into hematocele
Rupture of tunica vaginalis allow blood to collect
under scrotal wall causing scrotal hematoma

Doppler often sufficient to assess extent

Surgery for uncertain dx, tunica albuginea
rupture, compromised doppler flow

Testicular Hematoma
Blood as a filling
defect in testis

Other Causes of Pain

Incarcerated inguinal hernia
Henoch-Schonlein Purpura
Vasculitis of testicular vessels
Rarely presents with only scrotal pain

Referred pain
Retrocecal appendix, urolithiasis, lumbar/sacral nerve injury

Non specific scrotal pain

Minimal pain, nl exam return immediately for inc symptoms

Scrotal Swelling

Hydrocele
Varicocele
Spermatocele
Testicular Cancer

Hydrocele
Fluid accumulation
in potential space of
tunica vaginalis
May be primary from
patent PV or secondary
to torsion/epididymitis

Hydrocele
Transilluminating
anterior cystic
mass

Hydrocele
Mass increases in size during day or with crying
and decreases at night if communicating
If non-communicating and <1 yo follow
If communicating (enlarging), scrotum tense
(may impair blood flow) requires repair
Unlikely to close spontaneously and predisposes to
hernia

Varicocele
Collection dilated veins in
pampiniform plexus
surrounding spermatic cord
More common on left side
R vein direct to IVC
L vein acute angle to renal vein

~20% of all adolescent males

Varicocele
Often asymptomatic or c/o dull ache/fullness
upon standing
Spermatic cord has bag of worms appearance
that increased with standing/valsalva
If prepubertal, rapidly enlarging, or persists in
supine position rule out IVC obstruction
Most management conservatively
Surgery if affected testis < unaffected testis volume

Spermatocele
Painless sperm containing
cyst of testis, epipdidymis
Distinct mass from testis
on exam
Transilluminates
Do not affect fertility
Surgery for pain relief only

Testicular Cancer
Most common solid tumor in 15-30 yo males
20% of all cancers in this group

Painless mass
Rapidly growing germ cell tumors may cause
hemorrhage and infarction
Present as firm mass
Typically do not transilluminate
Diagnostic imaging with U/S initially

Acute Idiopathic Scrotal Edema

Scrotal skin red and tender
underlying testis normal
no hydrocele

Erythema extends off

scrotum onto perineum
Empiric tx, cause unknown
Antihistamine, steroids
Resolves w/in 48-72hrs

Conclusions
Clinical history and careful exam are key factors in
formulating accurate differential
Imaging and labs useful adjuncts in unclear cases
U/S superior to nuclear imaging if time essential

TIME IS TESTICLE
Early surgical intervention and GU involvement

Swelling without pain, usually less time sensitive

diagnostically

References

Ciftci, AO. Clinical Predictors for Diff. Diagnosis of Acute Scrotum,

European J. of Ped. Surgery. Oct 2004.
Blavis M., Emergency Evaluation of Patients Presenting with Acute
Scrotum, Academy of Emergency Medicine. Jan 2001
Doehn C., Value of Acute Phase Proteins in the Differential
Diagnosis of Acute Scrotum, Journal of Urology. Feb 2001.
Kaplan G., Scrotal Swelling in Children. Pediatrics in Review. Sep
2000.
Luzzi GA. Acute Epididymitis. BJU International. May 2001.
Fleisher G, Ludwig S, Henretig F. Textbook of Pediatric Emergency
Medicine. 2006.