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Wein: Campbell-Walsh Urology, 9th ed.

Copyright 2007 Saunders, An Imprint of Elsevier


ACUTE SCROTUM
A child or adolescent with acute scrotal pain, tenderness, or swelling should be looked
on as an emergency situation requiring prompt evaluation, differential diagnosis, and
potentially immediate surgical exploration. Adolescent boys do not always understand the
potential significance of acute scrotal conditions, and evaluation in many cases is delayed. As
a result, a subacute or even chronic scrotal condition may in certain situations merit prompt
evaluation and intervention.
Differential Diagnosis

The list of differential diagnoses for an acute scrotum is extensive. In all instances it is
imperative to rule out torsion of the spermatic cord, a clinical diagnosis requiring
emergency surgical intervention ( Table 127-1 ).
Table 127-1 -- Differential Diagnosis of Acute/Subacute Scrotum
Torsion of the spermatic cord
Torsion of the appendix testis
Torsion of the appendix epididymis
Epididymitis
Epididymo-orchitis
Inguinal hernia
Communicating hydrocele
Hydrocele
Hydrocele of the cord
Trauma/insect bite
Dermatologic lesions
Inflammatory vasculitis (Henoch-Schnlein purpura)
Idiopathic scrotal edema
Tumor
Spermatocele
Varicocele
Nonurogenital pathology (e.g., adductor tendinitis)

Torsion of the Spermatic Cord (Intravaginal)

Torsion of the spermatic cord is a true surgical emergency of the highest order.
Irreversible ischemic injury to the testicular parenchyma may begin as soon as 4 hours
after occlusion of the cord. Bartsch and colleagues (1980) demonstrated that although testes
operated on less than 8 hours after the onset of symptoms of torsion retained normal testis
size and showed just slight changes in testicular morphology, only 50% of men whose testes
underwent detorsion less than 4 hours after symptoms began had normal semen analysis. It

appears that the degree of torsion that occurs may have a significant influence on the
potential for viability of the testis over time. The significance of this situation is magnified by
the findings of Barada and coworkers (1989) , who reported that patients younger than 18
years were more prone to testicular loss after acute torsion because of a median delay in
medical evaluation of 20 hours after the onset of scrotal pain, an indication of the need for
improved awareness of the significance of scrotal pain in adolescents.
Intravaginal torsion, or torsion of the cord within the space of the tunica vaginalis, may
result from lack of normal fixation of an appropriate portion of the testis and
epididymis to the fascial and muscular coverings that surround the cord within the
scrotum. In effect, the normally segmental area of the free space between the parietal and
visceral layers of the tunica vaginalis is expanded to surround the testis and epididymis and
extends proximally up the cord for a variable distance. This creates an abnormally mobile
testis that hangs freely within the tunica space (a bell-clapper deformity) ( Fig. 127-9 ).

Figure 127-9 Anomalies of the inguinal canal and scrotum that may result from anomalous closure of the processus vaginalis.
(From Welch KA, Randolph JG, Ravitch MM, et al [eds]: Pediatric Surgery, vol 2, 4th ed. St Louis, Year Book, 1986, p 780.)

Although torsion of the cord does occur in prepubertal males, it appears that the added weight
of the testis after puberty adds a physical dimension that may be more likely to allow the
testis to twist on its vascular stalk. Torsion can occur in association with trauma or athletic
activity, but in most cases spontaneous torsion of the cord is reported; in many cases the
adolescent is awakened from sleep. It is thought that sudden contraction of the cremasteric
muscle, which inserts onto the cord in a spiral configuration, is the inciting event in most
cases and initiates a rotational effect on the testis as it is pulled upward. The cord may twist
as many as several complete (360-degree) rotations.
The classic manifestation of acute torsion of the spermatic cord is that of an acute onset
of scrotal pain, but in some instances the onset appears to be more gradual, and in some
boys the degree of pain is minimized. A large number of boys with acute scrotal pain
give a history of previous episodes of severe, self-limited scrotal pain and swelling. It is
likely that these incidents represent previous episodes of intermittent torsion of the cord with
spontaneous detorsion. Nausea and vomiting may accompany acute torsion, and some boys
have pain referred to the ipsilateral lower quadrant of the abdomen. Dysuria and other
bladder symptoms are usually absent.

The history is an important factor in the differential diagnosis of an acute scrotum, but the
physical examination may perhaps be even more crucial in determining whether the diagnosis
is torsion of the cord or otherwise (i.e., whether the patient does or does not require
immediate surgical exploration). Inspection of the genitalia may prove helpful if the affected
testis is riding high in the scrotum, perhaps indicating foreshortening of the spermatic cord as
the result of twisting of the cord. In some cases, the affected testis has an abnormally
transverse orientation, but in many cases, in particular when several hours have passed since
onset, an acute hydrocele or massive scrotal edema obliterates all landmarks. The absence of
a cremasteric reflex is a good indicator of torsion of the cord. Rabinowitz (1984) found
100% correlation between absence of a cremasteric reflex and the presence of torsion in 245
boys over a 7-year period. In some cases, assessment of this physical finding is difficult.
When the patient is cooperative enough to allow examination of the affected hemiscrotum,
effort should be made to assess anatomic landmarks to primarily look for an appreciation of
normal structures in an attempt to identify a swollen and tender epididymis or a twisted
appendix of the testis or epididymis. If torsion of the cord seems likely, manual detorsion
should be attempted as part of the initial examination because the patient may be
uncooperative with an extended examination because of discomfort. Classically, torsion of
the cord occurs such that the anterior surface of each testis turns toward the midline as
viewed from the patient's perspective ( Sparks, 1971 ). To accomplish detorsion of the cord, a
rotational effort should be made in the opposite direction. Kiesling and associates (1984)
described detorsion through two planes, with rotation in a caudal-to-cranial direction and
simultaneous medial-to-lateral rotation. In actuality, the examiner should try to twist or
unscrew the testis in one direction (usually outward, toward the thigh) and then in the
opposite direction if the first attempt is unsuccessful. When detorsion is successful, the testis
flips into a different rotation and pain relief may be almost instantaneous, with the cord
appearing to lengthen and the testis dropping into the scrotum. If manual detorsion does not
totally correct the rotation that has occurred, prompt exploration is indicated. However, when
the patient becomes almost immediately comfortable, it can be assumed that blood flow to
the testis has been restored, at least to a significant degree, yet this should not be used to defer
exploration.
When the diagnosis of torsion of the cord is suspected, prompt surgical exploration is
warranted. Although adjunctive tests are commonly used to aid in the differential
diagnosis of an acute scrotum, these tests are most appropriately performed when their
purpose is to confirm the absence of torsion of the cord in cases in which surgical
intervention is believed to be unnecessary. Doppler examination of the cord and testis to
determine whether blood flow is present was once touted as a helpful diagnostic test, but
false-positive and false-negative results have led most examiners to abandon this technique.
Color Doppler ultrasound examination has become the adjunctive investigation of choice in
many institutions for the evaluation of both acute and chronic scrotal conditions. Color
Doppler studies allow an assessment of anatomy (e.g., presence of a hydrocele, swollen
epididymis) while determining the presence or absence of blood flow to the testis. Baker and
associates (2000) showed that in patients with acute scrotal swelling and an uncertain
diagnosis, color Doppler examination had a diagnostic sensitivity of 88.9% and a specificity
of 98.8%, with a 1% rate of false-positive results. Allen and Elder (1995) , however, reported
five cases in which color Doppler interpretations were inconsistent with findings at surgery. It
is clear that as in most clinical situations, ultrasound imaging is inherently operator
dependent.

Radionuclide imaging, originally the study of choice for assessment of an acute scrotum, is
more limited because it allows evaluation of only testicular blood flow ( Kogan et al, 1979 ).
Although Levy and associates (1983) found the study to have a positive predictive value of
75%, a sensitivity of 90%, and a specificity of 89%, a false impression of blood flow may
result from hyperemia of the scrotal wall. In addition, children with small scrotal sacs and
testes that are not dependent may be difficult to image with radionuclide techniques. Despite
these shortcomings, Paltiel and colleagues (1998) found the efficacy of color Doppler
imaging and radionuclide imaging to be equivocal in the diagnosis of torsion of the spermatic
cord in boys with indeterminate clinical diagnoses. In most institutions, clinicians learn to
place most trust in the imaging technique and in radiographers with the most interest,
experience, and reliability in the differential diagnosis of an acute scrotum.
When surgical exploration is elected, it should be performed promptly. A median raphe
scrotal incision may be used to explore both sides, or a transverse incision following the skin
creases may be placed in each hemiscrotum. The separate incisions are more appropriate for
dartos pouch placement of the testes. The affected side should be examined first. After the
skin has been incised, a dartos pouch may be created into which the testis can later be placed;
then the tunica vaginalis is entered and the testis is examined. The cord should be detorsed to
reestablish blood flow to the testis. Testes with marginal viability should be placed in warm
sponges and re-examined after several minutes. A necrotic testis should be removed by
dividing the cord into two or three segments and doubly ligating each segment with silk
suture. Testes with marginal viability may be preserved, although there has been some
concern about sympathetic orchiopathy in the contralateral testis secondary to circulating
antibodies released from the injured testis ( Cosentino et al, 1982 ; Nagler and White, 1982 ).
The validity of comparing animal studies with the human situation, however, has been called
into question, and most urologists choose to preserve testes that seem marginally viable.
If the testis is to be preserved, it should be placed in the dartos pouch with suture fixation. It
has been shown experimentally that placing sutures through the tunica albuginea of the testis
can produce local injury to the testis, and therefore fixation should be performed with fine,
nonreactive, nonabsorbable sutures placed so that they avoid superficial blood vessels on the
surface of the testis ( Bellinger et al, 1989 ). When torsion of the spermatic cord is found,
exploration of the contralateral hemiscrotum must be carried out. In almost all cases a
bell-clapper deformity is found. The contralateral testis must be fixed to prevent
subsequent torsion.
Intermittent Torsion of the Spermatic Cord

A significant percentage of adolescents with acute torsion of the spermatic cord give a
history of previous episodes of acute, self-limited scrotal pain that appear clinically to
have been episodes of intermittent torsion with spontaneous detorsion ( Stillwell and
Kramer, 1986 ). It is not uncommon to be asked to evaluate an adolescent for one or more
episodes of acute scrotal pain that resolved spontaneously, was severe in nature, and in many
cases was associated with vomiting or even a visit to the emergency room. At the time of
evaluation the physical examination will be normal. If suspicion is strong that episodes of
intermittent torsion and spontaneous detorsion have occurred, our experience has been that
the finding of a bell-clapper deformity at exploration can be expected. Elective scrotal
exploration should be undertaken, and scrotal fixation of both testes should be performed
when bell-clapper deformities are identified ( Eaton et al, 2005 ). The purpose of prophylactic
fixation of the testes is to prevent an episode of torsion that might lead to testicular atrophy.

Torsion of the Testicular and Epididymal Appendages

The appendix testis, a mllerian duct remnant, and the appendix epididymis, a wolffian
remnant, are prone to torsion in adolescence, presumably as a result of hormonal stimulation,
which increases their mass and makes them more likely to twist on the small vascular pedicle
on which they are based.
The symptoms associated with torsion of an appendage are extremely variable, from an
insidious onset of scrotal discomfort to an acute condition identical to that seen with
torsion of the cord. In this sense, torsion of an appendage and epididymitis might be difficult
to distinguish clinically. When seen at an early stage, an adolescent with torsion of an
appendage may have localized tenderness of the upper pole of the testis or epididymis, where
a tender nodule may be palpated. In some instances, the infarcted appendage is visible
through the skin as a blue dot sign ( Dresner, 1973 ). In cases in which the inflammatory
changes are more significant, scrotal wall edema and erythema may be severe. The
cremasteric reflex should be present, and the testis should be mobile. Radionuclide scans or
color Doppler studies may show normal or increased flow, and ultrasound imaging may
delineate the swollen appendage. Though often interpreted as epididymitis, it is not likely
to be bacterial in origin.
When the diagnosis of torsion of an appendage is confirmed clinically or by imaging,
nonoperative management allows most cases to resolve spontaneously. Limitation of
activity, administration of nonsteroidal anti-inflammatory agents, and observation permit
most symptoms to subside as the acute changes of ischemic necrosis resolve. In an occasional
clinical situation, acute exploration is performed because of suspicion of torsion of the cord,
or delayed exploration is performed because of failure of spontaneous resolution of the
inflammatory changes and discomfort. Simple excision of the twisted appendage in these
cases is therapeutic.
Epididymitis

Inflammation or infection of the epididymis is an important part of the differential diagnosis


of an acute scrotum. Epididymitis is reported to be a rare clinical diagnosis in the pediatric
age group. Siegel and associates (1987) reported fewer than five cases per year at a major
pediatric hospital, most documented at the time of scrotal exploration. Likitnukul and
colleagues (1987) reported 35 cases in a 20-year retrospective review. The most common
clinical symptoms at the initial encounter are scrotal swelling, erythema, and pain; these
symptoms are found equally in boys subsequently determined to have anatomic anomalies of
the urogenital system and in boys with normal anatomy. In fact, it appears that in many cases
the diagnosis of epididymitis is a wastebasket diagnosis for patients without torsion of the
spermatic cord who have swollen, painful scrotal contents. It is possible that some cases of
appendage torsion, for example, are misdiagnosed as epididymitis. This results, in part, from
the varied severity of symptoms of epididymitis: from localized epididymal tenderness, to
tenderness and swelling of the entire epididymis, to a massively inflamed hemiscrotum with
absence of definable landmarks and increased blood flow on scrotal scintigraphy or color
Doppler study.
Epididymitis is classically described as an indolent process, in contrast to the rather acute
onset of torsion of the spermatic cord. In adolescents, however, clinical distinction between
the two entities is frequently less easily categorized. The presence of dysuria and fever is

more common in the epididymitis group, although many boys with clinical epididymitis have
neither. A past history of urinary tract infections, urethritis, urethral discharge, sexual activity,
urethral catheterization, or urinary tract surgery may indicate a higher likelihood for
epididymitis. Epididymitis has been associated with Henoch-Schnlein purpura, presumably
on a systemic inflammatory basis, and has been noted in boys treated with the antiarrhythmic
agent amiodarone ( Hutcheson et al, 1998 ). Dysfunctional voiding has also been implicated
as a potential cause of epididymitis, presumably as a result of urinary reflux into the
ejaculatory duct ( Bukowski et al, 1995a ). Physical examination may reveal localized
epididymal tenderness, a swollen and tender epididymis, or a massively swollen hemiscrotum
with the absence of landmarks. The cremasteric reflex should be present in patients with
epididymitis, and its absence is highly suggestive of torsion of the spermatic cord;
however, it may be difficult to demonstrate in the acutely swollen scrotum of those with
epididymitis ( Rabinowitz, 1984 ).
The presence of pyuria, bacteriuria, or a positive urine culture is important evidence
that epididymitis should be high on the list of differential diagnoses, although urine
cultures may be sterile in 40% to 90% of patients. Normal urinalysis results do not rule out
epididymitis. The most common finding in this age group is gram-negative bacteria
( Likitnukul et al, 1987 ; Siegel and Snyder, 1987 ). Our experience, in fact, would
demonstrate that most boys with a clinical diagnosis of epididymitis have sterile urine
( Gislason et al, 1980 ; Likitnukul et al, 1987 ; Siegel and Snyder, 1987 ). Conversely, there is
a low incidence of clinical epididymitis in patients who require nonsterile intermittent
catheterization. Thirumavalavan and Ransley (1992) found the incidence in this group to be
only about one episode of epididymitis per 10 patient-years. Bennett and colleagues (1998)
documented a relationship between epididymitis in boys with infected urine and the presence
of an uncircumcised penis.
Scrotal imaging may be an important part of making the diagnosis of epididymitis and thus
avoiding unnecessary surgery, especially in a patient with a massively swollen scrotum. Color
flow Doppler and radionuclide imaging reveal increased blood flow; ultrasound may
demonstrate a swollen testis or testis and epididymis, frequently with the presence of a
hydrocele, which may contain echogenic debris when bacterial infection is present. In current
practice, the trend toward imaging of an acute scrotum has made the finding of epididymitis
at scrotal exploration less common.
Radiographic imaging of the urinary tract is commonly performed during follow-up of boys
in whom epididymitis has been diagnosed. Likitnukul and coworkers (1987) found
radiographic abnormalities in four of five such boys with positive urine cultures.
Abnormalities included urethral stricture, ureteral ectopia into the seminal vesicle, and reflux
of contrast into the seminal vesicles in two patients. In Siegel and Snyder's series (1987) ,
47% of prepubertal boys with epididymitis were found to have radiographic abnormalities,
including ectopia of the vasa or ureter and urethral anomalies, all having the common end
result of predisposing the genital duct system to reflux of urine. The younger the child with
epididymitis, the more likely it is that a urinary tract infection, radiographic anomaly, or both
will be found ( Merlini, 1998 ). Because the majority of boys with epididymitis have
sterile urine and apparently radiographically normal urinary tracts, it would seem most
appropriate to reserve renal and bladder ultrasonography and voiding
cystourethrography for prepubertal boys with positive urine cultures. When epididymitis
is diagnosed on color Doppler study, it is expeditious to proceed with imaging of the bladder
and the upper urinary tract at the same sitting.

Epididymitis in adolescents should be treated aggressively, whether in an early or advanced


stage. Because all boys with acute scrotal swelling of any cause will clinically worsen when
allowed to resume normal activities, limitation of activity, especially that of a strenuous
nature, should be enforced. In many cases, bed rest for 1 to 3 days results in a less protracted
clinical course of pain and scrotal swelling. Following this period with a more extended
course of relative restriction (sports, gymnastics) continues to promote resolution of scrotal
swelling and discomfort. Scrotal elevation, the use of an athletic supporter, and the
application of cold or warmth to the area may prove beneficial in reducing discomfort.
Prompt and aggressive parenteral antibiotic therapy should be instituted when urinary tract
infection is documented or suspected. Urethral instrumentation should be avoided if at all
possible. After the acute episode has subsided, prophylactic antibiotic therapy should be
continued until a voiding cystourethrogram is performed. In boys with sterile urine, the same
limitations in physical activity should be imposed. Oral nonsteroidal anti-inflammatory
agents may promote resolution of the inflammation.
Miscellaneous Causes of Acute Scrotal Swelling

Scrotal swelling, erythema, or pain may be initiated by lesions primary to the scrotal
contents, the scrotal wall or skin, or the inguinal canal. On occasion, pain thought to originate
in the scrotum is found to have an extrascrotal origin.
Acute idiopathic scrotal edema is a self-limited process of unknown cause that is not usually
associated with scrotal erythema ( Qvist, 1956 ). Fever is not present, and scrotal tenderness
is usually minimal, but pruritus may be significant. Although the process is considered to be
idiopathic, allergic or chemical dermatitis, insect bites, trauma, and other known potential
causes of scrotal inflammation may be responsible but undiagnosed. Examination should
include a complete assessment of the perineum and perianal region to rule out scrotal edema
secondary to a contiguous process (e.g., perirectal abscess). In most cases, the scrotal wall is
thickened but the testes can be palpated. When in doubt about the cause of scrotal edema,
ultrasound evaluation with color flow Doppler should be performed. No therapy is indicated.
Henoch-Schnlein purpura is a systemic vasculitis that can cause scrotal swelling secondary
to involvement of the testis, epididymis, or both ( Clark and Kramer, 1986 ). The cause of
vasculitis is unknown. The purpura is a nonthrombocytopenic process that may be manifested
as abdominal and joint pain, nephritis and hematuria, and skin lesions. Scrotal involvement is
merely part of the systemic manifestation; it is seen in up to 35% of patients. Scrotal findings
are generally diffuse and consist of swelling, erythema, and tenderness. Urinalysis may
demonstrate hematuria and proteinuria. Color Doppler study or scintigraphy shows increased
blood flow. Observation of the scrotal findings is a part of managing the systemic symptom
complex, which is usually a self-limited process but may require steroid therapy.
Perinatal Torsion of the Spermatic Cord

Torsion of the spermatic cord may occur prenatally (months, weeks, or days before birth or
during the process of labor) or in the immediate postnatal period. Although the term
perinatal torsion has been used to group both prenatal and postnatal torsion into a single
clinical diagnosis, they may in fact represent distinctly different pathophysiologic processes
that should be approached very differently. The major points of contention that arise when
perinatal torsion is discussed are the utility of prompt surgical exploration and the need for
contralateral scrotal exploration and fixation of the testis.

Prenatal (in utero) torsion is typified by the finding at delivery of a hard, nontender testis
fixed to the overlying scrotal skin. The skin is commonly discolored by the underlying
hemorrhagic necrosis. This clinical scenario is pathognomonic of a resolving infarction
process, the acute phase of which occurred before delivery. Pathologic examination of testes
that have undergone prenatal torsion reveals that in most cases, extravaginal torsion (torsion
of the cord and its tunics) has occurred. Duckett (1991) argued that the incidence of prenatal
torsion is probably much higher than usually quoted. He postulated that the blind-ending
spermatic cord (vanishing testis) discovered on exploration for a nonpalpable testis is in
many cases the result of antenatal torsion. This thought is corroborated by the common
finding of hemosiderin in the pathologic examination of the distal sections of blind-ending
spermatic cords removed surgically. Prenatal torsion may merely be a late gestational
representation of the same process that if it had occurred earlier, would have produced a
blind-ending spermatic cord ( Duckett, 1991 ).
Classic teaching has held that testes found to be hard, nontender, and fixed to the skin at birth
do not merit surgical exploration because of the delayed nature of the pathologic process at
the time of initial evaluation. In fact, the reported salvage rate of testes presumed to have
undergone torsion before birth is negligible. Despite prompt exploration, Brandt found no
salvageable testes in 25 explorations, a finding confirmed by others ( Brandt et al, 1992 ;
Stone et al, 1995 ). However, controversy has arisen regarding the need for prompt
exploration of the contralateral testis.
Contralateral scrotal exploration traditionally has not been recommended in cases of prenatal
torsion because extravaginal torsion is not associated with the testicular fixation defect (bellclapper deformity) that is recognized as the cause of intravaginal torsion. However, reports of
asynchronous perinatal torsion have made the practice of avoiding prompt surgical
exploration of the contralateral testis controversial ( Olguner et al, 2000 ).
The postnatal manifestation of acute scrotal swelling may present a problem for urologists
who are unsure of whether the process is truly a prenatal or a postnatal event. Postnatal
torsion is usually associated with swelling and tenderness of the scrotum. Fixation of the skin
is not typically present. Burge (1987) described 30 infants with acute scrotal swelling, 18 of
whom underwent prompt surgical exploration. Ten were found to have extravaginal torsion, 3
had intravaginal torsion, 1 had torsion of an appendix testis, 1 had torsion of an undescended
testis, and 1 had a normal testis. Pinto and Noe (1987) described salvage of 2 of 10 testes
explored within 6 hours of discovery. The diagnosis may be aided by color flow Doppler
examination, even in small neonates ( Stone et al, 1995 ).
Prompt exploration of suspected postnatal torsion of the spermatic cord is indicated (in
conjunction with exploration of the contralateral testis) when the patient's general
condition and anesthetic considerations allow for a safe procedure. The 17% incidence of
bell-clapper deformity and the 20% incidence of salvage of a solitary contralateral testis
(prevention of anorchia) must be weighed against the risk associated with general anesthesia
in neonates. Tiret and colleagues (1988) reported the incidence of major anesthetic-related
complications in children older than 1 year to be 0.5 per 1000, and in those younger than 1
year it was 0.7 per 1000. Mortality occurred in 1 in 40,000 anesthesia procedures. Others
showed that the incidence of intraoperative and postoperative complications was greatest in
infants younger than 1 month ( Cohen et al, 1990 ). Clearly, the decision to subject a neonate
with suspected torsion of the spermatic cord to surgery should be carefully considered by
weighing the clinical assessment of the acuity of the torsion episode, the risk to the

contralateral testis, and the risk related to general anesthesia. The decision may be even more
difficult when the neonate is located at a distance from a tertiary referral center that can offer
skilled pediatric anesthesia because both the risk associated with neonatal transport and the
time lost in transport may be critical if acute postnatal torsion is to be salvaged. Clearly, if the
cause of scrotal swelling appears to be related to an acute postnatal event, all efforts should
be made to pursue prompt surgical intervention.
Exploration, when elected, should be carried out through an inguinal incision to allow for the
most efficacious treatment of other potential or unexpected causes of scrotal swelling. If
torsion is confirmed, contralateral scrotal exploration with testicular fixation should be
carried out ( Bellinger, 1985 ). The most effective and safest form of testicular fixation
involves dartos pouch placement ( Bellinger et al, 1989 ).

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