THE ACUTE SCROTUM Urology for Medical Students THINGS

THE ACUTE SCROTUM Urology for Medical Students

THINGS YOU SHOULD KNOW AS A JUNIOR DOCTOR There are multiple causes for acute scrotal pain and it is often difficult to differentiate them Acute testicular torsion is a urological emergency Do not delay surgical referral exploration for unnecessary investigations

TOPIC OUTLINE Trauma Causes Ischaemia Infection . Referred pain Other

CAUSES Ischaemia Infection Testicular Trauma Referred pain Varicocoele Epididymitis Torsion of testis Other Rupture Nerve root pain Hydrocoele Epididymo-orchitis Spermatocoele Torsion of appendage Orchitis Contusion or Haematoma Retrocaecal appendicitis Fornier’s Gangrene Testicular infarction Heinrech-Scholein purpura (HSP) vasculitis Haematocoele Cellulitis Strangulated inguinal hernia Urinary stone Testicular tumour (rapidly growing/necrotic)

ANATOMY OF TORSION Types Structures << Intravaginal twisted spermatic cord within tunica vaginalis Extravaginal >> twisted spermatic cord AND tunica vaginalis (in neonates) Testis Appendix epididymis Appendix testis

RISK FACTORS Bell-Clapper deformity Undescended testis Bell-Clapper Deformity (blue is tunica vaginalis)

SURGERY Immediate exploration Detorsion Fixation OR Orchidectomy

TESTIS/EPIDYDIMIS INFECTION Bacterial UTI younger/older patients usually gram negative bacteria STD sexually active patients Chlamydia trachomatis Neisseria gonorrhoeae Viral Mumps

INVESTIGATIONS Urine cultures Urinary STD screen in sexually active Doppler ultrasound (Bloods + blood cultures) Doppler ultrasound Microscopy of E. coli

TREATMENT Analgaesia & scrotal support Urinary tract source (for 14 days) – empirical Trimethoprim 300 mg PO daily OR cephalexin 500 mg PO QID OR augmentin 1 tab PO BD Sexually active young men – empirical Ceftriaxone 500 mg IV AND Azithromycin 1 g PO stat AND Doxycycline 100 mg PO BD (14 days) If not improving exclude abscess Ensure urine clear at end of antibiotics with U/A

FOURNIER’S GANGRENE Necrotising fasciitis of genitalia & perineum High mortality (30%) Rapidly progressing Risk factors – Diabetic, Immunocompromised, Alcoholic Treatment Rapid surgical debridement Supportive care & broad spectrum antibiotics Hypobaric oxygen

TRAUMA Testicular Rupture Requires prompt surgical repair Can only be seen on US in 20% - go by clinical suspicion Testicular Contusion/Intratesticular Haematoma Hypoechoic or haetrogenous area on ultrasound Usually explored because rupture cannot be excluded. Then managed symptomatically: Analgaesia Scrotal support & elevation Ensure resolution on follow-up ultrasound could be a testicular carcinoma!

REFERRED PAIN Retrocaecal appendicitis Urinary stones Nerve root pain

OTHER CAUSES Varicocoele Hydrocoele Spermatocoele Strangulated inguinal hernia Heinrech-Scholein purpura (HSP) vasculitis Testicular tumour (rapidly growing/necrotic)