Acute Scrotal Pathology

Symposium on Urologic Surgery

Acute Scrotal Pathology William C. Sharer, M.D.*

In this article the management of acute scrotal pathology will be reviewed. The emphasis will be on those acute diseases that require either emergency surgical intervention or specific medical therapy. For the sake of brevity, certain areas such as dermatologic lesions of the scrotal skin will be omitted.

TESTICULAR TORSION Testicular torsion is perhaps the most common acute scrotal illness in the pediatric and young adult patient population. Testicular torsion can be subdivided into two distinct clinical entitites, intravaginal torsion and extravaginal torsion.

Extravaginal Torsion Extravaginal torsion, by far the less common form of testicular torsion, occurs almost exclusively in neonates. In extravaginal torsion the testicle and the investing fascial tunics rotate about the spermatic cord well above the level of the tunica vaginalis. This fact has led some authors to use the term "torsion of the spermatic cord." Although it would be difficult to document, the torsion most likely occurs during neonatal testicular descent before the investing tunica becomes adherent to the scrotal wall. The clinical presentation is so striking as to leave little doubt concerning the correct diagnosis. At birth or shortly thereafter a firm smooth painless scrotal mass is identified. Scrotal skin reaction is variable but generally consists of mild erythema and edema. No inguinal masses are palpable. Urinalysis is normal. The differential diagnosis is limited and relatively easy to resolve. Testicular tumors, epididymitis, and orchitis are exceedingly rare in neonates. A hydrocele should be relatively soft and can be transilluminated. Careful physical examination will exclude the presence of a large inguinal hernia. The preferred treatment at present is elective unilateral scrotal exploration with orchiectomy. In a review of 48 cases of extravaginal testicular *Assistant Professor of Surgery (Urology), Washington University Medical Center, St. Louis, Missouri

Surgical Clinics of North America-Yo!. 62, No.6, December 1982

955

956

WILLIAM

C.

SHARER

torsion by Skoglund et al. the testicle was uniformly necrotic at the time of exploration. 45 They could not find any reported cases of asynchronous extravaginal testicular torsion. Unlike intravaginal torsion, extravaginal torsion does not appear to be related to anomalous suspension of the testicle within the investing tumca. These considerations underlie the recommendation of elective rather than urgent unilateral exploration for orchiectomy. Testicular scanning to confirm the absence of testicular blood flow is hard to justify in view of the clear cut clinical picture and invariable testicular necrosis at exploration. Predictably, normal contralateral anatomy seems to obviate the necessity for contralateral testicular fixation. This is supported by the lack of any reported cases of asynchronous contralateral torsion. It is likely that some future authors will recommend nonoperative management based on the following four observations: (1) successful testicular salvage has not been reported, (2) contralateral fixation is probably unnecessary, (3) the clinical picture is seldom confusing, and (4) the operative risk, although minimal, probably exceeds the risk of either subsequent testicular extrusion or a significantly incorrect diagnosis. Until the safety and wisdom of nonoperative management have been documented, we still recommend elective unilateral orchiectomy for extravaginal testicular torsion.

Intravaginal Testicular Torsion Intravaginal torsion of the testicle is considerably more common than extravaginal torsion. In fact, it is the most common diagnosis in virtually all series of acute scrotal pathology in children. Intravaginal testicular torsion occurs in a testicle that is suspended in an anomalous fashion. Normally the tunica vaginalis covers only the anterior surface of the testis. A patent processus vaginalis may cover the anteromedial surface of the spermatic cord, although obliteration of this space is the rule. The posterior surface of the testis and epididymis is fixed to the scrotal fascia, preventing any marked rotation. Although the anomalies of suspension predisposing to testicular torsion are variable, in general, the tunica vaginalis completely surrounds the testis and epididymis. Investiture of this distal spermatic cord as well is common. The testicle is relatively free to rotate within the tunica. Epididymal anomalies are also common. At times the epididymal attachment is sufficiently loose as to allow testicular torsion between the epididymis and the testis. More commonly, the testis rotates about the distal spermatic cord. Since the basic abnormality is developmental, bilateral anomalies are quite common. In 1970 Skoglund et al. reviewed 718 cases of testicular torsion reported in the world literature. 45 There were 48 cases of extravaginal torsion and 670 cases of intravaginal torsion. Although the patients ranged in age from newborn to 78 years, the vast majority were pubertal or prepubertal. They did not report any significant racial predilection. The left side was involved in 61 per cent of the cases versus 39 per cent with involvement on the right. Ectopic or undescended testicles are at risk for torsion if they are not surgically fixed or removed. The risk of such testicles undergoing torsion relative to normal testicles is unknown; Williamson reported 20 cases, 54 Wright reported 7 cases, 55 and Donohue and Utley reported 4 cases/ 4 suggesting that it is not a rare event. In a cumulative review of 520 cases

ACUTE SCROTAL PATHOLOGY

957

of testicular torsion, 34 (6.5 per cent) occurred in ectopic testicles. Acute abdominal pain ipsilateral to a nonpalpable gonad should suggest the possibility of acute torsion in an abdominal gonad, as Skogland et al. point out. In recent years a number of authors have reviewed their clinical experience with acute testicular torsion. 3• 6• 10• 12• 14• 26-28 , 30• 32• 34· 45• 53-55 Scrotal pain and swelling are invariably present. The pain associated with testicular torsion is classically described as very acute in onset; however, Kaplan and King reported 15 patients with surgically verified torsion out of 28 total patients who described their symptoms as gradual in onset. 26 Coexistent inguinal and abdominal pain have been reported in as many as 19 and 39 per cent of patients, respectively. 54 In fact, abdominal pain occasionally dominates the clinical picture. Since nausea and vomiting have been reported in as many as 42 per cent of patients, 54 it is not surprising that some patients are initially thought to have an acute abdomen. In various reports 37, 54 13, 53 53, 6 11, 45 and 503 per cent of patients with proven testicular torsion related a prior history of similar symptoms that resolved spontaneously. Voiding symptoms are rarely present. 6 • 28 • 54 A history of preceding strenuous exercise or minor scrotal trauma is not uncommon; however, the same is true for patients with testicular tumors and epididymitis. Since symptoms often begin during sleep it has been argued that cremasteric muscle contractions during vigorous exercise or rapid eye movement (REM) sleep may cause testicular rotation about the spermatic cord. This hypothesis remains quite conjectural. At the time of presentation as many as 50 per cent of the patients have had symptoms for more than 24 hours. In some cases the patient has already been examined by another physician who prescribed antibiotic treatment for the erroneous diagnosis of epididymitis. The subsequent failure of treatment suggests the correct diagnosis but only after a delay of days or weeks since the onset of symptoms. There are many signs noted on physical examination that suggest the diagnosis of acute testicular torsion, but none are pathognomonic. Scrotal edema is almost invariably present. Erythema has been reported in anywhere from 3654 to 10Q34 of cases. As a general rule, the scrotal contents are swollen, indurated, and indistinct so that the epididymis cannot be distinguished from the testis. Roughly 8 per cent of patients will have a reactive hydrocele. On occasion the contralateral testis will be noted to have either an abnormal position or an abnormal epididymal attachment or both. Prehn's sign refers to the diminution of testicular pain following scrotal elevation in patients suffering from epididymitis but not in those patients with testicular torsion. Most observers discount this sign as being clinically unreliable. 32 Ten to 20 per cent of patients have a fever of at least 100° F at presentation. 3• 6• 10• 12• 26• 28 • 34• 45 • 54 Pyuria, defined as more than 5 white blood cells per high power field noted on examination of the centrifuged urinary sediment, is extremely uncommon. Many large series do not record a single patient with pyuria, therefore, a working diagnosis of acute testicular torsion must be seriously questioned in the presence of pyuria. 6 • 10• 12• 28• 34 As expected, aerobic bacterial cultures of the urine are almost invariably negative. Finally, rapid resolution of unilateral scrotal pain and swelling prior to the initiation of treatment should suggest the diagnosis of testicular torsion with spontaneous derotation.

958

WILLIAM

C.

SHARER

Treatment. Considerable controversy continues to surround the treatment for intravaginal testicular torsion. Ischemic injury progresses with time, therefore prompt surgical treatment is desirable if testicular salvage is still possible. On the other hand, it is undesirable to subject a patient to an emergency surgical procedure with the attendant risks if the operation is either unnecessary, as in the case of epididymitis, or unlikely to achieve the stated goal, namely, testicular salvage, as in the case of prolonged testicular torsion with ischemic necrosis. It should be clear that the clinical evaluation and treatment must be viewed in a time frame based upon the progression of ischemic damage with respect to time. In 1955 Smith published a report concerning the cellular changes secondary to graded testicular ischemia in dogs. 46 Following a testicular biopsy, gonadal blood flow was interrupted with a tourniquet around the spermatic cord for a varying period of time. Blood flow was then restored. The gonads were biopsed 60 days later. An ischemic time of two hours did not produce any significant alterations in either the seminiferous tubules or the Leydig cell compartment. A four-hour period of ischemia was sufficient to stop spermatogenesis for at least 60 days. Although severely depleted in numbers, some viable Leydig cells could be identified in the testicular periphery in two of the three dogs. The testis became necrotic and sloughed in the third dog. By six hours the ischemic insult resulted in loss of spermatogenesis, severe Leydig cell depopulation, and mild degenerative fibrosis. At 10 hours the loss of functional elements appeared to be complete. Similar data are not available concerning the susceptibility of the human testicle to ischemic injury; however, some inferences can be derived from the various clinical series that have been reported. It is important to remember that the clinical impression of testicular necrosis at the time of surgery can usually be verified by subsequent microscopic examination of the surgical specimen. Most surgeons try to err on the side of fixing the marginally viable testis. Subsequent testicular function is inferred from the ultimate testicular size. Although this is a relatively crude estimate of spermatogenic function, it is impossible to estimate to what degree function of the Leydig cells might be preserved in a small atrophic testicle. In the review by Skogland et al, surgical restoration of blood flow within five hours of the onset of symptoms resulted in testicular salvage in 83 per cent of the cases. 45 If the operation was performed in less than 10 hours, the salvage rate fell to 70 per cent. If the procedure was delayed for more than 10 hours, the salvage rate plummeted to only 20 per cent. In a review Williamson found that testicular viability was virtually guaranteed if detorsion was achieved within three hours of the onset of symptoms. 54 Even by six hours a 90 per cent success rate was possible. Viability fell to 75 per cent by eight hours, 50 per cent by 10 hours, and less than 10 per cent, by 24 hours. In Williamson's personal series of 293 cases of testicular torsion, 162 testes were salvaged. Seventy-seven were removed for necrosis. Fiftyfour gonads were fixed but subsequently atrophied; 12 of these 54 gonads extruded through the scrotal skin. The findings of various other authors tend to be in agreement. 10• 14• 27 • 30• 32 · 55 The vast majority of gonads will be saved by surgery within 6 hours of the onset of symptoms, whereas a delay of more than 24 hours produces only anecdotal salvage. The period of time

ACUTE SCROTAL PATHOLOGY

959

from 6 to 24 hours is the critical gray zone. It is important to remember that even the cushion of time within the first six hours is not absolute. Cass et al. 10 and MacnicoP2 each had several cases of testicular necrosis within the six-hour time period. Kaplan and King were unable to save gonad in a child who reported only two hours of discomfort. 26

Testicular Scanning and Ultrasound It is impossible to accurately define the efficacy of the history and physical examination in establishing the correct diagnosis when treating acute scrotal pathology. In many cases the diagnosis is clear cut; however, at times even the most clinically experienced observer cannot separate testicular torsion from other pathologic conditions. In the large collective series by Williamson, 252 patients were explored with a preoperative diagnosis of testicular torsion. 54 Only 24 cases were incorrectly diagnosed. On the other hand, in a report by Cass et al. 10 a majority of the patients explored to rule out torsion in fact had other forms of scrotal pathology, most commonly epididymitis. Competing elements began to influence clinical management. Surgical restoration of blood flow to an ischemic organ is a relative emergency. It would appear that the testicle can survive several hours of warm ischemia without significant damage. Since the blood flow may not be totally interrupted, a relatively small number of gonads may survive from 12 to 24 hours of ischemia, whereas survival beyond 24 hours is anecdotal. For many years the motto "if there is any doubt-explore" ruled clinical decision making. In the report by DelVillar et al. 42 explorations were performed but only 9 cases of testicular torsion were identified compared with 29 cases of epididymitis. 12 Thus, a policy of early exploration to maximize testicular salvage can lead to a large number of explorations for nonsurgical diseases. Improved diagnostic accuracy was needed. The Doppler flowmeter had already demonstrated significant clinical uses in peripheral vascular disease. In the mid 1970s a number of papers reported the use of the Doppler stethoscope as an aid in the evaluation of acute scrotal pathology. Levy31 and Pedersen et al. 38 reported their experiences in 1975. Little or no arterial flow could be identified in seven patients with acute testicular torsion. For the 12 patients with epididymitis, blood flow was increased. The remaining 32 patients had normal flow patterns. Subsequent reports by Perri et al. 39 and Iuchtman et al. 25 confirmed these findings. Blood flow, as measured by Doppler ultrasonic examination, is almost invariably increased with epididymitis, absent with testicular torsion, and normal to increased with torsion of a testicular appendage. Unfortunately, Nasrallah et al. reported four cases offalse negative Doppler examinations in surgically proven torsion. 36 In two patients with longstanding symptoms the increased flow was attributed to intense scrotal inflammation surrounding a necrotic testicle. The other two patients were noted to have 180 degree torsions at the time of surgery. The Doppler stethoscope has proved to be quite useful Tor several reasons. Owing to widespread use in peripheral vascular surgery, Doppler stethoscopes are available in most medium to large general hospitals. Most surgeons trained in the last 15 years are familiar with the technique of use. The Doppler

960

WILLIAM

C.

SHARER

stethoscope can evaluate arterial blood flow quickly, painlessly, noninvasively, and inexpensively in the emergency room setting. Most published reports indicate a high degree of sensitivity and specificity with respect to torsion of the testicle in the evaluation of acute scrotal pathology when the Doppler stethoscope is used by a skilled physician. On the negative side, sensitivity and specificity diminish with the duration of symptoms, a considerable number of physicians still have no experience in the use of the Doppler stethoscope, and an experienced physician may not be readily available. Since arterial blood flow is measured, a testicle that spontaneously derotates will be identified as having normal arterial flow.

Radionuclide Imaging In 1974 Heck et al. investigated the value of99'fc pertechnetate scanning in the evaluation of testicular torsion. 21 During the last seven years numerous additional reports have appeared in the literature. 11• 20• 35 Although scanning techniques varied slightly, the general concept was the same. A bolus of 10 f.LCi of 99'fc pertechnetate was given intravenously. Serial scrotal images were taken 5 to 10 seconds apart to identify arterial blood flow to the gonads. A delayed image was taken roughly 15 minutes after the injection of tracer to identify tissue perfusion. Some centers took delayed images after a specific number of counts had been recorded (300,000 to 500,000). The angiographic and perfusion patterns associated with various types of common scrotal pathology are listed in Table 1. Acute testicular torsion is the only common condition that is associated with a decreased or absent va!icular phase and a photon deficient testicle on the static phase. Although other forms of pathology such as testicular abscess, hydrocele, or spermatocele may produce a photon deficient "cold" area on the static scan, the arterial phase will be either normal or accentuated. It is difficult to determine the true accuracy of scrotal scanning. Not all patients with acute scrotal pathology are studied. Of those studied not all are explored, since it would be difficult to justify an exploration if all clinical findings strongly indicated

Table 1.

Radionuclide Scan Findings in Acute Scrotal Pathology

CONDITION

FWW PHASE

Normal Testicular torsion Acute epididymitis Epididymitis with testicular abscess

Normal Decreased or absent Increased Increased

Torsion of testicular appendage Tumor Idiopathic scrotal edema Hydrocele Spontaneous untwisting of testicular torsion

Normal to increased Normal Normal Normal Normal

TISSUE PHASE

Normal Intensity Cold Hot Cold testis with surrounding ring of hyperemia Normal Normal Normal Crescentic lucency Normal or central cold area

ACUTE SCROTAL pATHOLOGY

961

a diagnosis of epididymitis. For these reasons estimates of accuracy are based upon surgically confirmed diagnoses, plus the diagnosis most compatible with the subsequent clinical course for those patients not explored. It is quite likely that the sensitivity and specificity of scrotal scanning with respect to acute testicular torsion are greater than 95 per cent. A rell!tively small number of false negative and false positive scans have been reported. 1• 42 • 52 A false negative scan might occur if the testicle spontaneously rotates. If the inflammation surrounding a necrotic long-standing testicular torsion is sufficiently intense, enough blood flow may be detected to obscure the nature of the process. False positive scans can be attributed to the combination of a large avascular mass such as a hydrocele, a spermatocele, or a twisted appendiceal testis associated with a small gonad. In general, false positive scans seem to outnumber false negative scans. Several questions concerning the clinical use of scrotal scanning in the management of acute scrotal pathology cannot be answered from the published reports. How long did each scan take to perform? This time period should begin when the scan is ordered and end when the official interpretation is given. How many scans in each series were done at night or on the weekends? How many patients were evaluated at pediatric referral centers, teaching hospitals, and community hospitals? How many patients were excluded from the studies because a scan could not be readily obtained? What is the cost of a scrotal scan? Were the scans read by one or several observers? Were the scans read in blinded fashion? Most importantly, how often did the scan alter the clinical management, particularly with respect to surgery?

Management of Suspected Testicular Torsion Suspected testicular torsion is a true surgical emergency. Testicular viability rapidly diminishes with time. Every effort should be made to derotate the gonad within six hours from the onset of symptoms. Further delay rapidly reduces the possibility of testicular salvage, so that very few testes can be preserved after 24 hours of ischemia. The clinical diagnosis is not always clear cut; however, the delay required to clarify the situation with a testicular scan jeopardizes the chances for functional preservation. Therefore, the proper evaluation and treatment for each patient will vary according to the duration of symptoms, the nature of symptoms, the physical findings, the age of the patient, and the relative likelihood of each diagnosis based upon these considerations. Subsequent torsion of the contralateral testicle is a well recognized phenomenon; therefore, bilateral orchiopexy is the procedure of choice. Every patient should have a careful history taken, and a physical examination including urinalysis should be performed. The vast majority of patients will have torsion of the testicle, epididymitis, or torsion of a testicular appendage. Much less common diseases to be considered are idiopathic scrotal edema, scrotal fat necrosis, testicular tumor, thrombosis of scrotal veins, orchitis, Henoch-Schonlein purpura, incarcerated inguinal hernia, trauma, and acute hydrocele. In the majority of cases the diagnosis is clear cut. In the event of testicular torsion, exploration should ensue as I

I.

962

WILLIAM

C.

SHARER

quickly as possible. It seems unreasonable to delay treatment to perform a testicular scan that will verify an already clear cut diagnosis, particularly within the first 12 hours of symptoms. At times the diagnosis will not be obvious. It would be desirable to devise a flow diagram to guide the evaluation of these patients; however, the clinical spectrum of signs and symptoms is too varied. There is only one acute scrotal disease other than trauma that demands prompt surgical therapy. That disease is torsion of the testicle. If the history, physical examination, and urinalysis suggest testicular torsion but are not diagnostic, additional tests such as Doppler flow study or testicular scan can be considered. Within the first 24 hours of symptoms, it is necessary to balance the possibility that an unnecessary operation will be performed on a patient with a diagnosis other than testicular torsion if the tests are not performed against the possibility that ischemic necrosis is present in a potentially salvageable gonad in a patient with testicular torsion if surgery is delayed to perform a testicular scan. After the first 24 hours, a twisted gonad is almost always necrotic, therefore a scan should be performed to document the absence of testicular blood flow before surgery is performed if there is any question as to the correct diagnosis. A sudden unexplained decrease in symptoms is characteristic of a testicular torsion that has spontaneously untwisted. Many patients with surgically confirmed torsion have a past history of scrotal pain that resolved spontaneously. Since there is no test that will confirm or refute a diagnosis of untwisted testicular torsion, any decision to proceed with orchiopexy must be based upon the strength of the clinical pattern. The risk of a possibly unnecessary operation must be weighed against the possibility that future surgery on an emergency basis to reduce a retorsion of the testicle will not be rapid enough to salvage the gonad.

EPIDIDYMITIS Epididymitis is the most common form of acute scrotal pathology in postpubertal males. In the large series reported by Cass et al., 263 males (80 per cent) had epididymitis compared with only 49 (15 per cent) cases of testicular torsion. 10 In those males over the age of 20, 90 per cent had epididymitis. Even below the age of 20, more patients carried a diagnosis of epididymitis (31 patients) than testicular torsion (23 patients).

Signs and Symptoms Unilateral pain and swelling associated with epididymitis develop over 24 to 48 hours, in contrast to the usual case of testicular torsion, in which the pain increases over several hours. Erythema and edema of the overlying scrotal skin are generally present, particularly if diagnosis and treatment have been delayed. Initially the swelling and induration are limited to the epididymis; however, as the inflammation intensifies the landmarks separating the gonad from the epididymis become obliterated. Forty to 50 per cent of patients are febrile at the time of diagnosis. 10• 12• 18 The literature is quite varied with respect to the presence of voiding symptoms and the findings on urinalysis. Perhaps 50 per cent of patients complain of dysuria. 7 The presence or absence of a urethral discharge depends upon the etiology

ACUTE SCROTAL PATHOLOGY

963

of the inflammation. In the report by Berger et al., all seven patients with gonorrhea had a discharge. 7 Eleven of 17 patients with a documented infection caused by Chlamydia trachomatis had a discharge. Only 2 of 13 patients with a gram-negative bacterial epididymitis had a discharge. In several series, more than 95 per cent of the patients had pyuria;6 • 39 however, in several other reports only 21, 43 or 24 per cent of the men had pyuria. 10• 12• 18• It is my personal belief that the vast majority of patients with epididymitis should have pyuria. The discrepency cited earlier can be attributed to several factors. It is quite likely that only midstream urine was examined in most instances. Since the two most common pathogens, Chlamydia trachomatis and Neisseria gonorrhea cause urethritis but not cystitis, it is important to examine both the initial and midstream urine samples in the search for pyuria. Second, it is common practice in most emergency clinics to send the urine to a central laboratory for examination. In our experience central laboratory urinalyses are frequently unreliable. It takes so little time, effort, and equipment to do a urinalysis that it is hard to justify this common practice. The third factor relates to the definition of significant pyuria. In several series the presence of five or more white blood cells per high power field were considered abnormal. 10• 12 In a third report at least 10 white blood cells per high power field were needed for the specimen to be considered abnormal. 18 This limit of normal is inappropriately high when the etiology of epididymitis is taken into account. We would be reluctant to consider more than 1 or 2 white blood cells per high power field in a centrifuged midstream urinary sediment to be normal, particularly if there were a greater number of white blood cells per high power field in the first voided urinary sediment.

Etiology The most comprehensive study of the etiology of epididymitis was published in several reports by Berger et al. 8 They studied 50 consecutive men with epididymal pain and swelling. A Doppler flow study indicated increased gonad blood flow in all 20 patients examined. A voided urine specimen or urethral swab was cultured for Chlamydia trachomatis, Neisseria gonorrhea, Ureaplasma urealyticum, Mycoplasma hominis, and aerobic bacteria. Nineteen patients con~ented to undergo epididymal aspiration to obtain additional material for culture. Sixteen of the patients were over the age of 35. Twelve of these older men had cultures positive for gram-negative bacteria (Table 2). One man was infected with Chlamydia trachomatis. Three men had negative cultures, and therefore the epididymitis was termed idiopathic. Of the 34 men below the age of 35, 16 had positive cultures for Chlamydia trachomatis, 7 for Neisseria gonorrhea, and only 1 for gram-negative rods. The epididymitis was attributed to trauma in two patients. Eight men had no apparent etiology for their epididymitis. Nineteen of the 34 young men had positive urine cultures for Ureaplasma urealyticum, including 8 of 10 men with traumatic or idiopathic epididymitis, 2 of 5 men with gonococcal epididymitis, and 9 of 16 men with chlamydial epididymitis. No epididymal aspirate was positive for Ureaplasma urealyticum. These differences were not statistically significant. Since Ureaplasma urealyticum can be isolated from the urine of many

964

WILLIAM

Table 2.

C.

SHARER

Etiology of Epididymitis in 50 Consecutive Men* NUMBER OF PATIENTS

Under 35 Years Gram-negative bacteria Chlamydia trachomatis Gonoo;hea Idiopathic Trauma .TOTAL

Over 35 Years

1

12

16

1 0 3 0 16

7 8 2 34

*Based on Berger et al."

sexually active, asymptomatic men, the role of this organism in the pathogenesis of urethritis and epididymitis remains to be clarified. Seven of the older men with gram-negative bacterial epididymitis had underlying urologic pathology. None of the younger men had similar problems. Six of the nine epididymal aspirates performed on men with gram-negative bacterial epididymitis were positive. No aspirate was positive in this group if the urine was sterile. Of the remaining 10 patients who agreed to epididymal aspiration, 6 had evidence for chlamydia! infection. In this group one man had a positive urethral swab but a negative aspirate, three men had positive urethral swabs and epididymal aspirates, and two men had negative urethral swabs but positive aspirates. Thus, epididymal aspiration improves the diagnostic accuracy in chlamydia} epididymitis. Finally, 4 of the 19 patients had no pathogens isolated.

Treatment Since the treatment for epididymitis should be based upon the etiology, significantly different recommendations are made based upon the age of the patient. If the man is less than 35 years of age, at least 75 per cent of the cases will be secondary to Neisseria gonorrhea or Chlamydia trachomatis. 7 A properly performed Gram stain on the urethral swabbing almost invariably identifies intracellular gram-negative diplococci if Neisseria gonorrhea is present. An appropriate treatment would be 4.8 million units of procaine penicillin administered intramuscularly along with 1 gm of probenecid taken orally. A 7 to 10-day course of oral tetracycline, ampicillin, or amoxycillin should also eradicate the organism. Follow-up cultures are useful to insure successful treatment. If the Gram stain does not demonstrate the presence of gonorrhea, Chlamydia trachomatis or possibly Ureaplasma urealyticum is the probable etiologic agent. For these organisms tetracycline is the treatment of choice. The appropriate duration of therapy has not been determined. Although a 7 -day course of therapy may suffice for urethritis, the longer 21-day course is probably more appropriate for epididymitis. 9 These are sexually transmitted infections, therefore concurrent treatment of all consorts is strongly recommended. Beta-lactamase antibiotics are generally ineffective in eradicating Chlamydia trachomatis. The use of ampicillin or cephalexin to treat younger men with epididymitis is irrational No further urologic evaluation seems indicated unless gramnegative bacteria are recovered or the patient has a history that suggests

ACUTE SCROTAL PATHOLOGY

965

structural abnormalities. Adjunctive measures such as scrotal support, sitz baths, antipyretics, and stool softeners can be helpful. We also personally recommend blocking the cord with 1 per cent bupivacaine (Marcaine), as this provides considerable relief from the pain while more specific therapy begins to work. As previously noted, epididymitis i.n older men is generally due to gram-negative bacteria. 7 Not infrequently, underlying urologic pathology such as benign prostatic hyperplasia, neurogenic bladder, or urethral stricture can be identified. Since prostatitis may coexist, it seems prudent to utilize an antibiotic such as trimethoprim-sulfamethoxazole, indanyl carbenicillin, or tetracycline, since each of these drugs has been demonstrated to be effective in the treatment of chronic bacterial prostatitis. The choice of antibiotic can be adjusted when sensitivity testing has been completed. A two- to three-week course of therapy should be sufficient. Thorough urologic evaluation seems appropriate once the infection has been controlled. Supportive measures similar to those recommended for younger men can be employed. Again, follow-up cultures are important to assess the adequacy of therapy. If the prostatic fluid has not been sterilized, an additional four to eight weeks of antimicrobial therapy are indicated. Persistence of bacteria in the prostatic fluid almost invariably leads to recurrent cystitis and epididymitis.

TORSION OF TESTICULAR APPENDAGES Torsion of testicular appendages accounts for roughly 5 per cent of acute scrotal pathology. 12• 14• 32• 34• 42 This percentage may rise to as high as 20 per cent, if only pediatric patients are considered. 26• 30• 54 Although there are four gonadal appendages, the appendix testis (a miillerian duct remnant) and the appendix epididymis ( a derivative of the wolffian duct) represent 98 per cent of the clinical cases. 44 In fact, the appendix testis is involved roughly 10 times more frequently than the appendix epididymis. 44 Unlike torsion of the testicle, torsion of the appendix testis is relatively common in young adults. In the series reported by Holland et al. roughly 50 per cent of the patients were at least 20 years of age. 24 The right and left sides are affected with equal frequency. Bilateral synchronous or asynchronous torsion of the testicular appendages seems to be quite rare. Although 20 to 40 per cent of the patients give a history of recent scrotal trauma or vigorous exercise, this type of history is common to all scrotal pathology, including epididymitis and neoplasms. 44 • 54 It is unlikely that trauma plays any significant role in the pathogenesis of this syndrome. Symptoms can arise either suddenly or gradually over several days. Virtually every patient seeks medical attention because oflocalized scrotal pain and tenderness. The pain is generally mild to moderate in severity. 44 Nausea and vomiting are seldom present, which is a distinct difference from what is seen in torsion of the testicle. 54 In 18 per cent of the cases from one large series, a prior history of similar symptoms was obtained. 54 Significant voiding symptoms are rarely present. Findings on physical examination can be quite variable. The "blue dot" sign, the cyanotic appendage seen beneath pink scrotal skin is said to be

966

WILLIAM

C.

SHARER

pathognomonic for torsion of the testicular appendix. Holland et al. noted this sign in 7 of 28 patients, mostly adolescent males. 24 A palpable tender nodule on the superior pole of the testis was noted in 19 of 43 patients in the series by Skoglund et al. 44 A reactive hydrocele and inflammation of adjacent structures such as the testis, epididymis, spermatic cord, and skin are variably present. The diagnosis of torsion of a testicular appendage is generally straightforward if a tender nodule can be localized to the superior pole of the testis. If the surrounding edema is sufficiently severe, a clear cut diagnosis is not so easily made. In young adults epididymitis must be considered; however, the absence of any voiding symptoms and clear urine should help rule out infection. The other major possibility is torsion of the testicle. A Doppler vascular flow study should indicate normal to increased flow for torsion of an appendage, in contrast to decreased flow for torsion of the gonad. A radionuclide scan should give similar results, although in young children with small gonads the scan can be difficult to interpret. It is not possible to differentiate torsion of an appendage with severe inflammation from a spontaneously rotated testicular torsion except by surgical exploration. There is some controversy concerning the proper management of this entity. If torsion of the testicle cannot be ruled out, surgical exploration is mandatory. Traditionally, unilateral scrotal exploration with excision of the appendix has been advised. Excision of the contralateral appendix is performed by some surgeons; however, subsequent contralateral torsion is quite rare if only one side is explored. Recently Holland et al. recommended nonoperative management of the patients in whom the diagnosis was certain. 24 In their series of 28 patients, 5 were explored to rule out testicular torsion. The pain subsided in two to five days in 20 of the remaining 23 patients. Management consisted of oral analgesics and restricted activity. Only three patients required a subsequent exploration to excise the persistently painful appendage. In view of the anesthetic risk, the expense of surgery, and the pain inherent in any surgical procedure, this recommendation seems eminently reasonable for patients with mild to moderate symptoms. If fully informed of the benefits and disadvantages of operative versus nonoperative management, it is quite likely that most patients will decline surgical exploration.

MISCELLANEOUS ACUTE SCROTAL PATHOLOGY Idiopathic Scrotal Edema Acute idiopathic scrotal edema, although much less common than testicular torsion, is still seen from time to time in any busy emergency room. Characteristically, this syndrome is seen in children somewhat younger than those seen in most other scrotal pathology. Evans et al. reviewed 30 episodes occurring in 26 children over an 8-year period. 16 The boys ranged from 2 to l l years of age. The presenting complaint was an erythematous, edematous scrotum. Although as many as 66 per cent of the boys described some degree of discomfort, it was rarely severe. 16 A history of trauma, allergy, or insect bite is rare. As a general rule, the child is afebrile. A

ACUTE SCROTAL PATHOLOGY

967

normal gonad can usually be palpated in each hemiscrotum. There is no adenopathy or marked scrotal tenderness. Urinalysis is normal. A Doppler How study or scrotal radionuclide scan should demonstrate normal perfusion of the testicle. The diagnosis can usually be made on clinical grounds; however, occasionally a testicular torsion cannot be ruled out. In these cases either a scrotal scan, if available, or scrotal exploration is justified. If the diagnosis is certain, no treatment is necessary. The edema usually subsides in several days. There is no indication for the use of antibiotics.

Scrotal Fat Necrosis This relatively uncommon condition is seen almost exclusively in prepubertal boys. Several reports in the literature suggest that the typical boy has a normal to obese body habitus. 37• 40 Physical activity, not necessarily traumatic, and hypothermia are common preceding factors. Playing outdoors on a cold day or swimming in cold water would be typical examples. The child complains of a painful unilateral or bilateral scrotal mass. These masses are distinctly separate from the testicle and cord structures. Confusion with torsion of the testicle is unlikely. The necrotic fat lobules are gradually resorbed over 7 to 10 days. There is no clear cut indication for surgery in these patients.

Henoch-Schonlein Purpura Occasionally a child with Henoch-Schonlein purpura will develop an acute painful swelling of the scrotum associated with a petechial rash. 48 Almost invariably these children have other manifestations of HenochSchonlein purpura. ·I am aware of at least one anecdotal case of testicular torsion in a child with Henoch-Schonlein purpura, therefore a Doppler flow study or radionuclide scan is reasonable if there is any question of testicular blood flow. The pain and scrotal swelling generally subside over several days. Treatment should be oriented toward the systemic disease in HenochSchonlein purpura.

Testicular Tumor On occasion, a male patient with a testicular neoplasm is seen in the emergency room with a complaint of acute scrotal pain. In keeping with the age distribution of testis tumors, these men will generally be postpubertal. The pain may have begun spontaneously and it may be related to scrotal trauma. The testis is generally enlarged, irregular, firm to hard, and tender. The epididymis is generally but not invariably palpable. A reactive hydrocele is sometimes present. The urinalysis should be normal. It is generally assumed that the pain is secondary to hemorrhage within the tumor. The clear urine and lack of voiding symptoms should eliminate epididymitis as a diagnostic possibility. In general, torsion of the testicle occurs in younger men. If a hard, irregular gonad is palpable, this should further help to eliminate torsion of the testicle from the differential diagnosis. A Doppler flow study or testicular scan will demonstrate good gonadal perfusion. After serum testicular tumor markers, alphafetoprotein and betaHCG, have been drawn, a radical inguinal orchiectomy is the procedure of choice.

968

WILLIAM

C.

SHARER

Testicular Trauma Although the testicles are in a relatively unprotected position, significant testicular trauma is rare. Cass et al. collected only 32 cases over a period of 10 years in the largest recent series. 13 In the vast majority of cases, blunt trauma is sustained during a sporting event or a straddle fall. 5· 13 The testicle is compressed against the pubic ramus. Penetrating trauma, usually a gun shot wound, is much less common. Twenty-two of 25 cases of penetrating scrotal trauma reported from the Vietnam war were caused by mine fragments. 49 Patients who have sustained scrotal trauma complain of a variable degree of scrotal pain and swelling. Voiding symptoms such as bloody urethral discharge, hematuria, dysuria, poor stream, or scrotal swelling with urination may be present if the adjacent urethra has received significant trauma. In mild cases of blunt trauma the physical examination may well be normal. In more severe cases, considerable scrotal swelling may be present owing to a collection of blood in and around the tunica vaginalis. The hemorrhage may be due to rupture of the testicle, epididymis, or a vein in the pampiniform plexus. Ecchymosis and edema of the scrotal skin can be seen in older injuries. The testicle cannot be palpated in most significant injuries because of the large hematocele. On occasion, the force and angle of the trauma are sufficient to dislocate the testicle into the inguinal canal. 15• 50 The urethra should be carefully palpated for evidence of trauma. Blood at the urethral meatus suggests significant urethal trauma. Voided urine should be inspected for microhematuria if urethral bleeding is not identified. If there is any evidence of urethral injury, a retrograde urethrogram should be performed. The successful passing of a urethral catheter does not rule out significant urethral injury. If there is any evidence for a urethral injury, instrumentation should be avoided until adequate xray films have been taken to document urethral integrity. An ultrasound examination of the scrotum can help to identify a rupture of the testicle ir borderline cases. 2 Minimal scrotal trauma can be managed conservatively with analgesics and decreased ambulation. Scrotal trauma sufficient to produce a hematocele should be explored. After the hematocele has been evacuated, the spermatic cord and gonad are inspected for active bleeding and viability. If the spermatic cord has been completely transected, an orchiectomy should be performed. Once hemostasis has been achieved, all necrotic tissue and extruded testicular contents can be debrided. A lacerated testicle should be debrided and reconstructed if possible. Only shattered or devascularized testicles need to be removed. In the report by Cass et al. only 5 of 32 gonads required excision. 13 Even in combat injuries the majority of testicles can be repaired. 49 Early exploration is strongly recommended. 2• 4• 5 • 15• 19• 41 • 49 • 50 • 51 Nonoperative treatment consisting of ice packs, elevation, compression, bed rest, and analgesics almost invariably leads to a prolonged convalescence with protracted pain and swelling. Early exploration within 72 hours from the time of injury markedly enhances the chances of gonadal salvage. In the series of Cass et al., 10 of 11 gonads were saved by prompt exploration, in contrast to the salvage of only 6 of 11 explored at a later

969

ACUTE SCROTAL PATHOLOGY

date. 13 Gross evaluated his own cases and reviewed the literature. 19 Early repair preserved 12 of 15 lacerated gonads. Seven of 19 gonads were saved by delayed repair. Therefore, early exploration and repair are recommended to enhance gonadal preservation and minimize morbidity.

REFERENCES 1. Abu-Sleiman, R., Ho, J. E., and Gregory, J. G.: Scrotal scanning: Present value and limits of interpretation. Urology, 13:326, 1979. 2. Albert, N. E.: Testicular ultrasound for trauma. J. Ural., 124:558, 1980. 3. Altaffer, L. F., Ill: Testicular torsion in men. J. Urol., 123:37, 1980. 4. Ashkar, L. N., and Schreck, W. R.: Traumatic rupture of the testis and epididymis. J. Ural., 99:774, 1968. 5. Atwell, J. D., and Ellis, H.: Rupture of the testis. Brit. J. Surg., 49:345, 1961. 6. Barker, K., and Raper, F. P.: Torsion of the testis. Brit. J. Ural., 36:35, 1964. 7. Berger, R. E., Alexander, E. R., Harnisch, J. P., et a!.: Etiology, manifestations and therapy of acute epididymitis: Prospective study of 50 cases. J. Ural., 121:750, 1979. 8. Berger, R. E., Holmes, K. K., Mayo, M. E., et a!.: The clinical use of epididymal aspiration cultures in the management of selected patients with acute epididymitis. J. Ural., 124:60, 1980. 9. Bowie, W. R., Alexander, E. R., Stimson, J. B., et a!.: Therapy for nongonococcal urethritis. Ann. Int. Med., 95:306, 1981. 10. Cass, A. S., Cass, B. P., and Veeraraghaven, K.: Immediate exploration of the unilateral acute scrotum in young male subjects. J. Ural., 124:829, 1980. 11. Datta, N. S., and Mishkin, F. S.: Radionuclide imaging in intrascrotal lesions. J.A.M.A., 231:1060, 1975. 12. DelVillar, R. G., Ireland, G. W., and Cass, A. S.: Early exploration in acute testicular conditions. J. Ural., 108:887, 1972. 13. DelVillar, R. G., Ireland, G. W., and Cass, A. S.: Early exploration following trauma to the testicle. J. Trauma, 13:600, 1973. 14. Donohue, R. E., and Utley, W. L. F.: Torsion of spermatic cord. Urology, 11:33, 1978. 15. Edson, M., and Meek, J. M.: Bilateral testicular dislocation with unilateral rupture. J. Ural., 122:419, 1979. 16. Evans, J. P., and Snyder, H. M.: Idiopathic scrotal edema. Urology, 9:549, 1977. 17. Falkowski, W. S., and Firlit, C. F.: Testicular torsion: The role of radioisotope scanning. J. Urol., 124:886, 1980. 18. Gislason, T., Noronha, R. F. X., and Gregory, J. G.: Acute epididymitis in boys: A 5 year retrospective review. J. Ural., 124:533, 1980. 19. Gross, M.: Rupture of the testicle: The importance of early surgical treatment. J. Ural., 101:196, 1969. 20. Hahn, L. C., Nadel, N. S., Gitter, M. H., eta!.: Testicular scanning: A new modality for the preoperative diagnosis of testicular torsion. J. U rol., 113:60, 1975. 21. Heck, L., Coles, J. C., Van Hove, E. D., et a!.: Value of "'fc pertechnetate imaging in evaluation of testicular torsion. J. Nuc. Med., 15:501, 1974. 22. Hitch, D. C., Gilday, D. L., Shandling, F., eta!.: A new approach to the diagnosis of testicular torsion. J. Ped. Surg., 11:537, 1976. 23. Holder, L. E., Martire, J. R., Holmes, E. R., eta!.: Testicular radionuclide angiography and static imaging: Anatomy, scintigraphic interpretation and clinical indications. Radiology, 125:739, 1977. 24. Holland, J. M., Graham, J. B., and Ignatofl", J. M.: Conservative management of twisted testicular appendages. J. Urol., 125:213, 1981. 25. Iuchtman, M., Zoireff, L., and Assa, J.: Doppler flowmeter in tile differnetial diagnosis of the acute scrotum in children. J. U rol., 121:221, 1979. 26. Kaplan, G. W., and King, L. R.: Acute scrotal swelling in children. J. Urol., 104:219, 1970. 27. King, L. M., Sekaran, S. K., Sauer, D., eta!.: Untwisting in delayed treatment of torsion of tile spermatic cord. J. Ural., 112:217, 1974.

970

ACUTE SCROTAL PATHOLOGY

28. Klingerman, J. J., and Nourse, M. H.: Torsion of the spermatic cord. J.A.M.A., 200:673, 1967. 29. Kogan, S. J., Lutzker, L. G., Perez, L.A., et al.: The value of the negative radionuclide scrotal scan in the management of the acutely inflammed scrotum in children. J. U rol., 122:223, 1979. 30. Leape, L. L.: Torsion of the testis. J.A.M.A., 200:669, 1967. 31. Levy, B. J.: The diagnosis of torsion of the testicle using the Doppler Ultrasonic stethoscope. J. Urol., 113:63, 1975. 32. Macnicol, M. F.: Torsion of the testis in childhood. Brit. J. Surg., 61:905, 1974. 33. Mishkin, F. S., and Lawrence, D.: Radionuclide imaging in scrotal abnormalities. J. Nucl. Med., 15:518, 1976. 34. Moharib, N. H., and Krahn, H. P.: Acute scrotum in children with emphasis on torsion of spermatic cord. J. Urol., 104:601, 1970. 35. Mukerjee, M. G., Voillero, R. A., Mittemeyer, B. T., et al.: Diagnostic value of 99 MTc in scrotal scan. Urology, 6:453, 1975. 36. Nasrallah, P. F., Manzone, D., and King, L. R.: Falsely negative Doppler examinations in testicular torsion. J. Urol., 118:194, 1977. 37. Nemoy, N. J., Rosin, S., and Kaplan, L.: Scrotal panniculitis in the prepubertal male patient. J. Urol., 118:492, 1977. 38. Pedersen, J. E., Holm, H. H., and Hald, T.: Torsion of the testis diagnosed by ultrasound. J. Urol., 113:66, 1975. 39. Perri, A. J., Slachta, G. A., Feldman, A. E., et al.: The Doppler stethoscope and the diagnosis of the acute scrotum. J. Urol., 116:598, 1976. 40. Peterson, L. J., Whitlock, N. W., Odom, R. B., et al.: Bilateral fat necrosis of the scrotum. J. Urol., 116:825, 1976. 41. Redman, J. F., Rountree, G. A., and Bissada, N. K.: Injuries to scrotal contents by blunt trauma. Urology, 7:190, 1976. 42. Riley, T. W., and Mosbaugh, P. G.: Use of radioisotope scan in evaluation of intrascrotal lesions. J. Urol., 116:472, 1976. 43. Rodriguez, D. D., Rodriguez, W. C., Rivera, J. J., et al.: Doppler ultrasound versus testicular scanning in the evaluation of the acute scrotum. J. Urol., 125:343, 1981. 44. Skoglund, R. W., McRoberts, J. W., and Ragde, H.: Torsion of testicular appendages: Presentation of 43 new cases and a collective review. J. Urol., 104:598, 1970. 45. Skoglund, R. W., McRoberts, J. W., and Radge, H.: Torsion of spermatic cord: A review of the literature and an analysis of70 new cases. J. Urol., 104:604, 1970. 46. Smith, G. 1.: Cellular changes from graded testicular ischemia. J. Urol., 73:355, 1955. 47. Stage, K. H., Schoenvogel, R., and Lewis, S.: Testicular scanning: Clinical experience with 72 patients. J. Urol., 125:334, 1981. 48. Turkish, V. J., Traisman, H. S., Belman, A. B., et al.: Scrotal swelling in the SchonleinHenoch Syndrome. J. Urol., 115:317, 1976. 49. Umhey, C. E., Jr.: Experience with genital wounds in Vietnam. J. Urol., 99:660, 1968. 50. Warden, S., and Schellhammer, P. F.: Bilateral testicular rupture: Report of a case with an unusual presentation. J. Urol., 120:257, 1978. 51. Wasko, R., and Goldstein, A. G.: Traumatic rupture of the testicle. J. Urol., 95:721, 1966. 52. Wasnick, R. J., Polutsky, K. R., and Maechia, R. J.: Testicular torsion and usefulness of radionuclide scanning. Urology, 15:318, 1980. 53. Williams, J. D., and Hodgson, N. B.: Another look at torsion of testis. Urology, 14:36, 1979. 54. Williamson, R. C. N.: Torsion of the testis and allied conditions. Brit. J. Surg., 63:465, 1976. 55. Wright, J. E.: Torsion of the testis. Brit. J. Surg., 64:276, 1977. 765 North Kellogg Street Galesburg, Illinois 61401