- Email: [email protected]
Current management of the acute scrotum
Seminars in Pediatric Surgery (2007) 16, 58-63
Current management of the acute scrotum John M. Gatti, MD, J. Patrick Murphy, MD From the Department of Surgery/Urology, University of Missouri at Kansas City School of Medicine, Children’s Mercy Hospital, Kansas City, MO. INDEX WORDS Testis; Torsion; Acute scrotum; Epididymitis; Orchitis
Pediatric surgeons and urologists are often asked to evaluate boys with acute scrotal pain and inflammation. Although there are myriad etiologies for this syndrome, testicular torsion should be at the top of the list. It is the one diagnosis that must be made accurately and rapidly if there is any hope for testicular salvage. The purpose of this article is to update/review the appropriate evaluation and management of the acute scrotum and to guide the clinician in distinguishing testicular torsion from the other conditions that commonly mimic this surgical emergency. © 2007 Elsevier Inc. All rights reserved.
Acute scrotal pain with or without swelling and erythema in the child or adolescent male should always be treated as an emergent condition. The numerous differential diagnoses for the acute scrotum are listed in Table 1. Most of the conditions are nonemergent, but of paramount importance is the prompt diagnosis and treatment of torsion of the spermatic cord to avoid permanent ischemic damage to the testicle. This article will discuss the evaluation and management of these various causes of acute scrotal pain, focusing on differentiating testicular torsion from other causes. The most common two causes of this condition are testicular (spermatic cord) torsion and torsion of the rudimentary vestigial appendages of the testicle or epididymis. The child’s age is the first clue to the etiology of the acute scrotum, since torsion of the appendix testes/epididymis is more common in prepubertal boys, whereas spermatic cord torsion more commonly presents in adolescents and newborns.1,2
Address reprint requests and correspondence: John M. Gatti, MD, University of Missouri at Kansas City School of Medicine, Department of Surgery/Urology, Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108. E-mail: [email protected].
1055-8586/$ -see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1053/j.sempedsurg.2006.10.008
Testicular torsion Torsion of the testicle results from twisting of the spermatic cord which compromises testicular blood supply. The number of twists determines the amount of vascular impairment, but generally there is a 4- to 8-hour window before significant ischemic damage occurs affecting long-term testicular morphology and sperm formation.3 Testicular torsion is a true surgical emergency. Even though adolescent males tend to present beyond the “golden” 4- to 8-hour period, emergent surgical treatment is indicated because viability of the testis is difficult to predict.4 Two types of testicular torsion may occur. Extravaginal torsion results from twisting of the cord proximal to the tunica vaginalis. It occurs perinatally during descent of the testicle before the scrotal investment of the tunica vaginalis has taken place, thus allowing the tunics and testis to spin on their vascular pedicle. The tunica vaginalis likely becomes adherent to the surrounding tissues by 6 weeks of age. Intravaginal torsion occurs beyond the perinatal period and happens because of abnormal fixation of the testicle and epididymis within the tunica vaginalis. Normally, the tunica will invest the epididymis and posterior surface of the testicle, which fixes it to the scrotum and prevents it from twisting. If the tunica vaginalis attaches in a more proximal position on the spermatic cord, the testicle and epididymis hang free in the scrotum and can twist within the tunica
Gatti and Murphy Table 1
The Acute Scrotum
Differential diagnoses of the acute scrotum
Torsion of spermatic cord Torsion of appendix testis/epididymis Epididymitis/orchitis Hernia/hydrocele Trauma/sexual abuse Tumor Idiopathic scrotal edema (dermatitis, insect bite) Cellulitis Vasculitis (Henoch-Schönlein purpura)
vaginalis. This abnormal fixation is classically described as the “bell-clapper” deformity and occurs in only a minority of males (Figure 1). The incidence has been reported to be as high as 12% in cadaveric studies and is often bilateral.5 Since the incidence of testicular torsion is significantly less than this, other factors play a role in the occurrence of torsion. Rapid cremasteric muscle contraction elevates the testicle and can have a rotational effect on the spermatic cord to induce torsion. Rapid growth and increasing vascularity of the testicle may also be a precursor to torsion. This phenomenon occurs at puberty and is thought to account for the age distribution of torsion, which is increased in adolescence. The congestion seen with an inflammatory process or minor trauma may also predispose to torsion in a male with a “bell-clapper” deformity. Therefore, it is especially important to maintain a high level of suspicion in boys who experience increasing pain after being diagnosed with epididymitis or mild blunt scrotal trauma and who may have developed testicular torsion as a secondary event. The classic clinical presentation of testicular torsion is the sudden onset of severe, unilateral pain, often with nausea and vomiting. The pain is usually unrelenting, but seemingly minimal pain may be seen in patients who are very stoic or when the torsion has been longstanding. A history of previous bouts of intermittent testicular pain may be present and likely represents previous intermittent torsion and detorsion. The physical examination should include thorough investigation of the abdomen, inguinal area, and scrotum. The abdomen and inguinal area should be inspected for other causes of scrotal pain such as an inguinal hernia. Depending on the duration of the torsion, the scrotum can show various degrees of erythema and induration. If landmarks are still present, the involved testicle may be higher riding, have a transverse orientation, or the epididymis may be located anteriorly. The cremasteric reflex is often absent with torsion, but presence of the cremasteric reflex certainly does not exclude torsion.6-8 The testicle itself is usually palpably tender with spermatic cord torsion, whereas the focal area of tenderness is in the superior testis or caput epididymis with a torsed appendix testis or epididymitis. In the later stages of testicular torsion, scrotal edema and erythema may obliterate these landmarks, making the examination more difficult.
59 When torsion is suspected and the patient’s pain tolerance allows it, manual detorsion may be attempted. Classically, the detorsion should be attempted in a medial to lateral or “open book” rotation.9 If successful, the testicle will change its orientation and usually drop lower in the scrotum. The patient will also report sudden pain relief. The direction of rotation described is only the case in about two-thirds of patients, and if the initial attempt at outward rotation is unsuccessful, an attempt in the other direction may be attempted.10 Analgesics are helpful when attempting this. Manual detorsion may not totally detorse the cord, so prompt surgical exploration is still warranted, even if the patient is symptomatically improved. Manual detorsion may decrease the degree of ischemia when a substantial delay to the operating room is anticipated, but is not a substitute for exploration and fixation. There are adjunctive diagnostic studies that may aid in determining the etiology of the acute scrotum. Urinalysis is indicated, since pyuria and bacteriuria are more likely in infectious epididymitis/orchitis. However, these findings can be present in torsion. High-resolution ultrasound with color-flow Doppler and radionuclide imaging are two studies which can provide information about testicular blood flow. Most clinicians use these studies to help confirm a
Figure 1 “Bell-Clapper” deformity of testicle with lack of investing tunica vaginalis so that the testicle is free to twist in the scrotum.
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clinical diagnosis other than testicular torsion. Radionuclide imaging of the scrotum was historically the study of choice. Ultrasound with color Doppler now has become a more popular study in most institutions because it allows determination of blood flow, is less time consuming, is more readily available, and does not expose the patient to ionizing radiation.11,12 Recent studies show a sensitivity of 89.9%, specificity of 98.8%, and false-positive rate of 1% for color flow Doppler ultrasound in experienced hands.13 The ability to evaluate the testicle and spermatic cord anatomically is an additional advantage of ultrasound. Coiling of the spermatic cord indicating testicular torsion may be detected even when testicular blood flow is normal.14,15 It cannot be overemphasized that these studies are adjunctive to the clinical evaluation of testicular torsion and are used when that diagnosis is equivocal. If torsion is strongly suspected by history and physical examination, imaging only wastes time when emergent surgical exploration is indicated. When surgical exploration is decided on, it should be done with as little delay as possible. Most surgeons use a midline median raphe incision, entering the symptomatic hemiscrotum initially to deliver the testicle to allow detorsion. With the torsion relieved, the testicle is placed in warm, moist sponges while exploring the opposite hemiscrotum. The contralateral testis is fixed in at least three sites with nonabsorbable suture. The suture should attach the testicle to the scrotal wall, excluding the tunica vaginalis by excising a portion or tucking it back in the scrotum. This allows better fixation of the testicle to the scrotal connective tissue, much like dartos pouch fixation used in newborn scrotal fixation.16,17 Attention is then returned to the affected testis. If it is obviously nonviable, it is removed. If the testis is re-perfused or fresh bleeding can be seen from the cut surface, it should be replaced in the scrotum and fixation performed in the same fashion as the contralateral testis. It should also be noted that testicular fixation is not an absolute guarantee against the possibility of future torsion, as cases of torsion after fixation have been reported. Any patient presenting with suspected testicular torsion should be evaluated and treated with the same diligence whether or not previous fixation has been performed.18 There has been concern regarding contralateral testicular damage secondary to sperm antibodies formed in response to testicular damage in the torsed gonad. This has been demonstrated in animals,19,20 but whether this is physiologically significant in humans remains questionable. As a result, some suggest removal of all testes which have experienced any significant ischemic change, but our practice is to remove the testis only if it appears nonviable.
ular pain which spontaneously resolve.21 These episodes may very well represent intermittent torsion with spontaneous resolution. In adolescent males who present with a history of significant acute testicular pain that has resolved (particularly with multiple events), intermittent testicular torsion should be strongly considered. Transverse testicular orientation or excess testicular mobility on physical examination adds to this suspicion. Ideally, a Doppler ultrasound during symptoms would provide the diagnosis, but may be difficult to obtain in a timely fashion. In this scenario, even with a normal examination, elective scrotal exploration looking for a “bell-clapper” deformity may be warranted. Scrotal ultrasound before elective exploration is reasonable to be sure no preclinical testicular lesions are present.
Intermittent testicular pain Intermittent testicular pain in adolescent males is not an unusual complaint. A number of boys who present with torsion will have a history of prior acute episodes of testic-
Perinatal torsion Perinatal torsion is a term used to include both prenatal and postnatal events. The difference between the two is important but sometimes may be difficult to determine clinically. Prenatal torsion classically presents at birth as a hard, nontender mass in the hemiscrotum, usually with underlying dark discoloration of the skin and fixation of the skin to the mass. This is characteristic of infarction of the testis secondary to remote torsion. Postnatal torsion will present with more classic, acute inflammation including erythema and tenderness. A report of a previously normal scrotum at delivery suggests an acute event. The difference is important since the postnatal torsion requires emergent exploration and treatment with detorsion and fixation. Most feel that testicular salvage in perinatal torsion is rare, but some authors have reported surprisingly good salvage rates.22 If there is any question about the timing of the torsion, prompt exploration is the best course unless underlying medical conditions make general anesthetic unduly risky. Color Doppler ultrasound may be useful in questionable cases. In patients with prenatal torsion and presumed infarction of the testes, the classic teaching has been that surgical exploration is not indicated and salvage rates are negligible.23 However, this doctrine has more recently been challenged, given reports of asynchronous torsion and the devastating loss of the remaining contralateral testis.24,25 Although extremely rare, many clinicians, perhaps fueled by fear of litigation, have become more aggressive with surgical treatment of these infarcted testes to fix the contralateral side to prevent potential asynchronous torsion. Unless medical conditions create an unacceptable anesthetic risk, it has been our practice to explore these testes early to prevent possible contralateral torsion and assure the correct diagnosis, since testicular teratoma or meconium/ blood in a hernia sac may present with the same findings. Many surgeons prefer an inguinal approach to the involved side, which allows an easier delivery and removal of the necrotic, fixed gonad. The inguinal approach is also more appropriate when an alternate diagnosis is suspected. Con-
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tralateral exploration is accomplished through a transverse scrotal incision with placement of the testis in a dartos pouch between the external spermatic fascia of the scrotum and the dartos layer. This technique is less traumatic to the small, delicate gonad and probably provides better fixation than suture.16,17
Conditions mimicking testicular torsion Inflammation Inflammation of the testis and epididymis in the adult are commonly attributed to bacterial epididymitis or epididymoorchitis that extends from the bladder and urethra in retrograde fashion, especially in postpubertal, sexually active males. True bacterial epididymitis/orchitis is quite rare in children, but is commonly given as an inaccurate, generalized diagnosis in the setting of scrotal pain in the absence of testicular torsion.
Torsion of testicular appendages Torsion of the appendix testis or appendix epididymis is a common cause of acute scrotal pain and frequently misdiagnosed as acute epididymitis or epididymoorchitis, implying a bacterial origin. Morgagni is credited with the first description of an appendix testis in Padua, Italy in 1761.26 Colt first reported torsion of the appendage in 1922 in Scotland.27 The testicular appendage is a remnant of the Mu¨llerian duct, whereas the epididymal appendages are of Wolffian duct origin. Torsion of an appendage occurs more commonly in the prepubertal age group and may be the result of hormonal stimulation which increases the mass of the pedunculated structures and makes them susceptible to twisting.28 The presentation can mimic testicular torsion with a sudden onset of pain; nausea and vomiting may also occur. The urinalysis is uniformly normal. Classically, these are associated with the “blue-dot sign,” when the inflamed and ischemic appendage can be seen as a subtle blue-colored mass through the scrotal skin.29 Early in the syndrome, the appendage can be palpated and is exquisitely and focally tender to examination. As local inflammation occurs, however, the epididymis, testis, and superficial tissues become edematous, and the diagnosis becomes more difficult to make. Early ultrasound can be diagnostic, showing the discrete appendage, but later the study may only show increased blood flow to the adjacent epididymis and testis and possibly a reactive hydrocele, resulting in the misdiagnosis of acute epididymitis or epididymoorchitis.30 The syndrome is self-limited and responds best to nonsteroidal antiinflammatory medications and comfort measures such as limited activity and a warm compress. As the appendage infarcts and necroses, the pain resolves. The syndrome can recur, as there are potentially five anatomic sites of appendages
Figure 2 Large necrotic testicular appendage (A) at superior pole of testis (T) at time of exploration.
which may experience torsion (appendix testis, appendix epididymis, paradidymis-organ of Giraldes, superior and inferior vas aberrans of Haller),31-33 and more than one appendage may occur in a given site. Surgical intervention is indicated in cases where the diagnosis of testicular torsion cannot be reliably eliminated or when the symptoms are prolonged and spontaneous resolution of the symptoms do not occur. Excision of the torsed appendage through a small scrotal incision is easily performed with excellent results in relief of symptoms (Figure 2).
Epididymitis Classic bacterial epididymitis generally has a slow onset, with scrotal pain and swelling worsening over days rather than hours. There is usually no nausea or vomiting. Bacterial infection is thought to reach the epididymis in retrograde fashion via the ejaculatory ducts, and can be associated with a clinical urinary tract infection or urethritis. A positive urinalysis and culture, or urethral swab in sexually active adolescents, suggests the diagnosis. Gonococcus and Chlamydia are classically described in the sexually active, but common urinary pathogens including coliforms, and mycoplasma species are more probable in younger children.
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When studies suggest a bacterial infection, appropriate antibiotics are indicated. Just as for any urinary tract infection in a boy, radiographic imaging including a renal bladder ultrasound and voiding cystourethrogram should be obtained after the infection has resolved. Anatomic abnormalities such as ectopic ureter (to the vas, ejaculatory duct or seminal vesicle), ejaculatory duct obstruction, or urethral valves are uncommon, but should be ruled out. Viral infections are felt to be a common cause of acute epididymitis, but are usually diagnosed presumptively. Mumps orchitis occurs in about one-third of postpubertal boys affected by the virus and is fortunately rare in the modern era of immunization.34 Adenovirus, enterovirus, influenza, and parainfluenza virus infections have also been described. Management is supportive, antibiotics are not indicated, and the pain syndrome is generally self-limited. Aggressive testing is usually not warranted, but viral cultures and serological studies may be useful in clustered familial or community cases.35
such as skin purpura, joint pain, and hematuria. Usually supportive measures are adequate, but systemic steroids are sometimes helpful.37,38 Despite the rarity of overlapping diagnoses, Henoch-Scho¨nlein purpura and torsion of the testis have been reported together.39
Scrotal pain Recurrent bouts of scrotal pain warrant special consideration, especially if bilateral. Voiding is a common but under-reported cause of scrotal pain, which frequently goes unrecognized unless the diagnosis is sought. The pathophysiology is that of bladder instability causing high pressure voiding against a voluntarily closed external sphincter. It is common to see dilation of the posterior urethra (“spinning-top urethra”) during voiding in children with voiding dysfunction undergoing a voiding cystourethrogram. Urine may be forced up the ejaculatory duct manifesting in local inflammation and a “chemical” epididymitis or epididymoorchitis may result.36 A renal– bladder ultrasound may show a thickened bladder wall, and is also useful to rule out ureteral ectopia to the ejaculatory duct or vas deferens as a potential cause in recurrent cases. There is no pathognomonic test for voiding dysfunction, but a thorough history will often reveal urinary urgency, incontinence, a staccato urinary stream indicative of inappropriate sphincter activity, and occult constipation. Treatment of these children with a timed-voiding regimen, dietary modification, aggressive management of constipation, and anticholinergic or alphaantagonist medication when appropriate is effective.
Idiopathic scrotal edema Scrotal swelling of unknown etiology is termed idiopathic scrotal edema. The syndrome is characterized by thickening and erythema of the scrotum, but the testes are generally not involved. Pruritus may be present, but the condition is not usually painful. Ultrasound shows normal testicular blood flow but is not usually required. Other causes should be sought to rule out cellulitis from an adjacent infection (inguinal, perirectal, or urethral). Undoubtedly, many cases of contact dermatitis, insect bites, and minor trauma are given this diagnosis. Management is supportive, and antihistamines or topical steroids may give considerable relief of symptoms. Occasionally, oral antibiotics are administered if cellulitis is a concern.40
Other causes Other less common causes of the acute scrotum, which must be considered, include hernia, hydrocele, sexual abuse or other trauma, and neoplasia. Usually a thorough history, physical examination, and imaging (if necessary) can differentiate these causes of scrotal swelling from testicular torsion.
Conclusion Acute scrotal pain in the child or adolescent male is a common event, but should always be treated as an emergent condition. Although the differential diagnoses are many, and most of the conditions are nonurgent, of paramount importance is the prompt diagnosis and surgical treatment of torsion of the spermatic cord to avoid permanent ischemic damage to the testicle. With a thorough history, physical examination, and imaging if warranted, an accurate diagnosis can usually be made.
Henoch-Scho¨nlein Purpura Henoch-Scho¨nlein Purpura is a vasculitic syndrome that can include the skin, joints, gastrointestinal, and genitourinary systems. In up to one-third of patients, pain, erythema, and swelling of the scrotum and spermatic cord may occur. This seems to occur more commonly in younger boys less than 7 years of age. The scrotal findings and onset of pain may mimic testicular torsion, but Doppler ultrasound reveals good blood flow to the testes. A thorough history and physical examination may reveal other systemic symptoms,
References 1. Baker LA, Sigman D, Mathews RI, et al. An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion. Pediatrics 2000;105(3):604-7. 2. Ballesteros Sampol JJ, Munne A, Bosch A. A vas aberrans torsion. Br J Urol 1986;58(1):97. 3. Bartsch G, Frank S, Marberger H, et al. Testicular torsion: late results with special regard to fertility and endocrine function. J Urol 1980; 124(3):375-8.
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4. Beard CM, Benson RC Jr, Kelalis PP, et al. The incidence and outcome of mumps orchitis in Rochester, Minnesota, 1935 to 1974. Mayo Clin Proc 1977;52(1):3-7. 5. Bellinger MF, Abromowitz H, Brantley S, et al. Orchiopexy: an experimental study of the effect of surgical technique on testicular histology. J Urol 1989;142(2):553-5, discussion 572. 6. Bentley DF, Ricchiuti DJ, Nasrallah PF, et al. Spermatic cord torsion with preserved testis perfusion: initial anatomical observations. J Urol 2004;172(6):2373-6. 7. Ciftci AO, Senocak ME, Tanyel FC, et al. Clinical predictors for differential diagnosis of acute scrotum. Eur J Pediatr Surg 2004;14(5): 333-8. 8. Clark WR, Kramer SA. Henoch-Schonlein purpura and the acute scrotum. J Pediatr Surg 1986;21(11):991-2. 9. Colt G. Torsion of the hydatid of Morgagni. Br J Surg 1922;9:464. 10. Cosentino MJ, Nishida M, Rabinowitz R, et al. Histological changes occurring in the contralateral testes of prepubertal rats subjected to various durations of unilateral spermatic cord torsion. J Urol 1985; 133(5):906-11. 11. Dresner ML. Torsed appendage. Diagnosis and management: blue dot sign. Urology 1973;1(1):63-6. 12. Hutson J. Undescended testis, torsion, and varicocele. In: Grosfeld JL, O’Neill JA, Coran AG, et al, eds. Pediatric Surgery. Philadelphia, PA: Mosby Elsevier, 2006:1193-214. 13. Kalfa N, Veyrac C, Baud C, et al. Ultrasonography of the spermatic cord in children with testicular torsion: impact on the surgical strategy. J Urol 2004;172(4):1692-5, discussion 1695. 14. Karmazyn B, Steinberg R, Kornreich L, et al. Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys. Pediatr Radiol 2005;35(3):302-10. 15. Karmazyn B, Steinberg R, Livne P, et al. Duplex sonographic findings in children with torsion of the testicular appendages: overlap with epididymitis and epididymoorchitis. J Pediatr Surg 2006;41(3):500-4. 16. Kiesling VJ Jr, Schroeder DE, Pauljev P, et al. Spermatic cord block and manual reduction: primary treatment for spermatic cord torsion. J Urol 1984;132(5):921-3. 17. King P, Sripathi P. The acute scrotum. In: Ashcraft KW, Holcomb GW, Murphy JP, eds. Pediatric Surgery. Philadelphia, PA: Elsevier Saunders, 2005:717-22. 18. Loh HS, Jalan OM. Testicular torsion in Henoch–Schonlein syndrome. BMJ 1974;2(910):96-7. 19. McAndrew HF, Pemberton R, Kikiros CS, et al. The incidence and investigation of acute scrotal problems in children. Pediatr Surg Int 2002;18(5-6):435-7. 20. Mor Y, Pinthus JH, Nadu A, et al. Testicular fixation following torsion of the spermatic cord: does it guarantee prevention of recurrent torsion events? J Urol 2006;175(1):171-3, discussion 173-4. 21. Murphy J. The acute scrotum. In: Ziegler MM, Azizkhan RG, Weber TR, eds. Operative Pediatric Surgery. New York, NY: McGraw-Hill, 2003:563-7.
63 22. Nagler HM, White RD. The effect of testicular torsion on the contralateral testis. J Urol 1982;128(6):1343-8. 23. Nelson CP, Williams JF, Bloom DA. The cremasteric reflex: a useful but imperfect sign in testicular torsion. J Pediatr Surg 2003;38(8): 1248-9. 24. Nussbaum Blask AR, Bulas D, Shalaby-Rana E, et al. Color Doppler sonography and scintigraphy of the testis: a prospective, comparative analysis in children with acute scrotal pain. Pediatr Emerg Care 2002; 18(2):67-71. 25. Olguner M, Akgur FM, Aktug T, et al. Bilateral asynchronous perinatal testicular torsion: a case report. J Pediatr Surg 2000;35(9): 1348-9. 26. Orazi C, Fariello G, Malena S, et al. Torsion of paradidymis or Giraldes’ organ: an uncommon cause of acute scrotum in pediatric age group. J Clin Ultrasound 1989;17(8):598-601. 27. Rabinowitz R. The importance of the cremasteric reflex in acute scrotal swelling in children. J Urol 1984;132(1):89-90. 28. Rabinowitz R, Hulbert WC Jr. Acute scrotal swelling. Urol Clin North Am 1995;22(1):101-5. 29. Rodriguez LE, Kaplan GW. An experimental study of methods to produce intrascrotal testicular fixation. J Urol 1988;139(3):565-7. 30. Rolnick D, Kawanoue S, Szanto P, et al. Anatomical incidence of testicular appendages. J Urol 1968;100(6):755-6. 31. Samnakay N, Cohen RJ, Orford J, et al. Androgen and oestrogen receptor status of the human appendix testis. Pediatr Surg Int 2003; 19(7):520-4. 32. Sessions AE, Rabinowitz R, Hulbert WC, et al. Testicular torsion: direction, degree, duration and disinformation. J Urol 2003;169(2): 663-5. 33. Somekh E, Gorenstein A, Serour F. Acute epididymitis in boys: evidence of a post-infectious etiology. J Urol 2004;171(1):391-4, discussion 394. 34. Soreide K. Surgical management of nonrenal genitourinary manifestations in children with Henoch-Schonlein purpura. J Pediatr Surg 2005;40(8):1243-7. 35. Sorensen MD, Galansky SH, Striegl AM, et al. Prenatal bilateral extravaginal testicular torsion: a case presentation. Pediatr Surg Int 2004;20(11-12):892-3. 36. Sorensen MD, Galansky SH, Striegl AM, et al. Perinatal extravaginal torsion of the testis in the first month of life is a salvageable event. Urology 2003;62(1):132-4. 37. Stillwell TJ, Kramer SA. Intermittent testicular torsion. Pediatrics 1986;77(6):908-11. 38. Stone KT, Kass EJ, Cacciarelli AA, et al. Management of suspected antenatal torsion: what is the best strategy? J Urol 1995;153(3 Pt 1):782-4. 39. Thind P, Brandt B, Kristensen JK. Assessment of voiding dysfunction in men with acute epididymitis. Urol Int 1992;48(3):320-2. 40. Wu HC, Sun SS, Kao A, et al. Comparison of radionuclide imaging and ultrasonography in the differentiation of acute testicular torsion and inflammatory testicular disease. Clin Nucl Med 2002;27(7):490-3.
Current management of the acute scrotum John M. Gatti, MD, J. Patrick Murphy, MD From the Department of Surgery/Urology, University of Missouri at Kansas City School of Medicine, Children’s Mercy Hospital, Kansas City, MO. INDEX WORDS Testis; Torsion; Acute scrotum; Epididymitis; Orchitis
Pediatric surgeons and urologists are often asked to evaluate boys with acute scrotal pain and inflammation. Although there are myriad etiologies for this syndrome, testicular torsion should be at the top of the list. It is the one diagnosis that must be made accurately and rapidly if there is any hope for testicular salvage. The purpose of this article is to update/review the appropriate evaluation and management of the acute scrotum and to guide the clinician in distinguishing testicular torsion from the other conditions that commonly mimic this surgical emergency. © 2007 Elsevier Inc. All rights reserved.
Acute scrotal pain with or without swelling and erythema in the child or adolescent male should always be treated as an emergent condition. The numerous differential diagnoses for the acute scrotum are listed in Table 1. Most of the conditions are nonemergent, but of paramount importance is the prompt diagnosis and treatment of torsion of the spermatic cord to avoid permanent ischemic damage to the testicle. This article will discuss the evaluation and management of these various causes of acute scrotal pain, focusing on differentiating testicular torsion from other causes. The most common two causes of this condition are testicular (spermatic cord) torsion and torsion of the rudimentary vestigial appendages of the testicle or epididymis. The child’s age is the first clue to the etiology of the acute scrotum, since torsion of the appendix testes/epididymis is more common in prepubertal boys, whereas spermatic cord torsion more commonly presents in adolescents and newborns.1,2
Address reprint requests and correspondence: John M. Gatti, MD, University of Missouri at Kansas City School of Medicine, Department of Surgery/Urology, Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108. E-mail: [email protected].
1055-8586/$ -see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1053/j.sempedsurg.2006.10.008
Testicular torsion Torsion of the testicle results from twisting of the spermatic cord which compromises testicular blood supply. The number of twists determines the amount of vascular impairment, but generally there is a 4- to 8-hour window before significant ischemic damage occurs affecting long-term testicular morphology and sperm formation.3 Testicular torsion is a true surgical emergency. Even though adolescent males tend to present beyond the “golden” 4- to 8-hour period, emergent surgical treatment is indicated because viability of the testis is difficult to predict.4 Two types of testicular torsion may occur. Extravaginal torsion results from twisting of the cord proximal to the tunica vaginalis. It occurs perinatally during descent of the testicle before the scrotal investment of the tunica vaginalis has taken place, thus allowing the tunics and testis to spin on their vascular pedicle. The tunica vaginalis likely becomes adherent to the surrounding tissues by 6 weeks of age. Intravaginal torsion occurs beyond the perinatal period and happens because of abnormal fixation of the testicle and epididymis within the tunica vaginalis. Normally, the tunica will invest the epididymis and posterior surface of the testicle, which fixes it to the scrotum and prevents it from twisting. If the tunica vaginalis attaches in a more proximal position on the spermatic cord, the testicle and epididymis hang free in the scrotum and can twist within the tunica
Gatti and Murphy Table 1
The Acute Scrotum
Differential diagnoses of the acute scrotum
Torsion of spermatic cord Torsion of appendix testis/epididymis Epididymitis/orchitis Hernia/hydrocele Trauma/sexual abuse Tumor Idiopathic scrotal edema (dermatitis, insect bite) Cellulitis Vasculitis (Henoch-Schönlein purpura)
vaginalis. This abnormal fixation is classically described as the “bell-clapper” deformity and occurs in only a minority of males (Figure 1). The incidence has been reported to be as high as 12% in cadaveric studies and is often bilateral.5 Since the incidence of testicular torsion is significantly less than this, other factors play a role in the occurrence of torsion. Rapid cremasteric muscle contraction elevates the testicle and can have a rotational effect on the spermatic cord to induce torsion. Rapid growth and increasing vascularity of the testicle may also be a precursor to torsion. This phenomenon occurs at puberty and is thought to account for the age distribution of torsion, which is increased in adolescence. The congestion seen with an inflammatory process or minor trauma may also predispose to torsion in a male with a “bell-clapper” deformity. Therefore, it is especially important to maintain a high level of suspicion in boys who experience increasing pain after being diagnosed with epididymitis or mild blunt scrotal trauma and who may have developed testicular torsion as a secondary event. The classic clinical presentation of testicular torsion is the sudden onset of severe, unilateral pain, often with nausea and vomiting. The pain is usually unrelenting, but seemingly minimal pain may be seen in patients who are very stoic or when the torsion has been longstanding. A history of previous bouts of intermittent testicular pain may be present and likely represents previous intermittent torsion and detorsion. The physical examination should include thorough investigation of the abdomen, inguinal area, and scrotum. The abdomen and inguinal area should be inspected for other causes of scrotal pain such as an inguinal hernia. Depending on the duration of the torsion, the scrotum can show various degrees of erythema and induration. If landmarks are still present, the involved testicle may be higher riding, have a transverse orientation, or the epididymis may be located anteriorly. The cremasteric reflex is often absent with torsion, but presence of the cremasteric reflex certainly does not exclude torsion.6-8 The testicle itself is usually palpably tender with spermatic cord torsion, whereas the focal area of tenderness is in the superior testis or caput epididymis with a torsed appendix testis or epididymitis. In the later stages of testicular torsion, scrotal edema and erythema may obliterate these landmarks, making the examination more difficult.
59 When torsion is suspected and the patient’s pain tolerance allows it, manual detorsion may be attempted. Classically, the detorsion should be attempted in a medial to lateral or “open book” rotation.9 If successful, the testicle will change its orientation and usually drop lower in the scrotum. The patient will also report sudden pain relief. The direction of rotation described is only the case in about two-thirds of patients, and if the initial attempt at outward rotation is unsuccessful, an attempt in the other direction may be attempted.10 Analgesics are helpful when attempting this. Manual detorsion may not totally detorse the cord, so prompt surgical exploration is still warranted, even if the patient is symptomatically improved. Manual detorsion may decrease the degree of ischemia when a substantial delay to the operating room is anticipated, but is not a substitute for exploration and fixation. There are adjunctive diagnostic studies that may aid in determining the etiology of the acute scrotum. Urinalysis is indicated, since pyuria and bacteriuria are more likely in infectious epididymitis/orchitis. However, these findings can be present in torsion. High-resolution ultrasound with color-flow Doppler and radionuclide imaging are two studies which can provide information about testicular blood flow. Most clinicians use these studies to help confirm a
Figure 1 “Bell-Clapper” deformity of testicle with lack of investing tunica vaginalis so that the testicle is free to twist in the scrotum.
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clinical diagnosis other than testicular torsion. Radionuclide imaging of the scrotum was historically the study of choice. Ultrasound with color Doppler now has become a more popular study in most institutions because it allows determination of blood flow, is less time consuming, is more readily available, and does not expose the patient to ionizing radiation.11,12 Recent studies show a sensitivity of 89.9%, specificity of 98.8%, and false-positive rate of 1% for color flow Doppler ultrasound in experienced hands.13 The ability to evaluate the testicle and spermatic cord anatomically is an additional advantage of ultrasound. Coiling of the spermatic cord indicating testicular torsion may be detected even when testicular blood flow is normal.14,15 It cannot be overemphasized that these studies are adjunctive to the clinical evaluation of testicular torsion and are used when that diagnosis is equivocal. If torsion is strongly suspected by history and physical examination, imaging only wastes time when emergent surgical exploration is indicated. When surgical exploration is decided on, it should be done with as little delay as possible. Most surgeons use a midline median raphe incision, entering the symptomatic hemiscrotum initially to deliver the testicle to allow detorsion. With the torsion relieved, the testicle is placed in warm, moist sponges while exploring the opposite hemiscrotum. The contralateral testis is fixed in at least three sites with nonabsorbable suture. The suture should attach the testicle to the scrotal wall, excluding the tunica vaginalis by excising a portion or tucking it back in the scrotum. This allows better fixation of the testicle to the scrotal connective tissue, much like dartos pouch fixation used in newborn scrotal fixation.16,17 Attention is then returned to the affected testis. If it is obviously nonviable, it is removed. If the testis is re-perfused or fresh bleeding can be seen from the cut surface, it should be replaced in the scrotum and fixation performed in the same fashion as the contralateral testis. It should also be noted that testicular fixation is not an absolute guarantee against the possibility of future torsion, as cases of torsion after fixation have been reported. Any patient presenting with suspected testicular torsion should be evaluated and treated with the same diligence whether or not previous fixation has been performed.18 There has been concern regarding contralateral testicular damage secondary to sperm antibodies formed in response to testicular damage in the torsed gonad. This has been demonstrated in animals,19,20 but whether this is physiologically significant in humans remains questionable. As a result, some suggest removal of all testes which have experienced any significant ischemic change, but our practice is to remove the testis only if it appears nonviable.
ular pain which spontaneously resolve.21 These episodes may very well represent intermittent torsion with spontaneous resolution. In adolescent males who present with a history of significant acute testicular pain that has resolved (particularly with multiple events), intermittent testicular torsion should be strongly considered. Transverse testicular orientation or excess testicular mobility on physical examination adds to this suspicion. Ideally, a Doppler ultrasound during symptoms would provide the diagnosis, but may be difficult to obtain in a timely fashion. In this scenario, even with a normal examination, elective scrotal exploration looking for a “bell-clapper” deformity may be warranted. Scrotal ultrasound before elective exploration is reasonable to be sure no preclinical testicular lesions are present.
Intermittent testicular pain Intermittent testicular pain in adolescent males is not an unusual complaint. A number of boys who present with torsion will have a history of prior acute episodes of testic-
Perinatal torsion Perinatal torsion is a term used to include both prenatal and postnatal events. The difference between the two is important but sometimes may be difficult to determine clinically. Prenatal torsion classically presents at birth as a hard, nontender mass in the hemiscrotum, usually with underlying dark discoloration of the skin and fixation of the skin to the mass. This is characteristic of infarction of the testis secondary to remote torsion. Postnatal torsion will present with more classic, acute inflammation including erythema and tenderness. A report of a previously normal scrotum at delivery suggests an acute event. The difference is important since the postnatal torsion requires emergent exploration and treatment with detorsion and fixation. Most feel that testicular salvage in perinatal torsion is rare, but some authors have reported surprisingly good salvage rates.22 If there is any question about the timing of the torsion, prompt exploration is the best course unless underlying medical conditions make general anesthetic unduly risky. Color Doppler ultrasound may be useful in questionable cases. In patients with prenatal torsion and presumed infarction of the testes, the classic teaching has been that surgical exploration is not indicated and salvage rates are negligible.23 However, this doctrine has more recently been challenged, given reports of asynchronous torsion and the devastating loss of the remaining contralateral testis.24,25 Although extremely rare, many clinicians, perhaps fueled by fear of litigation, have become more aggressive with surgical treatment of these infarcted testes to fix the contralateral side to prevent potential asynchronous torsion. Unless medical conditions create an unacceptable anesthetic risk, it has been our practice to explore these testes early to prevent possible contralateral torsion and assure the correct diagnosis, since testicular teratoma or meconium/ blood in a hernia sac may present with the same findings. Many surgeons prefer an inguinal approach to the involved side, which allows an easier delivery and removal of the necrotic, fixed gonad. The inguinal approach is also more appropriate when an alternate diagnosis is suspected. Con-
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tralateral exploration is accomplished through a transverse scrotal incision with placement of the testis in a dartos pouch between the external spermatic fascia of the scrotum and the dartos layer. This technique is less traumatic to the small, delicate gonad and probably provides better fixation than suture.16,17
Conditions mimicking testicular torsion Inflammation Inflammation of the testis and epididymis in the adult are commonly attributed to bacterial epididymitis or epididymoorchitis that extends from the bladder and urethra in retrograde fashion, especially in postpubertal, sexually active males. True bacterial epididymitis/orchitis is quite rare in children, but is commonly given as an inaccurate, generalized diagnosis in the setting of scrotal pain in the absence of testicular torsion.
Torsion of testicular appendages Torsion of the appendix testis or appendix epididymis is a common cause of acute scrotal pain and frequently misdiagnosed as acute epididymitis or epididymoorchitis, implying a bacterial origin. Morgagni is credited with the first description of an appendix testis in Padua, Italy in 1761.26 Colt first reported torsion of the appendage in 1922 in Scotland.27 The testicular appendage is a remnant of the Mu¨llerian duct, whereas the epididymal appendages are of Wolffian duct origin. Torsion of an appendage occurs more commonly in the prepubertal age group and may be the result of hormonal stimulation which increases the mass of the pedunculated structures and makes them susceptible to twisting.28 The presentation can mimic testicular torsion with a sudden onset of pain; nausea and vomiting may also occur. The urinalysis is uniformly normal. Classically, these are associated with the “blue-dot sign,” when the inflamed and ischemic appendage can be seen as a subtle blue-colored mass through the scrotal skin.29 Early in the syndrome, the appendage can be palpated and is exquisitely and focally tender to examination. As local inflammation occurs, however, the epididymis, testis, and superficial tissues become edematous, and the diagnosis becomes more difficult to make. Early ultrasound can be diagnostic, showing the discrete appendage, but later the study may only show increased blood flow to the adjacent epididymis and testis and possibly a reactive hydrocele, resulting in the misdiagnosis of acute epididymitis or epididymoorchitis.30 The syndrome is self-limited and responds best to nonsteroidal antiinflammatory medications and comfort measures such as limited activity and a warm compress. As the appendage infarcts and necroses, the pain resolves. The syndrome can recur, as there are potentially five anatomic sites of appendages
Figure 2 Large necrotic testicular appendage (A) at superior pole of testis (T) at time of exploration.
which may experience torsion (appendix testis, appendix epididymis, paradidymis-organ of Giraldes, superior and inferior vas aberrans of Haller),31-33 and more than one appendage may occur in a given site. Surgical intervention is indicated in cases where the diagnosis of testicular torsion cannot be reliably eliminated or when the symptoms are prolonged and spontaneous resolution of the symptoms do not occur. Excision of the torsed appendage through a small scrotal incision is easily performed with excellent results in relief of symptoms (Figure 2).
Epididymitis Classic bacterial epididymitis generally has a slow onset, with scrotal pain and swelling worsening over days rather than hours. There is usually no nausea or vomiting. Bacterial infection is thought to reach the epididymis in retrograde fashion via the ejaculatory ducts, and can be associated with a clinical urinary tract infection or urethritis. A positive urinalysis and culture, or urethral swab in sexually active adolescents, suggests the diagnosis. Gonococcus and Chlamydia are classically described in the sexually active, but common urinary pathogens including coliforms, and mycoplasma species are more probable in younger children.
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When studies suggest a bacterial infection, appropriate antibiotics are indicated. Just as for any urinary tract infection in a boy, radiographic imaging including a renal bladder ultrasound and voiding cystourethrogram should be obtained after the infection has resolved. Anatomic abnormalities such as ectopic ureter (to the vas, ejaculatory duct or seminal vesicle), ejaculatory duct obstruction, or urethral valves are uncommon, but should be ruled out. Viral infections are felt to be a common cause of acute epididymitis, but are usually diagnosed presumptively. Mumps orchitis occurs in about one-third of postpubertal boys affected by the virus and is fortunately rare in the modern era of immunization.34 Adenovirus, enterovirus, influenza, and parainfluenza virus infections have also been described. Management is supportive, antibiotics are not indicated, and the pain syndrome is generally self-limited. Aggressive testing is usually not warranted, but viral cultures and serological studies may be useful in clustered familial or community cases.35
such as skin purpura, joint pain, and hematuria. Usually supportive measures are adequate, but systemic steroids are sometimes helpful.37,38 Despite the rarity of overlapping diagnoses, Henoch-Scho¨nlein purpura and torsion of the testis have been reported together.39
Scrotal pain Recurrent bouts of scrotal pain warrant special consideration, especially if bilateral. Voiding is a common but under-reported cause of scrotal pain, which frequently goes unrecognized unless the diagnosis is sought. The pathophysiology is that of bladder instability causing high pressure voiding against a voluntarily closed external sphincter. It is common to see dilation of the posterior urethra (“spinning-top urethra”) during voiding in children with voiding dysfunction undergoing a voiding cystourethrogram. Urine may be forced up the ejaculatory duct manifesting in local inflammation and a “chemical” epididymitis or epididymoorchitis may result.36 A renal– bladder ultrasound may show a thickened bladder wall, and is also useful to rule out ureteral ectopia to the ejaculatory duct or vas deferens as a potential cause in recurrent cases. There is no pathognomonic test for voiding dysfunction, but a thorough history will often reveal urinary urgency, incontinence, a staccato urinary stream indicative of inappropriate sphincter activity, and occult constipation. Treatment of these children with a timed-voiding regimen, dietary modification, aggressive management of constipation, and anticholinergic or alphaantagonist medication when appropriate is effective.
Idiopathic scrotal edema Scrotal swelling of unknown etiology is termed idiopathic scrotal edema. The syndrome is characterized by thickening and erythema of the scrotum, but the testes are generally not involved. Pruritus may be present, but the condition is not usually painful. Ultrasound shows normal testicular blood flow but is not usually required. Other causes should be sought to rule out cellulitis from an adjacent infection (inguinal, perirectal, or urethral). Undoubtedly, many cases of contact dermatitis, insect bites, and minor trauma are given this diagnosis. Management is supportive, and antihistamines or topical steroids may give considerable relief of symptoms. Occasionally, oral antibiotics are administered if cellulitis is a concern.40
Other causes Other less common causes of the acute scrotum, which must be considered, include hernia, hydrocele, sexual abuse or other trauma, and neoplasia. Usually a thorough history, physical examination, and imaging (if necessary) can differentiate these causes of scrotal swelling from testicular torsion.
Conclusion Acute scrotal pain in the child or adolescent male is a common event, but should always be treated as an emergent condition. Although the differential diagnoses are many, and most of the conditions are nonurgent, of paramount importance is the prompt diagnosis and surgical treatment of torsion of the spermatic cord to avoid permanent ischemic damage to the testicle. With a thorough history, physical examination, and imaging if warranted, an accurate diagnosis can usually be made.
Henoch-Scho¨nlein Purpura Henoch-Scho¨nlein Purpura is a vasculitic syndrome that can include the skin, joints, gastrointestinal, and genitourinary systems. In up to one-third of patients, pain, erythema, and swelling of the scrotum and spermatic cord may occur. This seems to occur more commonly in younger boys less than 7 years of age. The scrotal findings and onset of pain may mimic testicular torsion, but Doppler ultrasound reveals good blood flow to the testes. A thorough history and physical examination may reveal other systemic symptoms,
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