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Acute Scrotal Pathology

Acute Scrotal Pathology. Henry Yao Pre-SET Urology Trainee Royal Melbourne Hospital. Case History. You are working in ED at night It is 4am and you are tired + hungry As you are about to go to get a snack 12 year old male presents with 2 hour history of pain in right side of scrotum.

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Acute Scrotal Pathology

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  1. Acute Scrotal Pathology Henry Yao Pre-SET Urology Trainee Royal Melbourne Hospital

  2. Case History • You are working in ED at night • It is 4am and you are tired + hungry • As you are about to go to get a snack • 12 year old male presents with 2 hour history of pain in right side of scrotum

  3. Question • What are your differential diagnoses?

  4. Differential diganoses • Hydatid of Mortgagni (60%) • Testicular Torsion (30%) • Epididymo-orchitis (<5%) • Idiopathic scrotal oedema (<5%)

  5. Question • What history questions would you ask?

  6. Case History • Scrotal pain came on over an hour • Steadily getting worse • Vomited once • Some vague lower abdominal and back pain • No trauma to testicles • Two years ago had an STI rx with antibiotics • Stable girlfriend for 12 months

  7. Question • What would you look for on examination?

  8. Cresmateric Reflex

  9. Testicular Torsion • IntravaginalvsExtravaginal

  10. Testis Anatomy • Paired solid viscera • Oval shaped • Left lies slightly lower than right • Epididymis posteriorly • Vas deferens postero-medially • Tunica albuginea covering • Tunica vaginalisantero-laterally • Appendix of testis located in upper pole

  11. Testis Anatomy • Arterial supply • Testicular artery • Venous drainage • Pampiniform plexus • Lymphatic supply • Para-aortic nodes at origin of testicular artery (L2) • Nervous supply • T10 sympathetic supply (sensory follows this)

  12. Presentation • Most commonly age 12-18 • Acute onset of severe testicular pain +/- swelling • On examination • Tender firm testicle • High riding testicle • Horizontal lie of testicle • Absent cremasteric reflex • No pain relief with elevation of testis • Thick or knotted spematic cord • Epididymis not posterior to the testis

  13. Diagnosis • Clinical suspicion • More likely when the onset of pain is acute and extremely intense • C.f. epididymitis more likely when onset of pain is gradual and progresses from mild to more intense • DO NOT WAIT FOR IMAGING if suspect torsion

  14. Management • IMMEDIATE SURGICAL EXPLORATION if suspected testicular torsion • Most testicles remain viable if detorsed within 6 hours • Few testicles remain viable after > 24 hours of torsion

  15. Surgical Exploration • Median raphe incision • Cut through all layers to get to testis • Detorse the testis • Three point fixation to Dartos • Do the contralateral side

  16. Imaging • Doppler USS • Torsion: decrease blood flow • Epididymitis: increased blood flow • Nuclear testicular scan • Torsion: decrease uptake • Epididymitis: increased uptake of radiotracer activity

  17. Hydatid of Mortgani • Torsion of appendage • Acute pain • Blue dot in upper pole • If in doubt  explore

  18. Epididymo-orchitis • Rare in childhood • Virtually never between 6 months and puberty • LUTS • Tender epididymis • Prehn’s sign • Dipstick and urine MCS • Rest, antibiotics, high fluid intake, alkalinisation of urine

  19. Idiopathic Scrotal Oedema • Causes unknown: ?allergy, ?insect bites • Scrotum symmetrically swollen, pink and less painful c.f. other causes • Erythema spread beyond the scrotum • Scrotal skin hard but testis and epididymis not painful

  20. Case 2 • 36 year old male • Day 2 post vasectomy • Presents with painful scrotum

  21. Question • What do you do?

  22. Case History

  23. Case History • Vital signs • Tachycardia 110 • Blood pressure 100/60 • Very tender scrotum • Hardened scrotal skin • Spreading beyond scrotum

  24. Question • What do you think is going on?

  25. Fournier’s Gangrene • Necrotizing fascitiis of male genitalia and perineum • 30% mortality • Rapidly progressive • Sources of bug from perianal region • Most common bug is E. coli but must also consider GPC and anaerobes

  26. Fournier’s Gangrene • Risk factors • T2DM • Alcohol • Other immunosuppressed patients • Spread across superficial fascial planes • Colles • Scarpa • Buck’s

  27. Presentation • Painful swelling and induration of the penis, scrotum or perineum • Oedema spread beyond area of erythema • Eschar, necrosis, ecchymosis, crepitus are later signs • Foul odour • Fever • Diagnosis is clinical  don’t wait for imaging

  28. Management • Broad spectrum IV antibiotics – consult VIDS • Cover GP, GN and anaerobes • Immediate aggressive tissue debridement  cut down to normal tissue • Send tissue for MCS • May require flaps • (Consider hyperbaric oxygen therapy)

  29. TGA Antibiotics

  30. Questions

  31. Acknowledgement • Dr. Kevin O’Connor (Urology Fellow)

  32. Thank You for Your Attention

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