taem10: acute scrotal pain
DESCRIPTION
นพ.ประสิทธิ์ วุฒิสุทธิเมธาวีTRANSCRIPT
![Page 1: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/1.jpg)
Acute Scrotal Pain13 Feb 2009
นพ.ประสิทธิ์ วุฒิสุทธิเมธาวี
หน่วยเวชศาสตร์ฉุกเฉิน
คณะแพทยศาสตร์
มหาวิทยาลัยสงขลานครินทร์
![Page 2: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/2.jpg)
BackgroundNot uncommon presentation
Maybe cause from serious condition; rupture AAA,
Strangurated IIH, Fournier’s gangrene
Chalanging EP
Early diagnosis can prevent function loss
or complications
![Page 3: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/3.jpg)
Anatomy
![Page 4: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/4.jpg)
History & Clinical
Age (host.)
Pain characteristic
Sexual function
+/- Undescended testis
![Page 5: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/5.jpg)
Pain Characteristic
Painless VS Painful
Sudden onset VS gradual onset
Location
Association symptoms: fever, dysuria
![Page 6: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/6.jpg)
Age- Neonate
- Prepuberty
- Post puberty : Epididymitis
- Adult : STD
Torsion of testis
![Page 7: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/7.jpg)
Physical ExaminationRelax
Reassure
Relate (compare) with other side
![Page 8: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/8.jpg)
![Page 9: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/9.jpg)
SignsScrotum
edema
erythema
size
tender
Testis
location / axis
size
tender
consistency
erythema
![Page 10: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/10.jpg)
Transillumination testHydrocele
+/- Chronic hydrocele
Reactive hydrocele
![Page 11: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/11.jpg)
![Page 12: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/12.jpg)
Cremasteric ReflexPinch inner thigh, observe testis
Present : testis elevate > 0.5 cm.
Absent : testis not elevate or elevate < 0.5 cm.
Torsion of testis
![Page 13: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/13.jpg)
Frehn’s SignScrotum elevation
Positive : pain relief
Negative : pain persist Torsion of testis
![Page 14: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/14.jpg)
InvestigationsUrine analysis (UA.) +/- U/C
Complete blood count
Plain X-rays
Color doppler USG
Nuclear scintigraphy
![Page 15: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/15.jpg)
Color Doppler USGNo clinical strongly of testicular torsion
No pain free intervals
No clinical diagnosis of epididymitis
Scrotal trauma
No pathognomonic findings
![Page 16: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/16.jpg)
Color Doppler USGIncrease blood flow
Epididymitis, Torsion of appendage
Decrease blood flow
Torsion of testis
![Page 17: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/17.jpg)
![Page 18: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/18.jpg)
![Page 19: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/19.jpg)
Nuclear Scintigraphy
Radioisotope (Tc99m)
Uptake at 30 min
Negative : no radioisotope uptake
(Testicular Scan)
Positive : radioisotope uptake
![Page 20: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/20.jpg)
![Page 21: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/21.jpg)
![Page 22: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/22.jpg)
Nuclear ScintigraphyAvailability
Can not identify anatomy if testicular rupture
Same result in epididymitis and
torsion of testicular appendage
Limitations
Can not detect spontaneous detorsion
![Page 23: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/23.jpg)
Common diagnosis
![Page 24: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/24.jpg)
Differential DiagnosisEmergent
Torsion of testis Rupture of testis
Fournier’s gangrene Peritonitis
AAA
![Page 25: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/25.jpg)
![Page 26: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/26.jpg)
Differential DiagnosisNon-emergent
Torsion of appendage Epididymitis
Orchitis Inguinal hernia
Scrotal hematoma / abscess
![Page 27: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/27.jpg)
Differential DiagnosisNon-emergent
Testicular neoplasm Renal colic
Hydrocele / Varicocele
Venomous insect bite
![Page 28: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/28.jpg)
![Page 29: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/29.jpg)
![Page 30: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/30.jpg)
Most common diagnosisTorsion of testis
Torsion of testicular appendage
Epididymitis
Orchitis
![Page 31: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/31.jpg)
Torsion of testis
![Page 32: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/32.jpg)
Incidence1/4,000 annual (men < 25 years old)
Dimorphic
Neonate : < 1 year
Pre-puberty : 12-18 years old (14 yrs)
Undescended testis
![Page 33: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/33.jpg)
Pathophysiology“Bell-Clapper” deformity
Redundant spermatic cord
Right: clockwise
Left : counterclockwise
Medial rotation (aldolescence)
![Page 34: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/34.jpg)
![Page 35: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/35.jpg)
![Page 36: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/36.jpg)
![Page 37: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/37.jpg)
Signs & SymptomsSudden scrotal pain +/- N/V, fever
High riding testis
Transverse axis of testis
![Page 38: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/38.jpg)
Suspicion Torsion of TestisHigh riding testis
Abnormal axis (upright position)
Abnormal position of the epididymis in
scrotumAbnormal axis in contralateral testis (bell
clapper” deformity) except in 180o rotation
![Page 39: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/39.jpg)
![Page 40: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/40.jpg)
InvestigationsUrine analysis
Complete Blood Count
Color doppler USG: decrease blood flow
Nuclear Scintigraphy: no isotope uptake
(Duration > 12 hrs immediate Sx.)
![Page 41: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/41.jpg)
![Page 42: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/42.jpg)
TreatmentGeneral treatment
Pain relief
Cold application
Correct Electrolyte imbalance
Pre-operative evaluation
![Page 43: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/43.jpg)
TreatmentSpecific treatment
Manual detorsion (temporaly)
Early Urologist (Gen Sx.) consultation
Scrotal exploration, opened
detorsion and bilateral orchiopexy
![Page 44: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/44.jpg)
![Page 45: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/45.jpg)
History, Physical Examination and urine analysis
Short duration of symptoms
Negative urine analysis
High probability of torsion
Long duration of symptoms
Positive urine analysis
Low probability of torsion
Surgical exploration Color doppler USG
Nuclear scintigraphy
> 6 hr< 6 hr
+ / -
![Page 46: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/46.jpg)
Color doppler USG
Nuclear scintigraphy
Decrease or absent blood flow
Equivocal
Increase or
Normal blood flow
Surgical exploration Non-operative management
Observation
![Page 47: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/47.jpg)
Epididymitis
![Page 48: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/48.jpg)
InfectionBacteria
STD :
TB :
UTI
Congenital anomaly
Retained foley catheter
Chlamydia trachomatis
N. gonorrhea, Syphilis
Cold abscess
![Page 49: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/49.jpg)
SymptomsGradual onset
Scrotal pain
Fever (95%)
Dysuria, Urethral d/c (30-50%)
Scrotal edema
![Page 50: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/50.jpg)
SignsScrotal swelling
Scrotal erythema
Tender at scrotal and groin
![Page 51: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/51.jpg)
Difficult to differentiate
from torsion of testis.
Torsion of testis
Sudden onset
High riding
Abnormal axis
Tender at groin
abdomen
Epididymitis
Gradual onset
Normal position / axis
Tender at superior pole
of testis
Fever, dysuria
![Page 52: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/52.jpg)
InvestigationsUrine analysis : pyuria (50%)
Complete Blood Count: leukocytosis (30-50%)
Color doppler USG: normal/increase blood flow
Nuclear Scintigraphy: normal isotope uptake
![Page 53: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/53.jpg)
![Page 54: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/54.jpg)
Criteria for DiagnosisGradual onset of pain
Dysuria, Urethral d/c
History of urinary tract infection
Fever ( BT > 38.3 oc)
Tenderness at epididymis
Abnormal Urine analysis
![Page 55: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/55.jpg)
Treatment
General treatment
Rest
Scrotal support
Analgesia (NSAIDs)
Cold application
Specific treatment
Antibiotic
STD: partner
![Page 56: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/56.jpg)
Orchitis
![Page 57: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/57.jpg)
![Page 58: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/58.jpg)
PathophysiologyHighly resistance to infection
Hematologic spread
Mump
Immunocompromise
![Page 59: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/59.jpg)
SymptomsPyogenic orchitis
Fever
Malaise
Dysuria
Viral orchitis
- Post parotitis 4-6
days
- 70 % unilateral lesion
![Page 60: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/60.jpg)
![Page 61: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/61.jpg)
Signs
Gradual onset
Scrotal swelling / pain / edema
Prehn’s sign: positive
![Page 62: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/62.jpg)
Investigations
Urine analysis : pyuria
Complete Blood Count: leukocytosis
Color doppler USG: normal/increase blood flow
Nuclear Scintigraphy: normal isotope uptake
![Page 63: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/63.jpg)
Difficult to differentiate from epididymitis
Orchitis
tender at testis
Epididymitis
tender at superior pole
of testis
![Page 64: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/64.jpg)
TreatmentGeneral treatment
Rest
Scrotal support
Analgesia (NSAIDs)
Cold application
![Page 65: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/65.jpg)
TreatmentSpecific treatment
Pyogenic orchitis antibiotic
Viral orchitis supportive treatment
Usually improve in 3-5 days
![Page 66: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/66.jpg)
Torsion of testicular appendage
![Page 67: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/67.jpg)
Background
Pre aldolescence
Age 3- 13 years old (peak 7-12 yrs)
Another diagnosis is torsion of epididymal
appendage
![Page 68: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/68.jpg)
Pathophysiology
Unknown
Increase estrogen level increase size of
appendage strangulation
Torsion obstruct venous flow decrease
arterial flow ischemia and necrosis
![Page 69: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/69.jpg)
![Page 70: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/70.jpg)
![Page 71: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/71.jpg)
SymptomsAcute onset
Scrotal pain +/- swelling
Nausea / Vomiting
Fever
Dysuria / Urethral d/c
![Page 72: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/72.jpg)
SignsPalpate mass at superior pole of testis
Tender at testis / swelling / Blue dot sign
+/- reactive hydrocele
Transillumination test Black dot sign
Dysuria / Urethral d/c
![Page 73: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/73.jpg)
Torsion of testis
Sudden onset
High riding
Abnormal axis
Tender through testis
Torsion of appendage
Sudden onset
Normal position / axis
Tender at superior testis
![Page 74: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/74.jpg)
InvestigationsUrine analysis
Complete Blood Count
Color doppler USG: normal/increase blood flow
Nuclear Scintigraphy: normal isotope uptake
![Page 75: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/75.jpg)
![Page 76: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/76.jpg)
TreatmentGeneral treatment
Rest
Scrotal support
Analgesia (NSAIDs)
Cold application
Usually improve in 7-10 days
![Page 77: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/77.jpg)
Conclusion
![Page 78: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/78.jpg)
Goal
To detect and exclude “Torsion of testis“
![Page 79: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/79.jpg)
Thank you for your attention
![Page 80: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/80.jpg)
![Page 81: TAEM10: Acute Scrotal Pain](https://reader034.vdocuments.site/reader034/viewer/2022052618/554b670fb4c90564168b4680/html5/thumbnails/81.jpg)