Acute Scrotal Pain: Clinical Features

Transcription

1 Acute Scrotal Pain: Clinical Features Vincenzo Mirone, Paolo Verze, and Davide Arcaniolo Contents 1 Introduction Torsion Extravaginal Torsion Intravaginal Torsion Clinical Presentation Intermittent Torsion of the Spermatic Cord Torsion of Testicular Appendages Acute Epididymitis Acute Infective Epididymitis Non-Infective Inflammatory Epididymitis Clinical Presentation Testicular Trauma References Abstract Acute scrotum is defined as an acute painful swelling of the scrotum or its contents, and is accompanied by local signs and general symptoms. Acute scrotal pain with or without swelling and erythema in child or adolescent male should always be treated as an emergency condition. The most frequent differential diagnosis of an acute scrotum includes spermatic cord torsion, torsion of testicular appendages, epididymo-orchitis, and trauma. The cause of an acute scrotum can usually be established based on careful history, physical examination, and appropriate diagnostic tests. The onset, character, and severity of symptoms should be clearly established to determine the appropriate and timely management. A correct diagnosis is mandatory as treatment options could differ dramatically depending on the disease process. Among these conditions, the spermatic cord torsion is of major concern because it requires immediate surgical intervention to avoid testicular loss. 1 Introduction V. Mirone (&) P. Verze D. Arcaniolo Urologic Clinic, University Federico II of Naples, Via S. Pansini 5, 80132, Naples, Italy mirone@unina.it Acute scrotal pain with or without swelling and erythema should always be treated as an emergency condition (Burgher 1998). The presence of acute testicular pain or swelling is often referred to as acute scrotum and can be determined by many different causes. There are a number of differential diagnoses to consider (Jefferson et al. 1997; Brandes et al. 1994) (Table 1). In fact, emergencies that involve the scrotum may be confined to the scrotal M. Bertolotto and C. Trombetta (eds.), Scrotal Pathology, Medical Radiology. Diagnostic Imaging, DOI: /174_2011_176, Ó Springer-Verlag Berlin Heidelberg

2 86 V. Mirone et al. Table 1 Differential diagnosis for acute scrotal pain and swelling Pain and swelling Pain alone Swelling Alone Testicular torsion Acute or Chronic epididymitis Hydrocele/Varicocele Torsion of appendages Torsion of appendages Hernia Acute epididymitis Adductor tendinitis Idiopatic scrotal oedema Hernia Hematocele Cyst of epididymis Fournier s gangrene Dermatological lesions Neoplasia Trauma Vasculitis (Henoch-Schönlein Spermatocele purpura) Vasculitis (Henoch-Schönlein purpura) structures or referred from other sources. It must also be taken into account that the scrotum itself contains numerous structures: the testicles, epididymis, spermatic cord, and the scrotal tissue itself, comprised of several muscular and fascial layers. A correct diagnosis is mandatory as treatment options (observation, surgery, antibiotics, etc.) could differ dramatically depending on the disease process. Testicular torsion, epididymo-orchitis, and torsion of the testicular appendages are the most common etiologies of acute scrotum, especially in younger men. Amongst emergencies involving the scrotum, those involving the testis certainly take on greater importance as the loss of a testicle due to a disregarded torsion, or a missed diagnosis of testicular cancer, can bring disastrous consequences. 2 Torsion Torsion of the spermatic cord (testicular torsion) is defined as the process whereby there is cessation of blood flow to the testicle because of an occlusion of arterial blood supply resulting from the twisting of the artery and associated structures. When not treated timely, this condition can lead to testicular loss. The incidence of torsion is about one in 125 males per year in Europe and it occurs most commonly in boys aged years old. It is considered the most common cause of acute scrotal pain and swelling in boys from birth to 18 years of age. Testicular torsion must be considered a surgical emergency because the cord occlusion can lead to an irreversible ischaemic injury to the testicular parenchyma, depending on the degree and duration of the torsion (McAndrew et al. 2002). From the anatomical point of view, testicular torsion can be classified as either intravaginal or as extravaginal. 2.1 Extravaginal Torsion This type of torsion can be either prenatal (in utero) or postnatal (in newborns). It is characterized by a lack of fixation of the gubernaculum testis and testicular tunica to the scrotal wall, which determines the torsion of the entire testis, spermatic cord, and tunica vaginalis, often to the level of the internal inguinal ring. Cryptorchidism is considered the most important risk factor for extravaginal torsion (Benjamin 2002). 2.2 Intravaginal Torsion This is the more common type of testicular torsion. In intravaginal torsion, the spermatic cord twist occurs within the tunica vaginalis. This is probably due to a failure of normal posterior anchoring of the gubernaculum, epididymis, and testis, which leaves the testis free to swing and rotate within the tunica vaginalis of the scrotum (Kapoor 2008). This anatomic relationship, in which the testicle has a transverse lie, is termed the bell-clapper deformity. This horizontal lie becomes a risk factor for torsion and after puberty the testis added weight increases its likelihood of twisting on its vascular stalk. An abrupt contraction of the cremaster muscle

3 Acute Scrotal Pain: Clinical Features 87 can cause an initial rotation of the testis. This contortion is caused by the spiral configuration of the muscle s insertion onto the cord, twisting it in such a way that each testis anterior surface rotates toward the midline. 2.3 Clinical Presentation The most common age for the development of torsion is early puberty, while the newborn period is the second most common. The vascular compromise results in the rapid onset of swelling because of venous outflow obstruction in the face of continued arterial inflow. Patients are usually presented with a sudden acute testicular pain, often being awakened from sleep, but sometimes the onset is more gradual and the pain less severe. In many cases, there is a history of previous episodes of severe, self-limiting scrotal pain and swelling. In testicular torsion, pain may be accompanied by nausea and vomiting and ipsilateral lower abdomen pain. Patients usually do not refer a history of associated lower urinary tract symptoms (Kapoor 2008). If the patient has mild pain, which has increased over few days time, a torsion of the testicular appendage should be suspected, rather than testicular torsion itself. If the patient complains of intermittent acute pain, which completely resolves, a diagnosis of intermittent testicular torsion should be suspected (Eaton et al. 2005). Typically, a patient with testicular torsion lies relatively still on the exam table, but feels a sharp pain upon walking. When palpating the scrotum the normal testicle, which should be in a vertical position, must be palpated first. Next, the spermatic cord of the affected testis is palpated. If painful and swollen, the suspicion of torsion is raised. Finally, the affected testis is palpated. Careful palpation of the scrotum will assess the asymmetric positioning of the testis within the scrotal sac. Examination will almost always detect an acutely sore and tender scrotum. The testis may be high-riding in the scrotum in an abnormal transverse position (Kapoor 2008). Pain at the lower pole of the testis is more likely to signify torsion than pain at the upper pole of the testis, which is where many of the testicular appendages are located. Hydrocele and scrotal oedema can be detected in established cases. A cremasteric reflex should be elicited next, before palpation, as absence of a cremasteric reflex is frequently associated with torsion. This finding is usually difficult to assess due to the presence of pain and swelling (Nelson et al. 2003). While scrotal ultrasound with a color doppler is commonly used, some clinics have the capacity to use rapid nuclear medicine imaging with technetium- 99 m radionuclide scanning which can detect blood flow to the testicle and is equally efficient (Nussbaum Blask et al. 2002). MR imaging can also be used to detect torsion. However, further intraoperative exploration may be required if a timely accurate image modality is obtained and index suspicion is high. In fact, the testicle can be completely salvaged with up to 6 h of torsion, but is unlikely to be salvaged beyond 12 h, so expedient diagnosis and surgical detorsion should be pursued (Mushtaq et al. 2003; Whitaker 1982). 2.4 Intermittent Torsion of the Spermatic Cord There are cases of some adolescents reporting episodic bouts of severe, acute scrotal pain, and swelling, accompanied by nausea and vomiting, that can resolve themselves without treatment. In these cases, physical examination following such episodes results normal, but most of these individuals are found to have a bell-clapper deformity. It is assumed that they must be experiencing spontaneous torsion and detorsion (Eaton et al. 2005). Misdiagnosis may create a cohort of boys with intermittent spermatic cord torsion who are at risk for acute unresolved torsion and potential testicular loss. Elective scrotal exploration and bilateral testicular fixation is strongly recommended when intermittent spermatic cord torsion is a likely diagnosis (Hayn et al. 2008). 3 Torsion of Testicular Appendages Four types of testicular appendages are recognized: the appendix testis (hydatid of Morgagni, remnant of the Müllerian duct); the appendix of epididymis (remnant of Wolffian ducts); the paradydimis

4 88 V. Mirone et al. (organ of Giraldes, remnant of mesonephric duct); and the vas aberrans of Haller. Testicular appendages become important clinically once they undergo torsion. The peak incidence of this event occurs in young teenagers due to the ensuing hormonal stimulation brought on by adolescence which increases testicular mass causing a propensity for the testes to twist on the vascular pedicle (Gatti and Murphy 2007). The onset of the pain in appendage torsions can be either insidious, with mild scrotal discomfort, or acute, making it indistinguishable from a torsion of the cord. Physical examination of the scrotum may reveal a small (3 5 mm) tender nodule at the upper pole of the testis or epididymis or even a bluish change in the skin color of the affected side. This feature is due to visualization of the infarcted appendage through the skin ( blue dot sign ). The blue dot is strongly specific for torsion, even though it is detectable in only about 21% of patients (McCombe and Scobie 1988). These findings are characteristic of the early stage, while as time passes, a massive edema develops, making physical examination really difficult. At this stage an ultrasound examination could be useful to evaluate whether testicular torsion is present. The presence of the cremasteric reflex should help to distinguish testicular torsion from torsion of the appendages. The appendix testis is the testicular appendage most susceptible to torsion and often presents the same symptoms as those for testicular torsion. Torsion afflicts most often adolescents who report a sudden onset of testicular pain. If diagnosis is uncertain, meaning that testicular torsion is suspected, then surgical exploration is mandatory (Gatti and Murphy 2007). 4 Acute Epididymitis Epididymitis is an inflammation of the epididymis that causes pain and swelling. It is classified as acute or chronic according to the onset and clinical course (Grabe et al. 2010). In some cases, the testis is involved in the inflammatory process (epididymoorchitis). Acute epididymitis is a pain and swelling of the epididymis lasting for a short period of less than 6 weeks representing the main differential diagnosis of testicular torsion. 4.1 Acute Infective Epididymitis In bacterial epididymitis, the infection usually spreads from the urethra, prostate, or bladder. Chlamydia trachomatis, Neisseria gonorrhoeae and the coliforms, and less frequently mycobacteria, brucella, and cryptococcus are the main pathogens. In the case of young children and older men, it is the coliforms that are responsible for infection and the epididymitis is almost always associated with bacteriuria or structural and/or functional abnormalities of the urinary tract. On the contrary, gonococcal and chlamydial infections are most likely to be found in men less than 35 years of age. Such infections are more commonly associated with urethritis, rather than bacteriuria. Coliform infection can also be found in young homosexuals who practice anal intercourse (Naber and Weidner 1999). 4.2 Non-Infective Inflammatory Epididymitis This is a rare pathological entity that has been reported in association with Behçet s disease and Henoch-Schönlein purpura. Iatrogenic epididymitis has also been observed after administration of amiodarone (Nikolaou et al. 2007). 4.3 Clinical Presentation Typically, the scrotal pain and swelling of epididymitis have a gradual onset, but in many cases pain can be described as sharp and acute. Fever or other nonspecific signs of infection can be associated. Pain may radiate along the spermatic cord and reach the abdomen. Other presenting symptoms include urethral discharge, dysuria, and other irritative lower urinary tract symptoms. These could also be signs of developing erythema, which is usually unilateral and found primarily in the posterior part of the scrotum, causing the epididymis to double in size in as little as 3 4 h. Physical examination findings range from inflammation and swelling of the tail of the epididymis to a massively inflamed erythematous hemiscrotum such that anatomical landmarks become unrecognizable. The spermatic cord is usually tender and swollen. A reactive hydrocele can be found which is caused by

5 Acute Scrotal Pain: Clinical Features 89 the secretion of inflammatory fluid between the layers of the tunica vaginalis. The most important differential diagnosis is torsion of the spermatic cord which is more probable if the onset of pain is sudden and severe in a patient younger than 20 years of age. When these symptoms are present, further scrotal exploration should be carried out if any pending doubt remain. 5 Testicular Trauma While the scrotum s mobility provides protection from serious injury, its exposure and dependent position can make it susceptible to traumatic injury. The testicles are further protected by the tough surrounding tunica albuginea and by the cremasteric reflex (Deurdulian et al. 2007). Blunt trauma, most often caused by athletic activity, is the cause of up to 85% of testicular injury and can result in local haematoma, ecchymosis of the scrotum, or injury to the testicle, epididymis, or spermatic cord. When blunt trauma occurs, patients usually suffer from immediate post-traumatic scrotal pain, nausea, vomiting and, at times, fainting. Most often they present a tender, swollen scrotum, and an impalpable testis (Munter and Faleski 1989). In testicular rupture a disruption to the tunica albuginea is found, whereas in intratesticular haematoma, the tunica albuginea remains intact. Trauma can result in haematoceles, which is an accumulation of blood in the space between the tunica albuginea and the tunica vaginalis. Hydrocele is a result of the accumulation of serum liquid in the space between the tunica albuginea and the tunica vaginalis. Penetrating injuries caused by knives, gunshot or missiles include lacerations, haematomas, and delayed blast-type injuries while projectile trauma can damage all of the scrotal contents. Injury caused by animal and human bites can involve the scrotum including the scrotal contents. Apart from externallyinflicted trauma, scrotal injury can also be caused by self-mutilation or assault (Deurdulian et al. 2007). References Benjamin K (2002) Scrotal and inguinal masses in the newborn period. Adv Neonatal Care 2: Brandes SB, Chelsky MJ, Hanno PM (1994) Adult acute idiopathic scrotal edema. Urology 44: Burgher SW (1998) Acute scrotal pain. Emerg Med Clin North Am 16: , vi Deurdulian C, Mittelstaedt CA, Chong WK et al (2007) US of acute scrotal trauma: optimal technique, imaging findings, and management. Radiographics 27: Eaton SH, Cendron MA, Estrada CR et al (2005) Intermittent testicular torsion: diagnostic features and management outcomes. J Urol 174: ; discussion 1535 Gatti JM, Murphy JP (2007) Current management of the acute scrotum. Semin Pediatr Surg 16:58 63 Grabe M, Bjerklund-Johansen TE, Botto H et al (2010) Guidelines on Urinary tract infection. European Association of Urology (EAU) pp Hayn MH, Herz DB, Bellinger MF et al (2008) Intermittent torsion of the spermatic cord portends an increased risk of acute testicular infarction. J Urol 180: Jefferson RH, Perez LM, Joseph DB (1997) Critical analysis of the clinical presentation of acute scrotum: a 9 year experience at a single institution. J Urol 158: Kapoor S (2008) Testicular torsion: a race against time. Int J Clin Pract 62: McAndrew HF, Pemberton R, Kikiros CS et al (2002) The incidence and investigation of acute scrotal problems in children. Pediatr Surg Int 18: McCombe AW, Scobie WG (1988) Torsion of scrotal contents in children. Br J Urol 61: Munter DW, Faleski EJ (1989) Blunt scrotal trauma: Emergency department evaluation and management. Am J Emerg Med 7: Mushtaq I, Fung M, Glasson MJ (2003) Retrospective review of paediatric patients with acute scrotum. ANZ J Surg 73:55 58 Naber KG, Weidner W (1999) Prostatitis, epididymitis, orchitis. In: Armstrong D, Cohen J (eds) Infectious diseases. Mosby. Harcourt Publishers Ltd, London, pp 1 58 Nelson CP, Williams JF, Bloom DA (2003) The cremasteric reflex: a useful but imperfect sign in testicular torsion. J Pediatr Surg 38: Nikolaou M, Ikonomidis I, Lekakis I et al (2007) Amiodaroneinduced epididymitis: a case report and review of the literature. Int J Cardiol 121:e15 e16 Nussbaum Blask AR, Bulas D, Shalaby-Rana E et al (2002) Color Doppler sonography and scintigraphy of the testis: a prospective, comparative analysis in children with acute scrotal pain. Pediatr Emerg Care 18:67 71 Whitaker RH (1982) Diagnoses not to be missed. Torsion of the testis. Br J Hosp Med 27:66 69