Scrotal emergencies in children and young adults

Dr Wrishi Raphael

An acute scrotum is defined as an acute painful swelling of the scrotum or its contents, accompanied by local signs or general symptoms. Emergencies of the scrotum must be attended with promptness and great finesse. The two most common emergencies of the scrotum which can affect children and young adults are torsion testis and epidymo-orchtis.
   Testicular torsion occurs when a testicle rotates, twisting the spermatic cord that brings blood to the scrotum. The reduced blood flow causes sudden and often severe pain and swelling. Epididymo-orchitis is an inflammation of the epididymis and/or testis. The epididymis is the duct behind the testis, along which sperm passes out of the testis and through the male genital tract. Epididymo-orchitis occurs usually due to infection, most commonly from a urine infection or a sexually transmitted infection. With torsion of the testicle there is pain of sudden onset, described as a severe, aching, sickening pain in the groin that may be accompanied by nausea and vomiting. With epididymo-orchitis the attack usually begins with malaise and fever and is often associated with a urinary infection. The testicle soon becomes swollen and acutely tender; however, elevation and support of the scrotum usually relieves pain in this condition (Prehn sign) while tending to increase it with a torsion.
Radiology as a diagnostic aid in Torsion Testis
Ultrasound, particularly colour Doppler, is useful in distinguishing a cystic scrotal lump (such as a hydrocele) from a solid tumour. Its use to distinguish between a torsion and epididymo-orchitis is controversial as it cannot reliably detect changes that are diagnostic of early
torsion. Since the investigation can involve unnecessary delay in treatment it is generally not recommended. A technetium-99m scan can differentiate between the two conditions: in torsion the testis is avascular while it is hyperaemic in epididymo-orchitis. But the technetium-99 scan is available only in select and specialized medical facilities in first world countries and not available in Bangladesh. If emergency physicians are able to make a diagnosis based on clinical grounds an emergency operation is essential.
Time factor in surgical intervention
The optimal time to operate for torsion of the testis is within 4-6 hours of the onset of pain. In the west about 85% of torsive testes are salvageable within 6 hours but by 10 hours the salvage rate has dropped to 20%.  During surgery the testicle is untwisted and if viable an orchidopexy is performed. A gangrenous (necrosis or death of soft tissue due to obstructed circulation) testicle is removed. Any gangrenous tissue must be removed with haste as it is capable of spreading to its adjacent structures and causing irreparable damage. Orchiopexy or orchidopexy is a surgery to move and permanently fix the testis to the scrotum so that it may not get twisted again. The opposite testis should also be fixed by orchidopexy. A person with a single operational testis is well capable of a normal and robust conjugal life and he can be a biological parent as well.
 Acute Epididymo-orchitis:
Apart from mumps, acute epididymo-orchitis is usually caused by sexually transmitted pathogens in young males and by urinary tract pathogens in the older males. In older men it usually follows urinary tract obstruction and infection or instrumentation of the lower genitourinary tract.
Investigations in Orchitis:
1] White cell count may be increased
2] If the orchitis is due to a urinary tract infection and the patient presents with complains like painful urination; a microscopic exam of urine is very helpful. If no features of infection are there, clinicians must be wary to exclude Chlamydia.
 3] Chlamydia test: Polymerase Chain Reaction test.
4]Ultrasound:  Can differentiate a swollen epididymis from testicular tumour
Treatment of Orchitis:
1] Bed rest
2] Elevation and support of the scrotum
3] Analgesics
4] Antibiotics are essential if a sexually transmitted infection or a urinary tract infection is identifiable.

 

Scrotal emergencies in children and young adults

Dr Wrishi Raphael

An acute scrotum is defined as an acute painful swelling of the scrotum or its contents, accompanied by local signs or general symptoms. Emergencies of the scrotum must be attended with promptness and great finesse. The two most common emergencies of the scrotum which can affect children and young adults are torsion testis and epidymo-orchtis. Testicular torsion occurs when a testicle rotates, twisting the spermatic cord that brings blood to the scrotum. The reduced blood flow causes sudden and often severe pain and swelling. Epididymo-orchitis is an inflammation of the epididymis and/or testis. The epididymis is the duct behind the testis, along which sperm passes out of the testis and through the male genital tract. Epididymo-orchitis occurs usually due to infection, most commonly from a urine infection or a sexually transmitted infection. With torsion of the testicle there is pain of sudden onset, described as a severe, aching, sickening pain in the groin that may be accompanied by nausea and vomiting. With epididymo-orchitis the attack usually begins with malaise and fever and is often associated with a urinary infection. The testicle soon becomes swollen and acutely tender; however, elevation and support of the scrotum usually relieves pain in this condition (Prehn sign) while tending to increase it with a torsion. Radiology as a diagnostic aid in Torsion Testis Ultrasound, particularly colour Doppler, is useful in distinguishing a cystic scrotal lump (such as a hydrocele) from a solid tumour. Its use to distinguish between a torsion and epididymo-orchitis is controversial as it cannot reliably detect changes that are diagnostic of early torsion. Since the investigation can involve unnecessary delay in treatment it is generally not recommended. A technetium-99m scan can differentiate between the two conditions: in torsion the testis is avascular while it is hyperaemic in epididymo-orchitis. But the technetium-99 scan is available only in select and specialized medical facilities in first world countries and not available in Bangladesh. If emergency physicians are able to make a diagnosis based on clinical grounds an emergency operation is essential. Time factor in surgical intervention The optimal time to operate for torsion of the testis is within 4-6 hours of the onset of pain. In the west about 85% of torsive testes are salvageable within 6 hours but by 10 hours the salvage rate has dropped to 20%. During surgery the testicle is untwisted and if viable an orchidopexy is performed. A gangrenous (necrosis or death of soft tissue due to obstructed circulation) testicle is removed. Any gangrenous tissue must be removed with haste as it is capable of spreading to its adjacent structures and causing irreparable damage. Orchiopexy or orchidopexy is a surgery to move and permanently fix the testis to the scrotum so that it may not get twisted again. The opposite testis should also be fixed by orchidopexy. A person with a single operational testis is well capable of a normal and robust conjugal life and he can be a biological parent as well. Acute Epididymo-orchitis: Apart from mumps, acute epididymo-orchitis is usually caused by sexually transmitted pathogens in young males and by urinary tract pathogens in the older males. In older men it usually follows urinary tract obstruction and infection or instrumentation of the lower genitourinary tract. Investigations in Orchitis: 1] White cell count may be increased 2] If the orchitis is due to a urinary tract infection and the patient presents with complains like painful urination; a microscopic exam of urine is very helpful. If no features of infection are there, clinicians must be wary to exclude Chlamydia. 3] Chlamydia test: Polymerase Chain Reaction test. 4]Ultrasound: Can differentiate a swollen epididymis from testicular tumour Treatment of Orchitis: 1] Bed rest 2] Elevation and support of the scrotum 3] Analgesics 4] Antibiotics are essential if a sexually transmitted infection or a urinary tract infection is identifiable.