Scrotal Pain. Table of Contents

Transcription

1 Emergency Medicine Board Review Manual Statement of Editorial Purpose The Hospital Physician Emergency Medicine Board Review Manual is a peer-reviewed study guide for residents and practicing physicians preparing for board examinations in emergency medicine. Each manual reviews a topic essential to the current practice of emergency medicine. PUBLISHING STAFF PRESIDENT, Group PUBLISHER Bruce M. White editorial director Debra Dreger EDITOR Robert Litchkofski associate EDITOR Rita E. Gould EDITORial assistant Farrawh Charles executive vice president Barbara T. White executive director of operations Jean M. Gaul PRODUCTION Director Suzanne S. Banish PRODUCTION assistant Kathryn K. Johnson ADVERTISING/PROJECT manager Patricia Payne Castle sales & marketing manager Deborah D. Chavis NOTE FROM THE PUBLISHER: This publication has been developed without involvement of or review by the American Board of Emergency Medicine. Endorsed by the Association for Hospital Medical Education Scrotal Pain Series Editor: Susan B. Promes, MD, FACEP Associate Professor, Division of Emergency Medicine, Department of Surgery, Director, Emergency Medicine Residency Program, Duke University School of Medicine, Durham, NC Contributor: Traci Thoureen, MD Assistant Professor, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD Table of Contents Introduction General Approach Critical Diagnoses of Scrotal Pain Emergent Diagnoses of Scrotal Pain Nonemergent Diagnoses of Scrotal Pain References Cover Illustration by Kathryn K. Johnson Copyright 2007, Turner White Communications, Inc., Strafford Avenue, Suite 220, Wayne, PA ,. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, electronic, photocopying, recording, or otherwise, without the prior written permission of Turner White Communications. The preparation and distribution of this publication are supported by sponsorship subject to written agreements that stipulate and ensure the editorial independence of Turner White Communications. Turner White Communications retains full control over the design and production of all published materials, including selection of appropriate topics and preparation of editorial content. The authors are solely responsible for substantive content. Statements expressed reflect the views of the authors and not necessarily the opinions or policies of Turner White Communications. Turner White Communications accepts no responsibility for statements made by authors and will not be liable for any errors of omission or inaccuracies. Information contained within this publication should not be used as a substitute for clinical judgment. Emergency Medicine Volume 9, Part 3

2 EMERGENCY MEDICINE BOARD REVIEW MANUAL Scrotal Pain Traci Thoureen, MD INTRODUCTION Scrotal pain is a relatively uncommon cause of presentation to the emergency department (ED), accounting for just 0.5% of total visits each year. 1 However, scrotal pain may indicate a true emergency. Red flags need to be recognized in these patients, and critical diagnoses or life-threatening conditions (Table 1) should be considered early in the course of evaluation so that patients may be rapidly assessed and managed. In addition, thorough evaluation of immunocompromised, diabetic, elderly, and young pediatric patients is necessary as these patients often have minimal clinical signs and symptoms despite the presence of serious scrotal conditions. This manual reviews the common differential diagnoses seen in the ED in patients who present with scrotal pain and the appropriate work-up, treatment, and disposition for these conditions. GENERAL APPROACH HISTORY AND PHYSICAL EXAMINATION History and physical examination, in conjunction with ultrasonography (US), are the most useful tools for determining the diagnosis of scrotal pain. Patients should be asked about the onset and duration of scrotal pain. As always, patients (or their parents) should be asked about underlying medical conditions, relevant family history, and any previous treatment of scrotal pathology as this information may guide the evaluation (see Special Considerations ). During the physical examination, particular attention must be paid to tenderness with palpation of the scrotum and testicles, discrepancies in size of the testicles, loss of testicular landmarks, or discoloration of the scrotal skin. 2 The inguinal canals should be examined as well for signs of fullness. The normal scrotum is relatively symmetrical, with both testicles of equal mass and volume. The normal testis is found in the vertical axis with a slight forward tilt, and the epididymis is above the superior pole in the posterolateral position. Eliciting the cremasteric reflex is an essential part of the scrotal examination and is done by stroking or pinching the inner thigh and observing an elevation of the ipsilateral testicle. Note that this reflex may be altered in certain conditions, such as cryptorchidism and myelomeningocele, and may not be consistently present in infants and teenagers. 3 Reassessment, including repeat scrotal examination, is indicated after any change in the patient s status, any new or worsening condition, or any therapeutic intervention. DIAGNOSTIC STUDIES Judicious use of laboratory and especially imaging studies is requisite in patients with scrotal pain. Younger adult patients who are able to provide a complete history and have few comorbidities may require fewer laboratory and imaging studies, whereas immunocompromised, elderly, diabetic and young pediatric patients often require a more liberal diagnostic work-up. Laboratory studies may include complete blood count (CBC), metabolic panel, and urinalysis, but urinalysis is the only critical study to obtain. Urine culture and occasionally blood cultures should be ordered if an infectious etiology is suspected. Patients who may require surgical intervention should have blood sent for coagulation studies and type and screen. Patients with evidence of blood loss, anemia, an abdominal aortic aneurysm (AAA), or hemodynamic instability should have blood sent for type and crossmatch. An electrocardiogram (ECG) should be ordered for all patients with acute scrotal pain thought to be an emergent diagnosis of referred pain (eg, AAA) or that is associated with upper abdominal pain for which a cardiac origin is suspected due to patient age (> 50 years), presence of cardiac risk factors, or presence of symptoms suggestive of cardiac events (ie, radiation of pain, diaphoresis, shortness of breath, exertional symptoms). Color Doppler US is the imaging modality of choice for scrotal pathology to detect or rule out surgical emergencies, such as testicular torsion. 4 It is also useful for detecting intraperitoneal fluid and the crosssectional diameter of an AAA. US can also detect hydronephrosis, which is an indirect indicator of an obstructing ureteral calculus that may cause referred pain Hospital Physician Board Review Manual

3 to the scrotum. A testicular nuclear scan may be useful to differentiate between testicular torsion and epididymitis if US is not definitive in determining testicular torsion. 4 Computed tomography (CT) of the chest, abdomen, and/or pelvis may also be used for staging purposes in the case of a testicular tumor and is useful for determining the extent of Fournier s gangrene. MANAGEMENT Basic Principles A cardiac monitor should be used for all patients who appear ill, may have potentially life-threatening conditions, or have abnormal vital signs. Two large-bore intravenous (IV) catheters (at least 18 gauge) should be started for patients with hemodynamic instability (systolic blood pressure < 90 mm Hg or heart rate > 90 bpm). Patients should be infused with fluid boluses of normal saline or lactated Ringer s solution ( ml for elderly patients and 1 L for younger adult patients), followed by reassessment of vital signs. Supplemental oxygen should be started for patients who are hemodynamically unstable, have potentially life-threatening conditions, or have an oxygen saturation level below 95%. Interventions Analgesia should be considered early in the course for patients in severe distress due to pain and if surgical consultation is delayed. Narcotics, such as IV morphine (2 5 mg every 5 10 min), can be administered until the patient is comfortable. Nonsteroidal antiinflammatory drugs (NSAIDs) can also be used as an adjunct but should not be given to patients who may require immediate surgery (eg, patients with testicular torsion, incarcerated inguinal hernia, AAA) due to platelet aggregation effects. Antibiotics need to be initiated early in patients with the clinical appearance of an infection. Infections are usually polymicrobial (mixture of grampositive, gram-negative, and anaerobic organisms). It is also important to test for and treat sexually transmitted diseases as they are common etiologies of acute scrotal pain. Finally, urinary catheterization may be performed in patients presenting with scrotal pain. A Foley catheter may be used to relieve bladder obstruction, in patients who are incontinent, for hemodynamically unstable or critically ill patients to ensure adequate urine output, or if an accurate urinalysis is needed. ED Course Surgical or urologic consultation should be obtained for any patient who may have a condition requiring surgical intervention. Early consultation must be sought for hemodynamically unstable patients with scrotal pain, Table 1. Differential Diagnoses of Scrotal Pain Critical diagnoses Abdominal aortic aneurysm Fournier s gangrene Incarcerated inguinal hernia Retrocecal appendicitis Testicular torsion Traumatic testicular rupture Emergent diagnoses Epididymitis Henoch-Schönlein purpura Idiopathic testicular infarction Orchitis (mumps) Scrotal abscess Fournier s gangrene, testicular torsion, suspected or actual perforation, obstruction, incarcerated inguinal hernia, or AAA because the ultimate therapy for the patient will be surgical. Any patient with systemic signs of toxicity, abnormal laboratory or imaging studies, persistent pain, or an abnormal scrotal examination that does not rule out critical or emergent causes of scrotal pain should be admitted to the hospital. A lower threshold for admission should be utilized for immunocompromised, elderly, and young pediatric patients due to the higher incidence of serious pathology despite minimal clinical findings in these patient populations. Patients with normal laboratory and imaging studies or patients whose symptoms improve after treatment in the ED and have a normal scrotal examination upon reevaluation may be discharged home with close follow-up within 24 hours and scrotal warnings (ie, a list of worsening symptoms that warrant an immediate return to the ED, such as severe pain, fever, increased swelling, difficulty urinating, or persistent vomiting). If the patient s primary physician cannot see the patient within 24 hours, the patient should return to the ED for follow-up, ideally with the ED physician who initially saw the patient or the consulting surgeon. In addition, the patient should be scheduled for urology follow-up within 2 weeks. Before discharge, the ED physician should also recommend nonpharmacologic treatment, such as bed rest, scrotal elevation, sitz baths, or ice packs, as appropriate. 5 SPECIAL CONSIDERATIONS Pediatric Patients Nonemergent diagnoses Cystocele Hydrocele Inguinal hernia Intratesticular arteriovenous malformation Lower lumbar/sacral nerve root impingement Nephrolithiasis (renal colic) Retroperitoneal tumor Testicular cancer (neoplasm, leukemia) Torsion of testicular appendices Varicocele Young pediatric patients may have minimal clinical signs and symptoms despite the presence of serious or surgical scrotal conditions. For example, young patients Emergency Medicine Volume 9, Part 3

4 with scrotal pathology may report hip or abdominal pain, whereas parents of infants may report their child has irritability with bathing. 5 These patients should have testicular torsion considered in their diagnostic work-up. Likewise, both the cremasteric reflex and Prehn s sign are less reliable in children. Also, particular care must be taken to privately elicit complete histories (including sexual history, when appropriate), especially in the adolescent population. Adolescent patients often present later than other patients would due to embarrassment. Elderly Patients Elderly patients are also less likely to present with classic signs and symptoms and are more likely to have a subtle or confusing presentation. Misdiagnosis and mortality rise significantly with patients older than age 50 years because older patients are more likely to have catastrophic illness rarely seen in younger populations (eg, ruptured AAA) or atypical presentations of more common diseases (eg, appendicitis). 6 In addition, elderly patients often have underlying urologic pathology (eg, benign prostatic hypertrophy, urethral strictures) complicating the diagnosis. It is also important to remember that medications commonly used by elderly patients can alter their response to pain and inflammation. Patients with Predisposing Conditions Patients with diabetes or who are immunocompromised are always at greater risk for complications of scrotal pathology, specifically infections. Patients with a testicular abnormality are also at higher risk for scrotal disorders. Special attention should be made when examining patients with syndromes with underlying macro-orchidism (eg, fragile X syndrome) as these patients can also develop any of the testicular diagnoses described in this review. Noonan s syndrome is a disorder that involves cryptorchidism, which increases the risk for carcinoma or torsion. In the pediatric population, acute scrotal pain is a known complication of familial Mediterranean fever (a rare recessively inherited genetic disease), Henoch-Schönlein purpura (HSP), and Kawasaki disease. 1,7,8 CRITICAL DIAGNOSES OF SCROTAL PAIN Critical diagnoses are those that require rapid identification and appropriate treatment and disposition from the ED due to their high morbidity and mortality. Critical differential diagnoses of scrotal pain include testicular torsion, Fournier s gangrene, incarcerated inguinal hernia, and ruptured AAA. TESTICULAR TORSION Testicular torsion causes venous engorgement that results in edema, hemorrhage, and subsequent arterial compromise, which results in testicular ischemia. The extent of testicular ischemia depends on the degree of torsion, which ranges from 180 to 720 degrees or more. Torsion may be complete, incomplete, or transient. Epidemiology Although testicular torsion can occur at any age, the age distribution occurs in 2 peaks: during the first year of life and during puberty, with the highest prevalence being between the ages of 12 and 18 years. The likelihood of developing testicular torsion by age 25 years is approximately 1 in Testicular torsion is 10 times more likely to occur in patients with an undescended testis, which has an incidence of 0.8% after age 1 year but occurs in one third of preterm births and 3% to 5% of live term births. 9 Pathogenesis Normally, the testicle is covered by the tunica vaginalis, which is attached to the posterolateral surface of the testicle. Increased mobility of the testicle may predispose it to torsion in 2 ways: intravaginally or extravaginally. Intravaginal torsion occurs due to a congenital malformation of the processus vaginalis, leading to the bell clapper deformity, in which the tunica vaginalis attaches above the epididymis allowing increased rotation that predisposes to torsion. This deformity occurs bilaterally in 80% of patients. 4 Extravaginal testicular torsion occurs exclusively in newborns, who present with swelling, discoloration of the scrotum on the affected side, and a firm but painless mass in the scrotum. The scrotum is usually infarcted and necrotic at birth. Extravaginal torsion occurs perinatally when the testis, spermatic cord, and tunica vaginalis twist together due to the lack of fixation to the scrotal wall. Generally, this type testicular torsion is asymptomatic and is discovered by the child s parents, who note a bluish scrotum. In older patients, torsion has been associated with a history of exertion or scrotal trauma or with sudden awakening at night. 10 It is theorized that a strong cremasteric reflex during nocturnal erection may be a cause of torsion. 11 History Patients usually complain of acute-onset, severe testicular swelling and pain that may radiate to the lower abdomen. These symptoms are often followed by nausea, vomiting, and a low-grade fever. There is a lack of urinary symptoms. Hospital Physician Board Review Manual

5 Patients may also complain of intermittent occurrences of scrotal pain, which may represent ischemic episodes that have spontaneously resolved, whereas continuous pain of more than 24 hours duration is associated with an infarcted testicle versus a less critical diagnosis (eg, epididymitis or orchitis). 5 Nearly 41% of patients report a history of similar pain that resolved spontaneously. 2 As noted earlier, young males may describe hip or abdominal pain, whereas the parents of infants may report irritability with bathing instead of scrotal pain. 5 Physical Examination On examination, the testicle may be elevated and lie horizontally. The entire testis is exquisitely tender and swollen. There is usually a negative Prehn s sign and ipsilateral loss of the cremasteric reflex. Prehn s sign has been used to help distinguish torsion from epididymitis because elevation of the scrotum relieves pain in those with epididymitis. However, this sign cannot reliably exclude the diagnosis, particularly in young patients. Examination of the contralateral testicle is also mandatory as the bell clapper deformity often occurs bilaterally, causing the testis to lie horizontally. 2 Diagnostic Testing In testicular torsion, laboratory studies and urinalysis are usually normal, although white blood cells may be elevated. Color flow duplex US to assess flow to the testicle is crucial. It has a sensitivity of 82% to 86%, a specificity of almost 100%, and an accuracy of 97% for diagnosing testicular torsion 4 and ischemia in patients with a painful scrotum. 12 US can be repeated in 30 to 60 minutes if definitive diagnosis is not established to make sure that blood flow is not decreasing; however, this is usually not done as urologic consultation is the cornerstone of diagnosis. Radioisotope scans have a similar sensitivity (80% 100%) and specificity (89% 100%) to US but take more time and are less practical. 13 Nuclear scans are generally not performed unless US is not definitive. Immediate urologic consultation is necessary as time to operating room is critical for survival of an ischemic testicle. 14 The testicular salvage rate depends on the degree of torsion and the duration of ischemia. A nearly 100% salvage rate exists within the first 6 hours after the onset of symptoms 14,15 ; the rate decreases to 70% after 6 to 12 hours and to 20% after 12 to 24 hours. 15 Manual detorsion can be attempted, especially if surgical consultation is delayed. Manual detorsion is performed in the medial to lateral direction ( opening the book ) and is only for pain relief. 16 Surgical correction, however, is the definitive treatment, and patients should still proceed to surgery even if manual detorsion successfully relieves discomfort. Urologic consultation should still be obtained for patients with intermittent pain, even if the pain disappears. FOURNIER S GANGRENE Fournier s gangrene is a urologic emergency with a mortality rate as high as 75% and an incidence of 1 in The mean age of affected patients is 50 years. 18 Fournier s gangrene is a polymicrobial necrotizing fasciitis of the perineal, perirectal, or genital area that predominantly affects the scrotum in men and may involve the lower abdominal wall due to spread along the fascial planes (most importantly Colles fascia). This disease is characterized by an obliterative endarteritis, which results in a cutaneous and subcutaneous vascular necrosis. 19 Approximately 95% of cases of Fournier s gangrene are due to a defined source of infection. 4 The most common single cause is perianal infection, either primary or secondary to surgery, accounting for 19% to 50% of cases. 18 The most common pathogens isolated in patients with Fournier s syndrome are anaerobic streptococci, Staphylococcus aureus, Bacteroides, and Escherichia coli. History and Physical Examination Patients may initially describe perianal or perineal pain. The scrotum is intensely tender, swollen, and warm without distinct fluctuance. Pain out of proportion to the examination is a common finding, especially early in the development of the disease. Later in the clinical course, the infection rapidly progresses with scrotal swelling, erythema, warmth, and purulent drainage. Necrosis of the scrotal skin is a late finding. The presence of crepitus on palpation of the perineum or scrotum may be noted and is considered by some to be pathognomonic when seen with skin necrosis. 20 There are often no or vague constitutional symptoms, although fever and chills can be present. Patients may have a recent history of instrumentation, indwelling catheterization, perirectal disease or infection, trauma, or anal intercourse. Predisposing conditions includes diabetes mellitus, alcoholism, HIV infection, cancer, chronic steroid use, or any other immunosuppressive condition. 4 Diagnostic Testing The diagnosis of Fournier s gangrene is primarily a clinical one. CBC, electrolytes, blood and urine cultures, cultures of any open wounds, and preoperative Emergency Medicine Volume 9, Part 3

6 coagulation studies as well as type and screen should be ordered, although many of the results (eg, cultures) will be used only in the postoperative setting to guide further antibiotic therapy. There is no specific test to confirm the diagnosis, although the Fournier s Gangrene Severity Index has been used to predict prognosis at presentation. 21 Hypocalcemia, which is caused by chelation of calcium by bacterial lipases, has been reported to be an important diagnostic clue. 18 Gas in the tissue has been reported in 18% to 62% of cases and can be detected by US, CT, and conventional radiography. 4 Although a plain film of the abdomen may demonstrate subcutaneous air, it is not an ideal study. However, subcutaneous gas within the scrotal wall detected on US is considered to be the sonographic hallmark of Fournier s gangrene. 22 Another sonographic finding is scrotal wall thickening without thickening of the testis or epididymis. An inguinoscrotal hernia can also present as gas on US, but the gas is located within the protruding bowel lumen and away from the scrotal wall. Abdominal/pelvic CT may be used to detect extent of infection and necrosis and is an important tool for preoperative planning. IV access should be started to facilitate fluid resuscitation. Broad-spectrum antibiotics (eg, a combination of a third-generation cephalosporin, clindamycin, and an aminoglycoside or imipenem-cilastatin as monotherapy) should also be started immediately. 5 Tetanus prophylaxis should be considered if open wounds are present. Urologic and surgical consultations are required as wide débridement is the definitive treatment for Fournier s gangrene. Early surgical débridement in conjunction with broad-spectrum antibiotic coverage is critical and is strongly correlated with better outcomes. 5 Despite an innocuous looking infection superficially, the deep-space infection is often much greater than the skin involvement would suggest. Patients should be resuscitated with IV crystalloid and given vasopressors if they are hypotensive as this may indicate extensive necrosis of underlying tissue and associated sepsis. INCARCERATED INGUINAL HERNIA The processus vaginalis is normally obliterated in the first few years of life but remains open in 20% of males and allows communication between the abdomen and scrotal sac. 23 When the bowel becomes trapped or incarcerated, edema may develop and the bowel becomes strangulated. Patients with a positive family history, undescended testis, and genitourinary abnormalities are at risk for incarcerated inguinal hernia. A forceful muscular event, such as coughing or lifting heavy objects, may precipitate the hernia. Evaluation On examination, the scrotum may appear enlarged on one side with tenderness to palpation. There may be bowel sounds auscultated over the swollen area of the hemiscrotum. Physical examination will generally confirm the diagnosis of incarcerated inguinal hernia. Laboratory studies should be ordered if surgery is anticipated. An abdominal radiograph with 2 views will confirm an associated obstruction. US may be performed if there are equivocal physical findings and scrotal swelling. The scan may show that the hernia contains either bowel or omentum, depending on which is present. Real-time peristalsis indicates the presence of bowel. Hyperemia of the bowel or scrotal soft tissue suggests strangulation. An akinetic, dilated bowel seen on scrotal US has been shown to have 90% sensitivity and 93% specificity for strangulation. 24 IV access should be established. Analgesia should be given to help the patient relax and to facilitate reduction of the hernia if the pain is of recent onset. Broad-spectrum antibiotics should be started in cases of prolonged pain as this suggests strangulation, and the risk of infection is elevated. If the incarceration cannot be reduced, the patient should not be fed by mouth, a nasogastric tube may be placed, and IV fluid should be started with crystalloid. Prompt consultation from general surgery is necessary to plan for operative management of irreducible hernias. RUPTURED ABDOMINAL AORTIC ANEURYSM An acute ecchymotic scrotum is a very rare presentation of a ruptured AAA. It is called the blue scrotum sign of Bryant and is seen in males with a patent processus vaginalis that allows blood to pool in the scrotum after rupture. 25 This finding may be an important visual clue for diagnosing ruptured AAA. In addition, these patients generally present in a hypovolemic shock state, which will distinguish AAA from other causes of acute scrotal pain in the age-group most commonly affected, namely men aged 50 years and older. Risk factors for AAA include connective tissue diseases, family history of aneurysm, and atherosclerotic risk factors. 26,27 Symptomatic AAA will most commonly present as back or abdominal pain, syncope, shock, or sudden death. Diagnosis may also be suggested by an abdominal radiograph showing calcification of the aorta. CT or US of the abdomen can confirm the diagnosis if the aorta Hospital Physician Board Review Manual

7 is dilated more than 5 cm in diameter and/or shows rupture. Patients who are hemodynamically unstable and in whom the diagnosis is considered should not undergo any radiologic testing and instead should have immediate surgical consultation. Standard initial resuscitative interventions in the ED (see Basic Principles ) are appropriate for these patients. Patients presenting with acute symptoms of pain or hypotension in whom AAA is highly suspected or confirmed by radiologic studies require immediate surgical referral. EMERGENT DIAGNOSeS OF SCROTAL PAIN Certain causes of scrotal pain still demand prompt action when diagnosed, although they are generally not life threatening. Diagnoses that fit this description include epididymitis, orchitis, HSP, pyocele, and testicular infarction. EPIDIDYMITIS Epididymitis is the most common inflammatory disease of the scrotum, accounting for more than 600,000 physician visits annually. 28 The average age of affected patients is 25 years. Epididymitis may be sexually transmitted or associated with previous urinary tract infection, anatomic abnormality, or prior urinary tract instrumentation. Bilateral involvement may result in sterility. Inflammation of the epididymis results from retrograde ascent of bacterial pathogens or, rarely, from hematogenous spread. 28 The inflammation begins in the tail of the epididymis and spreads to the rest of the epididymis. The epididymis becomes swollen and indurated, the spermatic cord thickens, and edema develops in the testis. In patients younger than age 35 years, the most common causes are the sexually transmitted pathogens: Chlamydia trachomatis (accounting for two thirds of cases) and Neisseria gonorrhea. 29 In patients older than age 40 years and in prepubertal boys, urinary pathogens (eg, E. coli, Klebsiella, Pseudomonas) should be suspected. In diabetic or immunocompromised patients, epididymitis may be caused by Mycobacterium, Cryptococcus, Toxoplasma, and Candida. Other less common causes include sarcoidosis, brucellosis, paramyxovirus infection (mumps), and amiodarone use. 4 Epididymitis can lead to orchitis, reactive hydrocele, testicular abscess, and testicular torsion. The diagnosis is most commonly confused with testicular torsion, torsion of the appendices of the testicle, and testicular tumor. Because testicular torsion is considered a critical diagnosis, it is the most important to investigate and rule out. As epididymitis and testicutar torsion are difficult to distinguish in the ED, the key features of their diagnostic work-ups have been compared in Table 2. History and Physical Examination Pain is gradual in onset over days and may be associated with nausea, vomiting, dysuria, and lower abdominal or inguinal canal pain. Fever is present in 95% of patients. A urethral discharge may also be present. History of urinary tract infections, benign prostatic hypertrophy, and recent urethral instrumentation or catheterization should be obtained as these are associated with the development of epididymitis. On physical examination, the scrotum is erythematous and edematous. The cremasteric reflex is usually intact. Swelling of the scrotum to twice its size may occur over 3 to 4 hours, and the scrotal skin will be warm. Due to congestion, the epididymis may be indistinguishable from the testis. Generally, the epididymis will be tender and the testis will not, but if the infection has progressed it may lead to epididymo-orchitis. 4 Diagnostic Testing Pyuria may be seen on urinalysis in 50% of patients. 30 CBC may reveal leukocytosis. Urine culture should be sent to define the causative organism, especially in men older than 35 years as urinary organisms are more likely in these patients. An intraurethral swab should also be sent for culture, Gram stain, and DNA probe. Color flow duplex/ Doppler US or radionuclide scintigraphy can help distinguish epididymitis from testicular torsion as blood flow in epididymitis is increased due to inflammation. Most patients can be treated as outpatients, with the exception of toxic-appearing patients, who should be admitted. Treatment includes antibiotics, pain management with NSAIDs or narcotics, scrotal elevation, and application of ice packs. Antibiotics should be tailored depending on culture results. Patients younger than age 35 years who are thought to be infected by a sexually transmitted pathogen (Chlamydia or N. gonorrhea) should be treated with ceftriaxone and doxycycline. 2 Patients older than age 35 years assumed to have infection with gram-negative bacilli should be treated with trimethoprim/sulfamethoxazole or a fluoroquinolone for 14 days. Patients should be referred to an urologist for follow-up. Resolution may take weeks. ORCHITIS Orchitis is an acute infection involving the testis; it develops in 20% to 40% patients with epididymitis by direct Emergency Medicine Volume 9, Part 3

8 Table 2. Key Findings on Diagnostic Work-up of Testicular Torsion Versus Epididymitis Testicular Torsion Epididymitis/Orchitis Average age Neonate, adolescent (14 yr) 25 yr Pain Sudden onset or after physical activity that is not affected by position Onset After exercise or sleep Rarely after sleep Time to presentation < 6 hr > 24 hr Gradual onset (orchitis may have sudden onset); worse when standing Past episodes Frequently > 2 wk past Only if previous infection Relevant history Sudden onset of pain at rest or after activity; history of trauma is uncommon Severity Peaks in hr Peaks in days Vomiting Common from pain Unusual Fever Up to 20% Up to 95% Testicular swelling Only after about 12 hr Common Dysuria or discharge Rare Common Sexual activity; urethral instrumentation; recent urinary tract infection Urinalysis/urinary history 30% have elevated WBCs/bacterial; voiding complaints rare 50% may be normal; voiding complaints Physical examination Nontender prostate Prostate tender Color Doppler US Decreased testicular flow Increased flow Data from Escobar JI, Eastman ER, Harwood-Nuss AL. Selected urologic problems. In: Marx JA, Hockberger RS, Walss RM, et al, editors. Rosen s emergency medicine: concepts and clinical practice. 5th ed. St. Louis: Mosby; 2002: ; Dogra V, Bhatt S. Acute painful scrotum. Radiol Clin North Am 2004;42:349 63; and Marcozzi D, Suner S. The nontraumatic, acute scrotum. Emerg Med Clin North Am 2001;19: US = ultrasonography; WBC = white blood cell. spread of infection. 4 Infection is most commonly viral or bacterial. Viral orchitis is usually caused by paramyxovirus, although Epstein-Barr virus, coxsackievirus, varicellazoster virus, and echovirus may also be implicated. Bacterial orchitis is most commonly caused by E. coli, Klebsiella, and Pseudomonas, but Staphylococcus and Streptococcus species may also be responsible. Orchitis is found in 20% to 30% of postpubertal males with mumps but is rarely seen in prepubertal boys. 31 Evaluation History and physical examination are usually adequate for diagnosing orchitis. As noted earlier, orchitis is often caused by epididymitis, which may be sexually transmitted. Thus, it is important to obtain a sexual history. Symptoms of mumps orchitis usually present 4 to 6 days after paramyxovirus-related parotitis develops; in 70% of cases, testicular swelling and pain presents unilaterally. 32 Bacterial orchitis may cause fever, swelling, and tenderness. On physical examination, the affected testis is edematous and tender and may be discolored. A prostate examination should be performed as acute or chronic prostatitis is often a predisposing condition for epididymo-orchitis. 2 Urologic consultation is required if there is a high degree of suspicion for testicular torsion or if there is a large reactive hydrocele that requires drainage. Laboratory studies (urinalysis; urine, urethral, blood cultures) can be helpful in identifying the causative organism if a bacterial source is suspected. Doppler US should be used if epididymo-orchitis is present and torsion cannot be ruled out. Supportive care with analgesia and antiemetics as well as symptomatic treatment is appropriate for all patients with orchitis. Symptomatic treatment includes ice packs, scrotal elevation, and bed rest. Mumps orchitis resolves within 4 to 5 days. Bacterial orchitis mandates antibiotic treatment aimed at gram-negative coverage or for sexually transmitted diseases. Untreated orchitis may result in testicular atrophy. Follow-up with an urologist is recommended. HENOCH-SCHÖNLEIN PURPURA HSP is a systemic vasculitis primarily involving the mesangial tissue of the small arterioles and capillaries, which undergo an acute inflammatory reaction that results in increased vascular permeability, exudation, and hemorrhage into the surrounding tissues. Patients with this nonthrombocytopenic purpura typically present with skin, renal, intestinal, and joint manifestations; however, pain and swelling of the spermatic cord and testicles may occur in 2% to 38% of male patients. 8 HSP usually occurs in patients between ages 2 and 20 years. 8 Hospital Physician Board Review Manual

9 Scrotal involvement in HSP may have a variable presentation. One to 3 days of mild, nontender testicular swelling may occur days to weeks into the course of HSP, or, more rarely, a swollen, tender testicle may develop over hours preceding other manifestations of the disease by up to 1 week. The scrotum may be swollen and erythematous with variable tenderness. Testicular lie may mimic testicular torsion. Evaluation and If HSP is suspected, obtaining CBC, urinalysis, blood urea nitrogen and creatinine levels, erythrocyte sedimentation rate, and a guaiac test may all be appropriate. These tests may reveal some of the associated findings of the syndrome, such as microscopic hematuria, which can help determine if admission is needed. However, there is no specific diagnostic test for this disease. Doppler US should be used to assess patients without systemic manifestations of HSP to rule out torsion. This study may be false-positive due to significant surrounding edema if the patient has underlying HSP. Patients previously diagnosed with HSP should undergo nuclear imaging and, if results are normal, be managed expectantly. If torsion cannot be ruled out by US due to edema, surgical exploration is mandatory and urologic consultation should be sought immediately. If US is negative for torsion, the patient may be managed conservatively with analgesia and corticosteroids. PYOCELE Intratesticular abscess or pyocele is an infected, fluid collection located within the tunica vaginalis and is relatively uncommon. Pyocele may occur when epididymo-orchitis compromises the testicular blood supply, leading to an infected testicular infarction that ruptures through the tunica albuginea to form the pyocele. Trauma may also cause pyocele formation when bacteria are introduced into a sterile hydrocele through breaks in the skin. After an intra-abdominal infection, pyocele formation is thought to be caused by tracking of bacteria from the abdomen via a patent processus vaginalis into the scrotum. 33 Superficial scrotal abscess typically arises from an infected hair follicle. History and Physical Examination Pyoceles may occur following a recent episode of untreated epididymitis or orchitis or as a complication of a ruptured appendicitis, circumcision or vasectomy, or Crohn s disease. Diabetes is also a predisposing risk factor. The patient will complain of pain and may have a history of fever; he may also note a drainage or discharge from the scrotum or an intratesticular mass. A complete genital examination is essential because Fournier s gangrene, a more critical diagnosis, is in the differential. Therefore, careful attention should be given to the entire perineal area. Physical examination reveals a swollen, tender, erythematous scrotum that may or may not have an area of fluctuance, depending on the timeline of the infection. Diagnostic Testing and Pyoceles can have several sonographic features that distinguish them from simple hydroceles, including internal echoes representing cellular debris, septae or loculations, fluid/fluid levels representing a hydrocele/ pyocele interface, and even gas in the case of gasforming organisms. 34 CT may be helpful in showing the extent of the abscess. Prompt urologic consultation for surgical drainage and consideration of orchiectomy is needed. Appropriate antimicrobial agents for intratesticular abscess should be initiated. A superficial scrotal abscess may be managed by incision and drainage. TESTICULAR INFARCTION Testicular infarction may be either global or segmental. Global infarction is usually the result of trauma, repetitive injury (eg, jack hammer use), spermatic cord torsion, or severe epididymo-orchitis or it may be idiopathic. Segmental infarction is rare. Most segmental infarctions are idiopathic; however, there are several predisposing factors, including sickle cell disease, polycythemia, intimal fibroplasia of the spermatic artery, hypersensitivity angiitis, and trauma. Patients with vascular disease are at higher risk for infarction. 35 Patients presenting with testicular infarction will usually complain of a painful scrotum, which may be tender to palpation. Urinalysis should be sent to rule out an infectious etiology for pain. Color Doppler US can differentiate between testicular tumor and infarction, as infarction will be characterized by poor or absent flow. Urologic consultation should immediately be sought as orchidectomy may be necessary. 35 NONEMERGENT DIAGNOSES OF SCROTAL PAIN Not all causes of scrotal pain require emergent therapy. After more severe etiologies have been ruled out, other well-known entities that may have scrotal pain or discomfort in their presentation (testicular malignancy, varicocele, hydrocele, scrotal edema, and torsion of the testicular appendices) should be considered. TESTICULAR MALIGNANCY Testicular cancer accounts or 1% of all cancers in Emergency Medicine Volume 9, Part 3

10 men. 34 It is the most common form of cancer in men between ages 20 and 35 years, with an incidence of 4 in 100,000. Approximately 10% of patients present with acute symptoms (eg, pain, fever) due to hemorrhage within the tumor, 10% after scrotal trauma, and 10% with metastases. 4 Most testicular cancers are of germ cell origin, with seminomas being the most common. Other types include teratomas, embryonal carcinomas, yolk sac tumors, choriocarcinomas, and Sertoli or Leydig cell tumors. Seminoma is the most common tumor to present with epididymo-orchitis. Lymphoma and leukemia may have similar presentations. Evaluation As a rule, the painless testicular mass should be considered to be carcinoma until proven otherwise. Patients should be asked about a previous history of cryptorchidism as it is a risk factor. On presentation, patients will usually complain of a painless mass or heaviness. Sudden pain is usually the result of hemorrhage into the tumor or is due to epididymo-orchitis. Ten percent of testicular tumors are recognized secondary to epididymo-orchitis. 34 Testicular carcinoma is commonly misdiagnosed as epididymitis. Minor trauma that results in severe swelling and pain may be the first sign of a tumor. On examination, the testicle may be firm and indurated. Some patients may present with diffuse swelling. A reactive hydrocele is present in 25% of cases. 35 The mass may be smooth or nodular and will not transilluminate. A complete physical examination with attention to lymphadenopathy, abdominal masses, and hepatosplenomegaly should be performed. Imaging studies for testicular malignancy include US, radiography, and CT. Scrotal US is used for identifying tumors; however, findings may be nonspecific. Chest radiography and abdominal/pelvic CT looking for metastases may be performed for staging purposes but are generally not done in the ED. of suspected malignancy begins with immediate urologic consultation. Hospitalization in orderto expedite orchiectomy may be necessary. VARICOCELE Varicoceles are usually seen in adolescent males but rarely in boys under age 10 years. They occur in approximately 15% in the general population and 40% in infertile men. 4 Patients may seek medical attention due to scrotal pain or heaviness. Pathophysiology The pampiniform plexus is responsible for venous drainage of the scrotum. Incompetent valves in the internal spermatic vein may cause abnormal dilatation of the pampiniform plexus, resulting in a varicocele. Secondary causes include increased pressure on spermatic vein by diseases such as cirrhosis, hydronephrosis, or abdominal neoplasm. Most varicoceles are left-sided due to the longer length of the left testicular vein and the fact that the left testicular vein enters the left renal vein at a right angle; however, varicoceles are found to be bilateral in up to 22% of cases. 37 Renal cell carcinoma may present with acute onset of a left-sided varicocele due to obstruction of the left renal vein. 38 Isolated right-sided varicoceles are caused by inferior vena cava thrombosis or compression from a tumor. Neoplasm is the most common cause of a nondecompressible varicocele in men over age 40 years and requires further evaluation to exclude a mass. 4 Evaluation A varicocele is usually a painless mass of dilated veins superior and posterior to the testis, which may increase when a Valsalva maneuver is performed. The patient should be examined in both the supine and standing positions because the mass will be more pronounced in the standing position and may be tender on palpation. Varicoceles can be palpated superior and posterior to the testis. The appearance and palpation is described as a bag of worms. An abdominal mass should always be suspected in men over age 40 years presenting with a new varicocele. 4 US should be performed to rule out other sources of testicular masses if the physical examination is unclear. Patients should be referred to an urologist for management. Urologic consultation is required for all painful, large, or bilateral varicoceles for surgical intervention. Outpatient referral for young patients is appropriate. Testicular atrophy may occur if varicoceles are not surgically repaired. Uncomplicated varicoceles do not require surgery. HYDROCELE A hydrocele is an abnormal collection of fluid in the tunica vaginalis. In communicating hydroceles, which are generally congenital, the scrotum and the peritoneum are connected due to a persistent upper processus vaginalis. The processus vaginalis normally obliterates within 12 to 18 months after birth and the 10 Hospital Physician Board Review Manual

11 hydrocele resorbs. Non-communicating hydroceles are mostly right sided. Although hydroceles may be present at birth, they more commonly develop during in infancy and are more prevalent in premature boys. Hydroceles may also be acquired through trauma, epididymitis, testicular torsion, or any inflammatory scrotal abnormality, which are more likely to have pain as the chief complaint. Up to 60% of testicular tumors are associated with a hydrocele. 39 At presentation, the patient or parent usually reports painless swelling of the testicle; however, pain may be present depending on the etiology. On physical examination, an enlarged scrotum may be palpated or transilluminated. It is important to palpate above the mass and locate a normal cord because a hydrocele can be difficult to differentiate from a hernia, particularly as they may coexist. Urinalysis and urine culture may be considered if epididymitis is suspected to be causative of the hydrocele. US can be used to determine the cause of the hydrocele and to rule out other pathology (eg, epididymitis, torsion, or tumor) in patients presenting with pain. Painless hydroceles in patients younger than 18 months can be discharged with follow-up by a urologist. Urologic consultation and surgical repair are usually necessary in patients with hydroceles persisting beyond 2 years of age. SCROTAL EDEMA Scrotal edema can occur for various reasons. In older men, it may be caused by comorbidity. Other causes include trauma (eg, human or insect bite) and contact dermatitis. Children aged 3 to 9 years may have idiopathic scrotal edema. In two thirds of these children, an allergen is not identified. Children will present with unilateral swelling and erythema that may be indurated and involve the penis, inguinal canal, and abdomen. The scrotum may be mildly tender or painless. Edema from a bite will usually have unilateral or local edema. Edema in an older patient with lower extremity edema will likely be bilateral. Systemic symptoms are rare, and there should not be any palpable masses. US will demonstrate a thickened wall of the scrotum, increased peritesticular blood flow, and, possibly, a reactive hydrocele. Edema usually resolves within 4 days but may recur in up to 20% of males in cases of idiopathic scrotal edema. 36 Children with idiopathic scrotal edema do not require treatment once acute pathology is ruled out as edema will resolve on its own. In the case of an insect or human bite causing scrotal edema, further work-up including CBC and preoperative laboratory evaluation may be needed. These patients will require antibiotic treatment and the mode of delivery (ie, oral versus IV) will depend on the patient s associated symptoms and the extent of the inflammation. This group of patients may require further follow-up depending on the extent of the injury. In older men, edema involving the scrotum and penis results from fluid overload states (eg, congestive heart failure, hypoalbuminemia) that cause lower extremity edema. should be aimed at the underlying condition. TORSION OF TESTICULAR APPENDICES Torsion of testicular appendages (the appendix testis, appendix epididymis, paradidymis, and vas aberrans) is usually seen in prepubertal males age 7 to 13 years who present with scrotal pain. Studies have shown appendage torsion accounts for 24% to 46% of acute scrotum presentations in pediatric patients. 1,40 The appendix testis, at the superior pole of the testis, and the appendix epididymis, located in the head of the epididymis, account for 99% of appendage torsions. 23 The appendage undergoing torsion will become ischemic and eventually infarct. Patients may present with gradual onset of unilateral scrotal pain, usually at the superior aspect of the testicle. Swelling may be apparent in later presentations. Systemic complaints (eg, nausea, vomiting, abdominal pain) are rare. A tender nodule or area on the testis or epididymis may be palpated while the body of the testicle and epididymis will be nontender with a normal lie. The cremasteric reflex will be present bilaterally. A small dark or blue dot, called the blue dot sign, may be seen when the affected appendage is brought against the scrotal skin and transilluminated or may be noticed through the scrotal skin on inspection. This sign may only be seen early in the presentation, as it is obscured later due to edema and erythema. The blue dot sign is pathognomonic for torsion of the appendages, but this sign is present in only 14% to 22% of cases. 41 Diagnostic testing is usually unnecessary and unhelpful. US should be performed if there is swelling and testicular torsion cannot be ruled out. The mainstay of treatment is pain management, rest, and scrotal elevation. The swelling and pain should resolve in 1 week. The torsed appendages will degenerate or calcify within 2 weeks. Urologic consultation may be necessary to rule out testicular torsion or if there is chronic pain from a torsed appendage that may need surgical removal. REFERENCES 1. Lewis AG, Bukowski TP, Jarvis PD, et al. Evaluation of acute scrotum in the emergency department. J Pediatr Surg 1995;30: Emergency Medicine Volume 9, Part 3 11