Acute pain or swelling of the scrotum

Differential diagnosis

• Ischemic - testicular torsion; appendiceal torsion (testis or epididymis)
• Trauma - testicular rupture, hematoma, hematocele
• Infection - epididymitis, orchitis, abscess, Fournier's gangrene
• Inflammatory - HSP of scrotum (vasculitis), fat necrosis
• Inguinal hernia - incarcerated/strangulated
• Acute on chronic - rupture/hemorrhage/infection of spermatocele, hydrocele, testicular tumor, varicocele

Scrotal ultrasound

• Normal dimensions: 3-5 cm long, 2-4 cm wide, 3 cm AP

Testicular torsion

• Type
• Intravaginal - torsion within the tunica vaginalis
• Tunica vaginalis normally attaches to posterior surface of testicle → immobilization
• "Bell-clapper" deformity - tunica attaches higher up on spermatic cord → testicle has transverse lie and is free to rotate (intravaginal torsion)
• Extravaginal - Spermatic cord + tunica twist as a unit
• In neonates; incomplete descent and the tunica vaginalis is not yet adherent to the dartos → increased mobility
• Cryptorchidism also a risk factor
• Presentation
• Most commonly age 12-18 (but consider in any age)
• Acute onset of severe testicular pain +/- swelling (L > R)
• Physical exam: tender, high-riding testicle with transverse lie, absent cremasteric reflex, no pain relief with testis elevation, thick spermatic cord, epididymis not posterior to testis
• Work-up:
• TWIST score for degree of suspicion
• Swelling = 2 points
• Hard testicle = 2 points
• No cremasteric reflex = 1 point
• High riding testicle = 1 point
• Nausea/vomiting = 1 point
• High degree of suspicion (TWIST = 6-7) - scrotal exploration, do not need to wait for imaging
• Questionable diagnosis (TWIST = 1-5) - scrotal US (torsion = absent arterial flow; epididymitis = normal/increased flow)
• Detorsion + orchidopexy
• < 6 hrs after onset - 100% salvage rate
• > 12 hrs - 20%; > 24 hrs - 0%
• Orchiectomy for necrotic testis
• Perform orchidopexy on contralateral side at same time to prevent future torsion (anchor tunica albuginea to overlying tunica vaginalis and dartos)
• Can attempt manual detorsion (external rotation) but should still perform b/l orchiopexy afterwards
• Torsion of appendages - acute scrotal pain, but testis has normal lie and perfusion. May see 'blue-dot' sign of ecchymotic appendage through the skin. Self-limited.

Epididymitis/epididymoorchitis

• Etiology
• < 35 yo: STDs (chlamydia, gonorrhea) (doxy 100 mg PO BID x 7d, + ceftriaxone 250 mg IM x 1)
• > 35 yo: BPH/UTIs (gram negative bacteria) (Ofloxacin 300 mg PO BID x 10days or Levofloxacin 500 mg PO once daily x 10 days)
• **hide**2/2 urinary reflux, extravasation after vasectomy, ectopic ureter
• Presentation
• History - STIs, sexual activity, voiding sx, BPH, UTI
• Testis is tender posterolaterally (location of epididymis)
• Scrotal US - normal or ↑ testicular perfusion, hypervascular epididymis
• Use Doppler US to differentiate from late torsion when swelling makes physical exam difficult
• Normal for mild pain or swelling to persist for 2-4 weeks
• Treatment
• Scrotal support
• Analgesics like NASIDS
• Application of ice pack to reduce swelling and decrease pain
• Starting empiric antibiotics 
• < 35 yo: doxy 100 mg PO BID x 7d, + ceftriaxone 250 mg IM x 1
• > 35 yo: Ofloxacin 300 mg PO BID x 10days or Levofloxacin 500 mg PO once daily x 10 days

Scrotal Abscess and Pyocele

• Scrotal Abscess: abscess of the scrotal skin that does not extend into the tunica vaginalis.
• Typically arises from a cutaneous source. Most common organism is Stap aureus.
• Presentation:
• Redness, warmth, swelling, pain, and fluctance.
• Inflammation to the lymph nodes.
• Fever or Leukocytosis
• Treatment: I+D (make sure to probe the abscess to breakup loculations and get a culture of the fluid).
• Pyocele: pus within the space between the tunica albuginea and the tunica vaginalis.
• Causes:
• Spread from extrascotal abscess.
• Complication of epididymitis or orchitis.
• Flow of pus from an intraperitoneal source i.e appendicitis through a patent process vaginnalis and into the scrotum.
• Work-up: Labs, Scrotal US (to determine extent of abscess and to determine if intrascrotal involvement) and abdominal CT (if concern from an intraperitoneal source).
• Treatment:
• Arise from intraperitoneal - treat primary infection
• Arise from epididymitis or orchitis - treat I+D of scrotal sac. With broad spectrum antibiotics.
• Consider orchiectomy if testis is necrotic or infarcted as the testis and epididiymis may harbor infection.

Testicular trauma

• Rupture = laceration of tunica albuginea, requires surgical repair
• Intratesticular hematoma should be assumed to have rupture → surgical exploration
• < 72 hrs: 80-90% salvage rate; > 72 hrs: 32-45% salvage rate
• **hide**Debride extruded testicular tissue, necrotic tissue (orchiectomy if minimal viable testis tissue)
• **hide**Close tunica albuginea with running 4-0 absorbable sutures
• **hide**Place penrose drain for 24-36 hrs
• **hide**Broad-spectrum abx x 7d
• Contusion, hematocele (intrascrotal hematoma) do not require surgery - pain control, ice, and rest. Large painful hematoceles can be drained.
• Penetrating injury
• Surgical exploration (testicular injury/rupture likely)
• Blunt injury
• Surgical exploration not needed if testis is palpable and normal
• If difficult to palpate, scrotal US to determine if rupture present
• Rupture appears as heterogeneous area; fracture site (loss of smooth contour) seen in 20% of cases
• Intratesticular hematoma cannot be reliably distinguished - inconclusive scrotal US → surgical exploration

Fournier's Gangrene

• Necrotizing fasciitis of scrotum and groin - rapidly progressive, life threatening (mortality 30%)
• a/w immunocompromised, diabetic, EtOH
• Diffuse swelling/induration, erythema, necrotic patches, crepitus
• Diagnosis based on clinical suspicion
• Mark the borders on evaluation and track for progression
• Spreads along dartos, Colles', and Scarpa's (contiguous layers)
• May obtain CT scan to evaluate for subcutaneous gas, extension to surrounding structures/need to involve general surgery
• Make sure to scan down to mid thigh to capture scrotum in images
• LRINEC score (risk indicator for nec fasc based on labs)
• CRP, WBC, Hgb, Na, Cr, glucose
• < 6 is cutoff for low risk of nec fasc (but not no risk)
• Broad spectrum abx (e.g. Vanc PLUS Zosyn/mero (beta-lactamase inhibitor) PLUS clinda (anti-toxin effect for clinda) )
• Polymicrobial infxn; E. coli most commonly cultured
• Urgent drainage/debridement of all tissue that does not bleed
• May create thigh pouch for testicles if necessary
• Send at least 1cc tissue for culture
• SP tube if penis/urethra involved (assess with cysto or RUG), diverting colostomy if rectal/colonic involvement
• Wet-to-dry dressings TID; control blood glucose
• Consent for serial debridements

Penile fracture (scrotum-adjacent, ok)

• Bottom section of GU trauma