Scrotal emergencies account for an extremely small percentage of emergency room visits. However, due to the nature of the emergency an early diagnosis is essential to exclude fertility-threatening diagnoses. In this presentation, we will review few of the common causes of acute scrotal pain in addition to the spermatic vein thrombosis to compare and contrast the patient presentation, imaging appearance and management.
Testicular torsion:
A misnomer as the true cause of acute scrotal pain is torsion of the spermatic cord. This can occur at any age, although is more common in adolescent boys. The torsion can be intra-vaginal or extra-vaginal. Majority of cases are intra-vaginal and are associated with “bell-clapper” deformity where the tunica vaginalis surrounds the epididymis, spermatic cord, and testis rather than attaching to the posterolateral testis. This allows free mobility and twisting of the spermatic cord by 90-720 degrees which initially results in venous outflow obstruction followed by engorgement, arterial inflow obstruction and testicular infarction within 6hrs.
Imaging diagnosis can be obtained rapidly via ultrasound. A torsed testicle is enlarged and heterogeneous in echotexture with lack of flow on color doppler imaging, when compared to the normal testis. Management of testicular torsion can be manual detorsion if possible, or surgical de-torsion followed by orchiopexy.
Appendix testis torsion:
The testicular appendix is a pedunculated remnant of Mullerian duct that can occasionally undergo torsion resulting in acute scrotal pain. Ultrasound demonstrates an enlarged appendix testis with absent color doppler flow.
Epididymitis and Epididymo-orchitis:
A common cause of acute scrotal pain with varying etiology depending on age of presentation. Infection of the testis and epididymis is caused by retrograde bacterial flow from the urinary tract and can result in abscess formation if left untreated. In a patient older than 35 or children, the cause of infection can be Escherichia coli or other urinary tract organisms. In an adult patient younger than 35, the most common cause of infection is Neisseria gonorrhoeae or Chlamydia trachomatis. A less common cause of these symptoms can be secondary to ‘chemical epididymitis’ secondary to retrograde of urine.
Ultrasound demonstrates an enlarged epididymis with areas of heterogeneity, with similar findings seen in the testis. A focal hypoechoic area can be seen in the presence of an abscess. The epididymis and testis demonstrate increased color flow secondary to hyperemia, with or without scrotal wall thickening and hyperemia. Rarely, an untreated orchitis can result in infarction, which can demonstrate lack of flow on color doppler imaging. Management of epididymitis-orchitis involves antibiotic therapy.
Fournier’s Gangrene:
Necrotizing infection that involves superficial to deep tissues are generally polymicrobial involving symbiotic infection by both aerobic and anaerobic organisms. This infection has a slightly male predominance with higher incidence among patients with diabetes mellitus and alcoholism. Fournier’s gangrene carries high morbidity and mortality if left untreated.
CT is the diagnostic tool of choice which can demonstrate soft tissue gas in the superficial and deep fascial layers of the pelvis and abdomen with or without fluid collections. Ultrasound is not an ideal diagnostic tool secondary to small field of view and patient’s inability to tolerate pressure. The management of this infection involves emergent irrigation and debridement followed by broad spectrum antibiotic therapy.
Traumatic rupture/fracture:
Testicular trauma is rare due to their mobility within the scrotal sac. However, the right testicle is predisposed to injury in the setting of blunt trauma. Testicular rupture occurs when there is disruption of the tunica albuginea with extrusion of intra-testicular components. Testicular fracture occurs when there is injury to the tunica albuginea resulting in a hematoma or infarction.
Ultrasound demonstrates disruption of the hyperechoic tunica albuginea with extrusion of parenchyma with or without a hematoma, hemorrhage or ischemia in the case of a rupture. On the contrary, a testicular fracture demonstrates a hypoechoic line through the testis without internal flow and with or without a hematoma. Management of testicular rupture and fracture vary as the first requires emergent surgical management to preserve fertility, while the latter is conservative depending on the degree of ischemic parenchyma.
Other rare causes of scrotal pain can be nonspecific angioedema, inguinal-scrotal hernia and testicular tumor. Discussion of these cases is beyond the scope of current presentation.