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Acute scrotum is a common clinical problem and establishing its etiology can be difficult, often necessitating scrotal exploration. We report here a very rare case of acute scrotum: torsion of the epididymis. Only one such case has been reported previously in the literature.
Acute scrotum presenting as the only initial manifestation of Henoch-Schönlein purpura (HSP) is so unusual that the diagnosis can easily be missed. We report this condition in a 4-year-old boy admitted with bronchopneumonia. Bilateral painful scrotal swelling with ecchymosis occurred on the second day of hospitalization. Scrotal sonography was performed and a good blood supply was documented. Scrotal nuclear scanning was performed and was consistent with bilateral epididymoorchitis. Multiple purpuric lesions over the lower extremities and perineal region developed on the third day of hospitalization. Intermittent abdominal pain and knee pain developed thereafter. HSP was diagnosed and steroids were prescribed. The symptoms subsided gradually and no complication was noted. This case reminds us that an acute scrotum may be the only initial manifestation of HSP. Sonography and nuclear scanning can help rule out other diseases.
Acute scrotum is a condition which often causes diagnostic difficulties despite all the available investigation methods. Ruling out or confirming torsion of the testis is the main problem in most cases. Other more rare conditions, however, need acute exploration such as illustrated in this case report, where the sudden bleeding in a testicular neoplasm caused severe acute symptoms. The tumor may not necessarily be clearly apparent during surgery. Peroperative analysis of a specimen of testis tissue is therefore recommended in such cases.
Acute scrotum is a clinical syndrome which includes various disorders. Differential diagnosis of these disorders is not always easy. We reviewed cases experienced in our hospital, focusing on diagnostic procedures. Final diagnosis in 39 cases were acute epididymitis in 23 cases, torsion of the testis in 13 cases, torsion of appendix epididymis in 2 cases and torsion of appendix testis in 1 case. It became clear ultrasonography was a useful diagnostic procedure; if the torsed portion is delineated, torsion of the testis can be diagnosed. Heterogenous echoes from the interior of the testis indicate the necrosis of the testis. Inspection was also useful; if the blue dot sign is detected, torsion of the appendix testis/epididymis is indicated. However, Doppler ultrasound did not always provide a correct diagnosis of torsion of the testis. If torsion of the spermatic cord cannot be completely ruled out, early surgical intervention and treatment are considered essential.
Acute scrotal swelling is a potential urologic emergency. There are many conditions which may present with scrotal swelling including spermatic cord torsion, torsion of testicular appendages, epididymitis, orchitis, incarcerated scrotal hernia, hydrocele, varicocele, trauma, tumor and testicular pain in vasculitis syndromes such as Schoenlein-Hennoch purpura. Testicular torsion is the most important condition that must be proven or ruled out to avoid loss of testicular function. History, physical examination and perhaps color-coded doppler-sonography are the tools to diagnose torsion. Using these tools, three diagnostic categories will be defined: Torsion, non-torsion or equivocal diagnosis. In every doubtful case scrotal evaluation is done surgically. Non-torsion is treated according to the different diseases.
Acute scrotal pain accounts for approximately 0.5% of total emergency department (ED) visits. Despite this relatively low percentage, these patients can present a considerable challenge to the treating emergency physician (EP) since the etiologies of acute scrotal pain range from organ-threatening disease to minor idiopathic pain. Few data exist on EP use of bedside ultrasound to evaluate scrotal pain, but there is some suggestion that this may represent a beneficial future application for emergency ultrasonographers. This paper briefly describes the technology and technique involved with the performance of testicular ultrasound examination and briefly discusses its potential application at bedside in the ED.
The acute epididymitis in children is an uncommon disease which occurs mainly in adolescents. The pediatric surgeon must remember this illness whenever he observes a child with acute scrotum. The aim of this study is to review our experience at the Pediatric Surgery Department in Siena with 17 children (mean age: 7.53 years) underwent to surgery for acute scrotum and affected by primitive acute epididymitis without any other local or systemic associated disease. Our study shows that in children the acute epididymitis is more common than testicular torsion. It is often quite difficult to find the origin of epididymitis in children with no genito-urinary anomalies; so the acute scrotum and in particular the epididymitis require a standardized diagnostic and therapeutic approach based on an accurate physical exam, quickly feasible diagnostic procedures and a prompt surgical exploration of the scrotum.
The acute scrotum remains a difficult clinical challenge because of numerous etiologies including inflammatory processes, testicular torsions, traumas, and tumors that can justify early surgery. Ultrasound study appears to be the imaging modality of choice to confirm the clinical assessment. We reviewed 825 scrotal scans performed with high-resolution scanners; 283 were considered pathologic and classified as follows: 27 tumors (9.5%), 21 traumas including torsions (7.4%), 142 infectious diseases (50.1%), 99 dystrophic diseases (29.2%), and 16 miscellaneous (5.6%). Acute scrotal pain was the only symptom in 83 cases (29.3%). In this paper, we emphasize the different roles of ultrasound depending on the initial clinical presentation, which determines the clinician's questions. In the typical cases, ultrasound has a major role in the prognosis, as it allows evaluation of the severity of the lesions. On the other hand, in atypical cases, ultrasound has a decisive role in planning the management, which will be immediate surgery when sonographic findings highly suspicious for testicular torsion or acute ischemia of the testis are found. Based on our experience, we believe that ultrasound is a highly reliable modality for guiding medical or surgical treatment of an acute scrotum.
The acute scrotum generates a long list of differential diagnoses. An unusual etiology includes insect envenomation, which typically is an acute process with rapid onset of symptomatologies. Two patients with genital envenomation are reported. We review the reported cases at our institution with all types of bites and stings. Symptoms of pain and pruritus, and signs of ecchymosis and edema preceding exfoliating dermatitis were evident in both cases. Mild analgesics and antihistamines promoted resolution in each instance.
Acute scrotum in children is generally a symptom. Several pathologies of the testis, scrotum or groin may cause it, including inflammatory as well as ischaemic processes. Testicular torsion with ischaemia of the testis is an emergency requiring prompt surgical intervention. Even experienced paediatric surgeons and urologists may have difficulties differentiating an ischaemic from an inflammatory aetiology solely on the basis of clinical signs and symptoms. In cases of aetiologic uncertainty, operative exploration has to be performed to rule out ischaemia, which led in the past to a high rate of surgery. More recently, colour Doppler ultrasonography (CDUS) has become an imaging modality for the examination of the acute scrotum with the purpose of detecting ischaemia, thus reducing the need for explorative surgery. In this study we examined the reliability of CDUS, comparing the sonographical diagnoses with both the intraoperative findings and the clinical course. We present here 132 consecutive cases of acute scrotum in children, who were admitted from 01/98 through 10/02 to our hospital. All patients underwent CDUS. Patients with ultrasonographic signs of ischaemia of the testis (group A) and patients with demonstrated perfusion and suspicious or severe clinical symptoms (group B) were operated immediately. Patients with demonstrated perfusion without suspicious or severe symptoms (group C) were treated conservatively. Thirty-eight patients (28.8%) were treated operatively. Eleven cases of testicular torsion in group A (12 pat.) could be confirmed intraoperatively, in one case there was no testicular torsion but a severe inflammation of the testis with torsion of the appendix testis. In group B (26 pat.) operative exploration revealed one case of testicular torsion. In group B two cases of sonographically suspected torsions of the appendix testis also emerged as epididymitis intraoperatively. In the other cases postoperative diagnosis was in agreement with the preoperative CDUS. The clinical course of 94 conservatively treated patients (71.2%) (group C) confirmed in all cases a non-ischaemic aetiology. There was a total of 12 cases (9.1%) where acute scrotum was caused by testicular torsions. This relatively low rate underlines the necessity to differentiate between ischaemic and other aetiologies, thus avoiding operation in many patients. 71.2% of our patients could be treated conservatively. However, it is essential to exclude an ischaemic cause before opting for conservative therapy. Even though CDUS is a very valuable diagnostic tool in this sense, this exclusion cannot be ensured in every case and is highly dependent on the expertise and technique of the investigator. Therefore in cases with any doubts an operative exploration has to be performed to avoid the most dreaded complication in the treatment of acute scrotum.
The acute scrotum in the pediatric patient frequently presents a diagnostic dilemma for even the most experienced clinician. In an effort to improve testicular salvage in equivocal cases, immediate surgical intervention has been recommended, despite a large number of unnecessary explorations. Evaluating the sodium pertechnetate Tc 99m radioisotopic scan in 46 boys, we found this study to be a rapid, reliable, sensitive, and noninvasive test that allows the selection of those patients who require immediate surgical intervention.
Acute scrotum is a frequent reason for consultation at the urological emergency service. The most common causes, apart from trauma, are acute orchiepididymitis, torsion of the hydatids of Morgagni and torsion of the spermatic cord. Apart from a detailed examination of patient history and a careful physical examination, few diagnostic techniques can be utilized. To date, only the Doppler ultrasound has proved useful in corroborating the suspicion of vascular involvement, although this technique is very limited. With the availability of the duplex ultrasound, the possibility of making the differential diagnosis in the acute scrotum is enhanced. This technique permits morphological and functional assessment and avoids unnecessary exploration surgery within the scrotum.
Acute scrotum following perforated appendicitis is a rare complication. This usually occurs in the presence of a patent processus vaginalis in children. We report a case of acute scrotum presenting after appendectomy for perforated appendicitis in a young adult.
Acute scrotum is an exceptional form of presentation of acute appendicitis in the pediatric age group. Only 14 cases have been described in literature. The authors report a case of an 8-year-old boy with a 12-hour history of right hemiscrotal pain secondary to acute retrocecal nonperforated appendicitis. Surgical exploration showed a patent "processus vaginalis."
BACKGROUND: The acute scrotum in children frequently presents a diagnostic dilemma. The objective of this study is to review the experience of patients with acute scrotum in children. METHODS: From April 1986 until March 1998, we encountered 40 cases of acute scrotum in children less than 15 years old diagnosed by surgical exploration. RESULTS: Final diagnoses consisted of 14 patients with torsion of the spermatic cord (35%), 22 patients with torsion of the testicular appendage (55%), 3 patients with acute epididymitis (7.5%), and patient with a strangulated hernia (2.5%). Of 22 patients with torsion of the testicular appendage, which were the most frequent cause of acute scrotum, 20 had torsion of the testicular appendix and 2 had torsion of the epididymal appendix. The age distribution of the patients with torsion of the spermatic cord was biphasic, with the highest frequencies occurring in patients 2 years old and 14 years old. In contrast, the age distribution of patients with torsion of appendage showed a single peak incidence at 9 years of age. Those with epididymitis were younger than 2 years old. Of 14 cases of torsion of the spermatic cord, orchiectomy was performed in 6 cases (42.9%) because of testicular necrosis. CONCLUSION: Although surgical exploration is no longer necessary for all patients with torsion of the appendage, this review revealed that patients complaining of severe or persistent pain usually require surgery to diagnose and treat the problem.
Acute scrotum is one of the rare presentations of acute appendicitis (AA) in paediatric patients. We report a case of acute scrotum due to a retrocaecal, non-perforated AA with a patent processus vaginalis. To date, 15 such cases have been reported in the literature.
In the acute scrotum, diagnosis can be difficult in certain cases. In 107 patients the value of static and dynamic radionuclide imaging was evaluated. Static images provide a sensitivity and reliability of over 90%. Quantitative measurements do not give additional information in the differential diagnosis of these patients. Generally, scintigraphy can only be advocated if available as an emergency procedure. It is not necessary in cases with clinically obvious diagnosis of acute testicular torsion or epididymitis, but can be very helpful and reliable in unclear cases, i.e. for the evaluation of testicular perfusion after scrotal trauma.
The pediatric acute scrotum can be a diagnostic dilemma. The history, physical examination, and appropriate tests are important. The correct diagnosis will be arrived at if the systematic approach is remembered (Figure 14). In cases where testicular torsion cannot be ruled out (such as an epididymitis or torsion of the appendix testis where torsion of the testis is mimicked), the patient will need scrotal exploration. It is hoped that with further availability of scanning and expertise by pediatric surgeons the false negative exploration will decrease in number. Remember, occasionally a patient will require scrotal exploration with biopsy of the epididymis to delineate the underlying cause. In most cases of epididymitis, effort should be made to identify the cause by culture of urine, urethral discharge, or appropriate fluid from the epididymis. Urological evaluation will be necessary in the younger boys, particularly those with recurrent episodes, to rule out congenital anomalies. Only by following this systematic approach can clinicians hope to preserve gonadal function and achieve best care of their patients.