Acute scrotum: differential diagnosis and treatment

Abstract

Acute scrotum (AS) is a clinical syndrome characterized by scrotal pain of acute onset, often accompanied by scrotal swelling and other local and systemic signs and symptoms. It may be the initial presentation of several diseases including testicular torsion, orchitis, epididymitis, hydatid torsion, strangulated hernia and, less frequently, scrotal hematoma and testicular tumor. In the setting of emergency services, physicians should be extremely careful with the possibility of testicular torsion. This condition consists in the torsion of the spermatic cord, leading to an interruption of the testicular blood flow, with ischemia and ultimately necrosis. It is associated with acute severe pain, nausea, absence of the cremasteric reflex, and a high-riding testis. Physical examination may help diagnosis. However, a color Doppler ultrasound of the scrotum is usually required for a definitive diagnosis. Ultrasound will reveal a reduction or no blood flow to the affected testis; surgical treatment is mandatory and should be performed as early as possible. A differential diagnosis is orchiepididymitis. It may be of viral etiology in early childhood and bacterial after the beginning of sexual activity. The most specific sign associated with this condition is the relief of pain after elevation of the testis, known as Prehn’s sign. Treatment for bacterial cases requires antibiotics, while cases of viral etiology require only symptomatics. Hydatid torsion, including torsion of appendix testicularis and appendix epididymis may mimic testicular torsion but on ultrasound, blood flow is preserved, and a twisted appendix is often seen. Treatment for this condition consists only in symptomatic control. Testicular torsion should be treated as early as possible, since a delay of 6 hours may result in organ loss. Surgery consists of bilateral orchiopexy in case of a viable testicle and orchiectomy of a necrotic organ, always with fixation of the contralateral testicle.

Testicular salvageability and its predictors among patients with testicular torsion in a resource limited setting: a multicentre longitudinal study

“…In our study with low salvage rates, the majority (53.7%) of the patients with testicular torsion presented after 48 h. Evidence suggests that presentation after 48 h reduces the chance of testicular salvage to 25% [ 3 ]. According to the literature, when twisting takes more than 6–8 h duration, the blood supply is interrupted and cellular death ensues, necessitating the removal of the dead testis [ 8 ].…”

“…The diagnosis of testicular torsion was done on the basis of history of recent sex, trauma, pain, nausea, and vomiting, clinical signs of elevated tender testicle, twist criterion [ 8 ], and intra operative findings. To clinically assess the severity of testicular torsion, the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score has been developed to risk stratify testicular torsion in males presenting with an acute scrotum (AS).…”

“…To clinically assess the severity of testicular torsion, the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score has been developed to risk stratify testicular torsion in males presenting with an acute scrotum (AS). The TWIST score is based on the sum (ranging from 0 to 7) of the following historical and physical examination findings: testicular swelling (2 points), hard testicle (2 points), absent cremasteric reflex (1 point), nausea or vomiting (1 point), and high riding testicle (1 point).The risk stratification scores for patients at low risk for testicular torsion is 0 to 2 points, the intermediate risk is 3 to 4 points, and high risk for testicular torsion is 5 to 7 points [ 8 ].…”

“…Testicular torsion presents a diagnostic challenge due to the overlap of its clinical presentation with that of epididymitis and torsion of appendix testis [ 7 ]. Though testicular torsion is a surgical emergency that warrants operation within 6 h of onset [ 8 ], epididymitis and torsion of the appendix testis do not require such urgency. Patients in resource limited settings often present late as they wait for the pain to resolve with self-medication.…”

Validation of TWIST score in the diagnosis of testicular torsion in children: A Prospective study

“…However, routine DUS can delay surgical exploration. On the other hand, it may burden the system with unnecessary tests because TT is found in 15 -30% of children with acute scrotum [6,7].…”