What to do when the balls are in your court:

An Approach to the Acute Scrotum

Resident Clinical Pearl (RCP) – October 2018

Devin Magennis – Family Medicine, PGY2, Dalhousie University, Charlottetown PEI

Reviewed by Dr. David Lewis

The acute scrotum is a syndrome characterized by intense, new onset scrotal pain which can be accompanied by other symptoms such as inflammation, abdominal pain, or fever³. The incidence of acute scrotal pain is highest under the age of 15³, yet it can occur at any age.  To successfully diagnosis and manage the patient with an acute scrotum it is useful to formulate a differential diagnosis using the I VINDICATE mnemonic.

Table 1- Differential diagnosis for scrotal pain organized using I VINDICATE format. The diagnoses in bold are or have the potential to be life-threatening or testicle threatening. The diagnose in Italics are common.

Review of Clinically Relevant Anatomy:

It is important to remember that during development the testicles originate in the posterior abdominal wall before migrating down into the scrotum⁴. Consequently, testicular pathology can present not just as scrotal pain but also as: flank pain, abdominal pain or inguinal pain².

Once in the scrotum, the testicle sits in a vertical lie. The anterior portion of the testicle adheres to the scrotal wall via the tunica vaginalis. The tunica vaginalis is double-layered. Between these layers is a potential space for fluid to collect. Along the postero-lateral aspect of the testicle is the epididymis. It originates at the postero-superior pole, runs along the lateral aspect of the testicle down to the inferior pole⁴

Figure 1- Anatomy of the testicle. Right side of photo is anterior, left side is posterior

When trying to localize a patient’s symptoms it helps to divide the genital tract into segments: lower segment and the upper segment. The lower genital tract consists of the urethra. While the upper genital tract consists of the testicles, epididymis and prostate.

Testicular torsion

In a patient presenting with an acute scrotum the most important diagnosis to consider is testicular torsion^1-5. Classic teaching states testicular torsion occurs in the perinatal period and during puberty. and Reported will be: sudden onset of severe unilateral testicular pain within 12 hours of presentation¹. Patients will typically have had similar previous episodes, feel nauseated, may have vomited and occasionally have a history of trauma¹. On inspection there will be scrotal erythema; a swollen, high-riding testicle with a horizontal lie. On palpation of the testicle it would be found to be exquisitely tender and the cremasteric reflex would be absent.

Unfortunately, testicular torsion usually does not present as described above².  In one case series 1 in 5 patients diagnosed with testicular torsion had only abdominal pain and no scrotal pain². While in another case series 7% of patients diagnosed with testicular torsion presented with complaints of dysuria and/or urinary frequency. Furthermore, other acute scrotal conditions have considerable overlap with the classic description of torsion². Both epididymitis and torsion of the testicular appendage can present with sudden onset of pain². Patients with any scrotal condition can have an absent cremasteric reflex as it is absent in 30% of the population and just to make matters more confusing, multiple case series report patients with testicular torsion still having an intact cremasteric reflex¹.

Approach

Management

The Bottom Line

1. Testicular torsion is the one diagnosis that must be made quickly and accurately to avoid the loss of a testicle.¹
2. The classic teaching that testicular torsion can be diagnosed on history and physical exam alone is a myth. If you suspect torsion get an ultrasound and consult urology.²
3. Torsion becomes exceedingly rare over the age of 25; however it is still possible.¹
4. Abdominal aortic aneurysm, appendicitis, nephrolithiasis and other causes of abdominal and flank pain can present as scrotal pain. Testicular torsion can present as abdominal or flank pain.²

References:

1. Jefferies MT, Cox AC, Gupta A, Proctor A. The management of acute testicular pain in children and adolescents. BMJ. 2015;350:h1563. doi: 10.1136/bmj.h1563 [doi].
2. Mellick LB. Torsion of the testicle: It is time to stop tossing the dice. Pediatr Emerg Care. 2012;28(1):80-86. doi: 10.1097/PEC.0b013e31823f5ed9 [doi].
3. Lorenzo L, Rogel R, Sanchez-Gonzalez JV, et al. Evaluation of adult acute scrotum in the emergency room: Clinical characteristics, diagnosis, management, and costs. Urology. 2016;94:36-41. doi: 10.1016/j.urology.2016.05.018 [doi].
4. Drake R, Vogl AW, Mitchell AWM. Gray’s anatomy for students. Saint Louis: Elsevier; 2014. Accessed 8/11/2018 11:47:58 AM.
5. Rottenstreich M, Glick Y, Gofrit ON. The clinical findings in young adults with acute scrotal pain. Am J Emerg Med. 2016;34(10):1931-1933. doi: S0735-6757(16)30284-4 [pii].

This post was copyedited by Dr. Mandy Peach