Assessment of Acute Scrotum

Abstract

Acute scrotal pain is a common clinical problem. Unfortunately symptoms are vague and clinical findings are non-specific. Immediate surgical exploration is advised in patients with Acute scrotal pain unless a definitive diagnoses of causes other than torsion can be made. In about 30 - 50 % cases the different underlying pathological conditions cannot be distinguished by clinical exam or lab tests .Ultrasound offers timely and accurate differentiation of the causes of scrotal pain. • Torsion of the Testis. 30% • Epididymo-Orchitis. 37% • Torsion of Testicular appendage. 11% • Idiopathic scrotal edema. 09% • Incomplete Torsion & de-torsion. • Acute hydrocele. • Strangulated Hernia. • Henoch Schonlein purpura. • Hemorrhage into a testicular neoplasm. • 20-30% of patients with Acute scrotal pain. • Haste is essential as testicular salvage rate reduces with passage of time in Ac. Torsion Testicular torsion occurs due to twisting of the testis on cord due to an underlying Bell and Clapper anomaly. Initially the testis swells up due to venous compression, later as the arterial flow is compromised ischemia sets in and tissue necrosis may occur. Sonography and color Doppler ultrasound reflect these developments. On gray scale ultrasound the testis appears slightly enlarged. Color Doppler scan will reveal reduced or absent flow. Careful examination of cord must be performed to look for the whirlpool sign – confirming the twisting of the cord. In a child torsion of the testicular appendage is a more common cause of acute scrotum as compared to torsion of the testis itself. Sonography reveals a small focal hypoechoic mass adjacent to the epididymis. The epididymis and testis appear normal in size and reveal normal vascularity. This is often a diagnosis of exclusion. Epididymo-orchitis is a more common cause for Acute scrotum, particularly in young children. Gray scale ultrasound reveals enlarged epididymis and testis. Echostructure is usually altered and hypoechoic. Testicular involevement is often later and lesser. Color Doppler reveals increased vascular flow signals in epididymis and testis. Some studies have shown that increased vascularity on color Doppler may be the only sign of Acute Epididymitis or Orchitis in 20-40%. Trauma can cause bleeding in the tunical sac producing a hematocele, or it can cause a rupture of the testis itself. Testicular conturs may become irregular, but more often rupture is seen as focal areas of altered echogenecity in the testis. • Partial Torsion – some flow may still occur. • Spontaneous detortion – flow may be normal or increased. • Orchitis may cause sudden swelling and global ischemia of testis