1. Acute scrotal pain, tenderness, swelling
Acute Scrotum
Acute scrotal pain, tenderness, swelling

2. Differential Diagnosis of the Acute/Subacute Scrotum
Torsion of the spermatic cord
Torsion of the appendix testis
Torsion of the appendix epidibymis
Epididymitis
Epididymo-orchitis
Inguinal hernia
Communicating hydrocele
Hydrocele
Hydrocele of the cord
Trauma/insect bite
Dermatologic lesions
Inflammatory vasculitis (Henoch-Schonleiin purpura)
Idiopathic scrotal edema
Tumor
Spermatocele
Varicocele
Nonurogenital pathology (e. g., adductor tendinitis)

3. Torsion of the spermatic cord
Irreversible ischemic injury may begin as soon as 4 hrs
50% of men whose testes were detorsed less than 4 hrs had normal S/A
Pts younger than 18 yrs were prone to testicular loss
It is most common during adolescence
(12-18yrs)
The incidence is estimated to be 1 in 4000 male Pts less than 25 yrs.

4. Etiology Intravaginal torsion Bell-clapper deformity
Added weight of the testis after puberty

5. Testicular Torsion Trauma Athletic activity Awakened from sleep
Contraction of the cremasteric muscle

6. Presentation Acute onset of scrotal pain
Some instance the onset appears to be more gradual
Prior episode of sever, self limited scrotal pain and swelling
Nausea, vomiting

7. Physical examination High-riding Transverse orientation
Acute hydrocele or massive scrotal edema
Absence of a cremasteric reflex (100%)
Manual detorsion may not totally correct the rotation

8. Imaging Color doppler U.S: sensitivity 88.9%, specificity 98.5%
Radionuclide imaging: sensitivity 90%, specificity 89%

9. Treatment
When the diagnosis of torsion of the cord is suspected, prompt surgical exploration is warranted
Sympathetic orchiopathy
The contralateral testis must be fixed

10. Intermittent Torsion of the Spermatic Cord
H/O prior episode of acute, self-limited scrotal pain, intermittent
Elective scrotal exploration

11. Torsion of Testicular and Epididymal Appendages
Hormonal stimulation
Insidious onset, acute presentation
Localized tenderness
Blue dot sign
Cremastric reflex should be present
Radionuclide scan or color doppler (normal or
increased flow)

12. Treatment
When the diagnosis of a torsed appendage is confirmed clinically or by imaging, non operative management is suggested
NSAIDs

13. Acute idiopathic scrotal edema
Self-limited, unknown cause
Not associated with scrotal erythema
Minimal tenderness
Pruritus
Idiopath, allergic or chemical dermatitis, insect bites, trauma
U. S, color doppler

14. Perinatal Torsion of the Spermatic Cord
prenatally
Immediate postnatally

15. Prenatal torsion
Hard, non tender testis, fixed to the overlying scrotal skin at delivery
Discolored skin by underlying hemorrhagic necrosis
Extravaginal torsion
Blind-ending spermatic cord (vanishing testis)
Hard, non tender and fired to skin at birth don not merit surgical exploration, contralateral scrotal exploration has not been recommended

16. Postnatal torsion swelling, tenderness of the scrotum
Extravaginal torsion, intravaginal torsion
Prompt exploration
Exploration of contralateral testis (17% bell clapper deformity)

17. Epididymitis Acute: pain, swelling and inflammation less than 6 wk
Chronic
Abscess, infraction, chronic pain, infertility

18. Etiology
Sterile urine refluxing into the vas while the Pt strained against a closed external urethral sphincter (10%)
STD organsm-N.gonorrhoeae, C.trachomatis (<35yr)
Bacteriuria (>35yr)
Homosexual; coliforms, H.influenzae
Older men, pediatrics: bacteriuria
Cryptorcoccus, brucellu, T. B
Amiodarone

19. Diagnosis Swelling begin in the tail of the epididymis
Indolent process
50% of men with G. C epididymitis did not have a urethral dischange
Past H/O UTI, urethritis, urethral dischange,sexual activity, urethral cath, urinary tract surgery

20. Diagnosis The cremastric reflex should be present
Pyuria, bacteriuiria or positive urine culture
Urine culture may be sterile in 40% to 90% of pediatria
Normal U/A dose not rule out epididymitis
Most boy with a clinical diagnosis of epididymitis have sterile urine

21. Diagnosis
Color Doppler sonography
Radionuclide imaging

22. Radiographic imaging
Sterile urine: U. S
Positive culture: U. S, VCUG

23. Treatment Bed rest for 1-3 day Scrotal elevation NSAIDs
STD related: ceftriaxone 250 mg IM + TCN 500mg
Doxycycline 100 mg
- Bacteriuria: (Levofloxacin or ofloxacin or systemic AB for days)
For days