• Information
  1. Differential Diagnosis
  2. Testicular Torsion
  3. Fournier's Gangrene
  4. Other Causes of Scrotal Pain

A. Differential Diagnosis

1. Torsion of Testicles or Testicular Appendages
2. Epididymitis
3. Orchitis
4. Hydrocoele
5. Trauma
6. Acute Hernia
7. Fournier's Gangrene

B. Testicular Torsion

1. 1:4000 males, usually age 9 to 15
2. Usually due to maldevelopment of normal layers of scrotum
3. Mechanism
   1. Occurs during forced contraction of cremaster muscle
   2. Leads to obstruction of venous return leading to edema, congestion, and pain
   3. Infarction and testicular necrosis may follow if not relieved
4. Diagnosis
   1. Tender, swollen, firm, painful hemiscrotum
   2. Prehn's Sign - relief of pain with elevation of testes (also in epidymitis)
   3. Usually no transillumination (unless hydrocoele also present)
   4. Should be able to palpate the testes
   5. Technitium testicular scan - decreased uptake in torsion, increased in epididymitis
   6. Ultrasound - size of structures, rule out abscess, hematocele, hydrocele, masses
5. Treatment
   1. Surgical restoration of vascular supply is critical
   2. Spermatogenesis usually lost within 5-6 hours of vascular compromise
   3. Leydig cell necrosis in 10 hours
   4. Necrotic testicles must be removed

C. Fournier's Gangrene [1,2]

1. Abrupt onset of progressive genitourinary gangrene with men mean age 51 years old
2. Focus is usually invasive infection of lower GU tract, anorectal region, genital skin
3. Presentation typically delayed (average ~5 days post onset of fever)
4. Symptoms
   1. Often toxic appearing patients (shock in ~40% of patients)
   2. Scrotal Pain and Erythema 100%
   3. Leukocytosis 100%
   4. Scrotal Edema 86%
   5. Fever 72%
   6. Scrotal Crepitus 62% (pathognomonic)
   7. Glycosuria 47%
   8. Perineal skin necrosis 46%
5. Infections usually mixed G- enteric aerobes and anaerobes
   1. Ticarcillin-Clavulonate (Timentin®) or Piperacillin-Sulbactam (Zosyn®)
   2. Aminoglycoside (usually single dose) may be added if toxic appearing
   3. Triple therapy: Vancomycin + Aminoglycoside or Cephalosporin + Metronidazole
   4. Therapy must cover Bacteroides fragilis and Clostridia ssp .
6. Aggressive surgical therapy with broad spectrum antibiotics required (orchiectomy ~10%)

D. Other Causes of Scrotal Pain

1. Trauma
   1. Blunt or pendetrating to scrotum with impingement on symphysis pubis
   2. Testicular examination: large, tender, blue scrotal mass (rupture)
   3. Ultrasound of little benefit to distinguish contusion from rupture
2. Hernia
   1. Acute bowel herniation into scrotum is rare
   2. Pain, when it occurs, usually due to compression of structures feeding testicle
   3. Bowel sounds may be heard in hernia area
   4. Reduction of hernia is required
3. Hydrocele
   1. Fluid collection within tunica vaginalis (infection vs. congenital)
   2. Painful when associated with infection
   3. Normal testes should be palpable
   4. Transillumination should be possible
   5. Surgical drainage or repair may be indictated
4. Tumor
   1. Overall fairly rare (~2:100,000 men)
   2. Most are malignant
   3. Distinguish between seminiferous vs. non-seminiferous
5. Orchitis
   1. In younger men, viral cause is most common
   2. Pyodermic orchitis is usually secondary to epidymitis

References

1. Paty R and Smith AD. 1992. Urol Clin N Amer. 19(1):149
2. Anzai AK. 1995. Am Fam Phys. 52(6):1821