Acute scrotum, acute swelling or pain of the scrotum and/or testis - Pediatric Surgery

Acute scrotum, acute swelling or pain of the scrotum and/or testis - Pediatric Surgery Acute Scrotum, Acute Swelling or Pain of the Scrotum and/or Testis . Torsion of the Testis. click the images for more details   Incidence.  The torsion of the testis may occur at any age in childhood. It is relatively frequent perinatally and during puberty. The torsion of the testis belongs together with the epididymitis and torsion of the testicular appendages to the main causes of an acute scrotum. Clinical significance. 1. A delayed diagnosis and treatment can lead to an irreversible damage to the testis and to a later loss of fertility. 2. Behind every scrotal swelling a torsion of the testis may be hidden.  Etiology.  In 85 percent there is an intravaginal torsion, in which twisting is promoted by high investment of the cord by the tunica vaginalis. This variation is bilateral.   Pathology, anatomical types.Illustrations In contrast to the intravaginal torsion of the testicle where the torsion occurs within the tunica vaginalis, in the extravaginal torsion the entire spermatic cord is twisting above the upper end of the tunica vaginalis. The latter is observed mainly details Pathophysiology . Illustrations The degree and sequels of ischemia depend on the duration of torsion and the degree of torsion in the clockwise or counterclockwise direction. In addition some pre-existing histological changes may be observed similar to those in cryptorchidism. show details Clinical Presentation (history, findings, clinical skills) . Illustrations History: Spontaneously or following sport sudden onset or less frequently gradual increase of severe pain in the scrotum and in the groin and the lower abdomen occurs associated with nausea and vomiting. Local findings: Depending on the stage of the disease at consultation. In early stage the testicle is in the scrotum visible and lies in a high and horizontal position and is very painful on palpation; the cremasteric reflex is absent. In late stage these findings are increasing hidden by redness and swelling due to an involvement of the skin; but the testicle remains painful and the cremasteric reflex absent. show details Natural history.  Without treatment loss of the testicle of the involved side, and total loss of fertility because torsion may occur sooner or later on the other side, too. On the other hand slight types of torsion with spontaneous reduction may occur. They can lead to recurrent pains in the scrotum and the groin and to false-negative ultrasound findings.  Differential diagnosis.Illustration Figure The differential diagnosis includes lesions leading to an acute scrotum, an abdominal emergency, or recurrent pains in the scrotum or in the details Work-up examinations. Illustrations In case of a reliable clinical diagnosis or an urgent suspicion of testicular torsion additional examinations are not necessary. A Doppler ultrasound performed by an experienced pediatric radiologist is indicated if another cause of acute scrotum is more probable than a testicular torsion due to the history or the local details Therapy.Illustrations Immediate revision, untwisting of the torsion, and fixation of the testicle to avoid further torsion, the latter is performed also on the opposite side. Excision of the testicle only in case of proofed necrosis. At the end of growth an testicular implant may be necessary for psychological reasons. show details Prognosis.  Following a torsion of more than 24 hours and of 360 degree and more, total loss of the testicle in more than 50 percent.