SCROTAL SWELLING AND PAIN IN CHILDREN

Presented by Dr munir suwalem S.H.O Peadiatric surgery

B.M.C Benghazi - libya

The Scrotum is a cutaneous pouch which contains the testes and parts of the spermatic cords. It is divided on its surface into two lateral portions by a ridge or raphé,

which is continued forward to the under surface of the penis, and backward, along the middle line of the perineum to the anus

the scrotum consists of two layers ,the outer layer is integument and the inner layer is  dartos tunic, which divides the scrotal pouch into two cavities for the testes,

Vessels and Nerves.— The arteries supplying the coverings of the

testes are: the superficial and deep external pudendal branches of the femoral, the superficial perineal branch of the internal pudendal, and the cremasteric branch from the inferior epigastric. The veins  follow the course of the corresponding arteries.

The lymphatics  end in the inguinal lymph glands.

The nerves are the ilioinguinal and lumboinguinal branches of the lumbar plexus, the two superficial perineal branches of the internal pudendal nerve, and the pudendal branch of the posterior femoral cutaneous nerve.

The function of the scrotum appears to be to keep the temperature of the testes slightly lower than that of the rest of the body.

the temperature should be one or two degrees Celsius below body temperature (around 37 degrees Celsius or 99 degrees Fahrenheit);

higher temperatures may be damaging to sperm count.

CLASSIFICATIONscrotal swelling is usually classified as:

Painful or painless

Acute or chronic

Acute scrotal swelling with pain

Torsion of spermatic cord Torsion of appendix testis Acute epididymitis-orchitis Trauma Insect bite Thrombosis of spermatic vein Fat necrosis inguinal Hernia(incarcerated) Folliculitis Henoch-Schönlein purpura

Scrotal swelling without pain

Tumor Idiopathic scrotal edema Hydrocele Inguinal Hernia Henoch-Schönlein purpura

Chronic scrotal swelling

Hydrocele Inguinal Hernia Varicocele Spermatocele Sebaceous cyst Tumor

EPIDEMIOLOGYPrevalence

Inguinal hernias and hydroceles are the most common causes of scrotal swelling.

Testicular torsion occurs in 1:4000 boys.

Varicoceles are present in 15% of male adolescents and adults.

EPIDEMIOLOGYAge Hernias can occur at any age but are more

common in premature infants. Testicular torsion most commonly occurs

between the ages of 12 and 18 years. Idiopathic scrotal edema affects children < 14

years. Acute inflammation of the epididymis or testis,

including mumps orchitis, can occur at any age but is uncommon before adolescence.

Varicoceles are usually asymptomatic and are usually detected between 10 and 15 years of age.

MECHANISMAcute scrotal swelling with pain Torsion of the testicle

Twisting of the spermatic cord, with resulting compromise of the blood supply to the testis

Torsion of the appendix testisWhen the appendix testis torses,

inflammation and swelling of the testis and epididymis ensue, causing testicular pain and scrotal erythema.

MECHANISM Acute epididymitis-orchitis usually after

UTI Results from an anomaly of the urinary tract, either congenital or acquired:

Renal duplications and posterior urethral valves are among the more common anomalies.

With intermittent catheterization, the condition can occur from retrograde passage of bacteria back from ejaculatory ducts at the level of the prostate to the testis and epididymis.

MECHANISM Henoch-Schönlein purpura

Systemic vasculitis that can cause abdominal and joint pain , May involve the scrotal wall in a minority of cases

Trauma A similar appearance can follow a difficult

breech deliverySevere blunt trauma affecting the scrotal

contents Scrotal skin disease

Insect bites, folliculitis, and allergic dermatitis may cause erythema and edema of the scrotal wall.

MECHANISMScrotal swelling without pain Hernias and hydroceles

Most are caused by persistent patency of the processus vaginalis

Layers of the processus vaginalis condense late in gestation or early postnatally.

Obliteration of the processus vaginalis only around the testis leads to an indirect inguinal hernia with protrusion of fluid (or other contents) through the internal ring to the end of the pouch and potentially to the scrotum.

MECHANISM

Communicating hydrocele occurs when fluid travels through a processus vaginalis into the tunica vaginalis around the testis.

Scrotal hydrocele occurs after complete obliteration proximally with patency distally.

Hydroceles of the cord occur when the processus vaginalis obliterates proximally and distally, leaving a patent area in the midportion with retained fluid.

MECHANISM Varicoceles

A predilection for the left side exists, reflecting anatomy of the left gonadal vein entering the left renal vein at a right angle.

The right gonadal vein enters the vena cava directly at an angle, precluding reflux of venous blood.

HISTORYAcute scrotal swelling with pain Torsion of the testicle

Acute onset of constant, severe scrotal pain aggravated by physical activity

Nausea and vomiting may occur.Possible history of incidental antecedent

scrotal trauma, but pain usually occurs during rest or sleep

Neonatal testicular torsion Can exhibit at delivery as a nontender hard scrotal mass

HISTORY Torsion of the appendix testis

Onset of pain and swelling is commonly acute but can be progressive, usually occurring during rest.

Pain can be severe, but nausea and vomiting are less common than with testicular torsion.

Acute epididymitis-orchitisHistory can reveal acute or more protracted

onset of pain.The patient may have fever or dysuria or

pyuriaEpididymal inflammation may arise after

scrotal trauma.

HISTORY

Henoch-Schönlein purpuraOnset may be insidious or acute,

producing a variable degree of erythema and edema.

In more severe cases, the process may involve the testis and epididymis, mimicking testicular torsion.

Focal fat necrosisCan exhibit with scrotal pain and

swelling, usually after trauma in an obese boy

HISTORY

TraumaHistory (eg, injury from zipper entrapment

of scrotal skin) can be definitive.

Mumps orchitisRarely occurs in isolation; pain and swelling

usually occur within a week after parotitis.

Scrotal skin diseaseHistory may be of limited utility.

HISTORYScrotal swelling without pain Inguinal hernias and hydroceles

HerniaSwelling expands with increases in intraabdominal pressure (eg, crying, bowel movements, coughing).

The parent or child often reports the swelling to be smallest in the morning and largest late in the day.

HISTORY Hydrocele Whether the hydrocele is acute

or whether the scrotum has been chronically enlarged is often unclear.

The patient may have a history of trauma to the scrotum that stimulates production of serous fluid.

When the scrotum changes size during the day, suspect a communicating hydrocele.

HISTORY Tumors

Usually present as a hard, painless mass (or vague heavy feeling) in the testicle detected by the child, parent, or examining physician

Spermatoceles and epididymal cystsPainless and round, they usually remain stable

in size but can sometimes enlarge.

PHYSICAL EXAMAcute scrotal swelling with pain Torsion of the testicle

Scrotal erythemaSwelling of the involved hemiscrotumHigher-than-normal position of the testis within the

scrotumPalpation may show a horizontal rather than normal

vertical orientation of the testicle.Evaluation of the cremasteric reflex should begin on

the contralateral side; palpate the apparently unaffected testis to confirm normal size and position.Unilateral loss of the cremasteric reflex on the side of the swelling and pain highly correlates with the presence of torsion.

PHYSICAL EXAM The testis should then be palpated.

Despite the pain this maneuver may cause, it helps differentiate torsion from epididymitis.

Actual point of torsion of the spermatic cord can sometimes be palpated.

Associated hydrocele may be palpated and confirmed by transillumination.

PHYSICAL EXAM torsion of the appendix testis May demonstrate

hemiscrotal erythema and swelling A blue-dot sign, if the necrotic appendage

visible through the scrotal skin, can help make the diagnosis.

A normal cremasteric reflex is present bilaterally, and the testis is normally positioned within the scrotum.

Testicular discomfort, if present, is typically mild, but point tenderness may be elicited from uppermost pole of the testis near the head of the epididymis.

PHYSICAL EXAM Acute epididymitis-orchitis Scrotal

erythema and swelling are present, along with an intact cremasteric reflex.

Palpation during early phase of the inflammatory process demonstrates tenderness limited to the epididymis.

In the later phase, tenderness and inflammation include both epididymis and testis, and the distinction between the 2 structures may be difficult to appreciate.

The Prehn sign (relief of pain with testicular elevation) may be positive.

PHYSICAL EXAM Trauma

Examination must include both hemiscrotums and surrounding structures (penis, perineum), assessing for swelling, ecchymosis, and bleeding.

Tenderness may be limited to testis or epididymis, depending on extent of trauma.

Mumps orchitisTender testis

Scrotal skin diseaseRedness and edema limited to scrotum, with

normal testicle and spermatic cord

PHYSICAL EXAMScrotal swelling without pain Inguinal hernias and hydroceles

Feel for the testis first and keep it in mind during the rest of the examination.

Avoid confusing testis with contents of an incarcerated hernia.

PHYSICAL EXAMHernia

A bulge in the inguinal region with fluid that can be gently reduced back into the abdomen is diagnostic of an inguinal hernia.

In the cooperative child who can increase his intraabdominal pressure, this procedure may be repeatedly shown, particularly with the child standing.

Presence of thickened spermatic cord or silk-stocking sign (the feel of the layers of the processus vaginalis being rubbed against each other) suggests patency of the processus vaginalis or a hernia.

PHYSICAL EXAM Hydrocele When fluid is limited to the

testis and spermatic cord can be palpated above the fluid, a hydrocele is present.

Hydrocele of the spermatic cord feels distinct from the testis and is round or ovoid, possibly mimicking the presence of an additional testis.

Hydroceles (communicating, scrotal, or of the cord) are rarely associated with tenderness on palpation

PHYSICAL EXAM

TumorsOn palpation, mass is harder than the

substance of the testis, but this distinction may be difficult to discern.

Mass may bulge from surface of the testis.

Spermatoceles and epididymal cystsSeparate from the testis and can be

transilluminated

Diagnosis

Suggestive features on history

Suggestive features on examination

Torsion of the testis

Sudden onset testicular pain and

swelling; occasionally nausea, vomiting.

Note: pain may be in the iliac fossa

Discolouration of scrotum; exquisitely

tender testis, riding high

Torsion of

(hydatid of

Morgagni)

More gradual onset of testicular pain

Focal tenderness at upper pole of testis;

"blue dot" sign – necrotic appendix seen through

scrotal skin

Epididymoorchitis

Onset may be insidious; fever,

vomiting, urinary symptoms; rare in pre-pubertal boys, unless underlying

genitourinary anomaly, when

associated with UTI.

Red, tender, swollen hemiscrotum;

tenderness most marked posteriolateral to testis. Pyuria may be present.

Incarcerated

inguinal hernia

History of intermittent

inguinoscrotal bulge, with associated irritability

Firm, tender, irreducible,

inguinoscrotal swelling

Idiopathic scrotal oedema

Swelling noted but child not distressed

Bland violaceous oedema of

scrotum, extending into perineum + penis; testes not

tenderHydrocel

eSwollen

hemiscrotum in well, settled baby

Soft, non-tender swelling adjacent

to testis; transilluminates

brightly.

Henoch Schonlein

purpura

Painful scrotal oedema, with

purpuric rash over scrotum. May have

associated vasculitic rash of buttocks and

lower limbs, arthritis, abdominal

pain with GI bleeding, and

nephritis

may be difficult to distinguish from

testicular torsion in absence of other

features

Testicular or

epididymis rupture

Scrotal trauma eg. straddle injury,

bicycle handlebars, sports injury.

Delayed onset of scrotal pain and

swelling.

Tender swollen testis. Bruising, oedema,

haematoma, or haematocele may be

present.

LABORATORY EVALUATION

Urinalysis may help distinguish orchitis from torsion of the spermatic cord or testicular appendage when leukocytes or nitrites are present.

Acute scrotal swelling with painTorsion of the testicle

Urinalysis is unremarkable.Although the leukocytes count may be mildly elevated, it is not discriminating.

LABORATORY EVALUATIONAcute epididymitis-orchitis

Urinalysis may prove positive for leukocytes and nitrite but is often unremarkable among adolescents.

The leukocyte count is usually elevated

LABORATORY EVALUATIONScrotal swelling without pain Inguinal hernias and hydroceles

Laboratory tests are useful only for incarcerated inguinal hernias, with an elevated leukocyte count and possible acidosis.

TumorsPreoperative tumor markers (α-

fetoprotein, β-human chorionic gonadotropin) should be measured and used for postoperative monitoring.

IMAGINGAcute scrotal swelling with pain

Torsion of the testicleImaging by Doppler ultrasonography

or nuclear scintigraphy should be done if the diagnosis of testicular torsion is in question.

Perform imaging only when it will not delay surgical exploration if torsion exists, adding to the risk of testicular loss.

IMAGING Torsion of the appendix testis

If an inflammatory process resulting from torsion of the appendage makes differentiation from true spermatic cord torsion impossible, imaging may be helpful.

Scrotal Doppler ultrasonography or nuclear scintigraphy will show normal or increased flow to ipsilateral testis.

IMAGING Acute epididymitis-orchitis Ultrasonography and nuclear

scintigraphy show normal symmetric blood flow or increased blood flow to an enlarged epididymis or testis.

Voiding cystourethrography has been a routine part of the evaluation, but its yield is low with a normal ultrasound and a sterile urine.

IMAGING

TraumaScrotal ultrasonography can document

the integrity of the testis and of the tunica albuginea and the adequacy of blood flow.

IMAGINGScrotal swelling without pain Ultrasonography can determine cystic

or solid nature of a tense scrotal mass (eg, hydrocele, tumor) or spermaticoInguinal hernias and hydrocelesUltrasonography can delineate

scrotal contents, especially when a large or tense hydrocele limits physical examination of mass (eg, hydrocele of the cord, paratesticular tumor).

IMAGING Tumors

Scrotal ultrasonography is used to delineate the mass.

VaricocelesTesticular size, most accurately

assessed by ultrasonography, should be measured; significant loss of testicular volume is an indication for surgery.

TREATMENTAcute scrotal swelling with pain

Torsion of the testicleSurgical intervention is indicated not

only when testicular torsion is strongly suspected, but also in equivocal cases when torsion cannot be convincingly excluded.

The likelihood of salvaging the testis is highest when surgery is done shortly after onset of pain.

TREATMENTWith surgery, first explore the affected

testis, and, when torsion is present, detorse the cord.

Explore the contralateral testis (will have the same defect in anatomy) and fix it in place to avert a future torsion.

If the testis can be saved, fix it in the scrotum.

TREATMENT Torsion of appendix testis Management

is nonsurgical. The patient should rest and use

nonsteroidal pain relievers and cold compresses for several days to reduce inflammation, swelling, and pain.

Surgical intervention is indicated only when acute testicular torsion cannot be excluded.In these cases, the infarcted

appendage is removed at surgical exploration.

TREATMENT Acute epididymitis-orchitis Treat with

antibiotics based on the results of the urine culture and sensitivities.

Anti inflammatory agents, scrotal elevation, and rest should be prescribed.

TREATMENT Trauma

Testicular or spermatic cord contusions: Manage symptomatically.

Testicular rupture requires surgical exploration, evacuation of the hematoma, debridement, and repair (when possible).

Mumps orchitisTreatment is symptomatic.

TREATMENTScrotal swelling without pain Inguinal hernias and hydroceles

Repair on diagnosis to prevent incarceration , Perform surgery inguinally; isolate the sac from the cord structures and ligate it at the level of the internal ring.

Inspect the contralateral ring using diagnostic laparoscopy through the isolated ipsilateral sac.If the internal ring is open, proceed with contralateral surgical correction.

If the hydrocele is painful, then surgery should proceed sooner.

TREATMENT Tumors Perform radical orchidectomy

through an inguinal approach. If the mass is not suspicious for cancer, a

possible approach is to enucleate the mass and proceed with orchidectomy only if the frozen section is positive.

Spermatoceles and epididymal cysts Management typically is observation.

Surgery may be indicated when pain or significant enlargement is present.

PROGNOSISAcute scrotal swelling with pain Torsion of the testicle

Spermatogenesis may be compromised after 4–6 hours of ischemia.

Testicular salvage is time dependent, with universal loss of the testis after 24 hours of torsion.

Neonatal testicular torsionNeonatal testicular torsion can exhibit at delivery

as a nontender hard scrotal mass.Salvage in these cases is rare.

.

PROGNOSIS

Mumps orchitisInfertility may occur when the condition

results in atrophy of both testicles.Scrotal swelling without pain hydroceles

Most hydroceles resolve spontaneously by 1 year and should be repaired if they persist beyond this age.

Thank you for attention