Medical Student Curriculum: Acute

Scrotum
This document was amended in November 2022 to reflect literature that
was released since the original publication of this content in May 2012.
This document will continue to be periodically updated to reflect the
growing body of literature related to this topic.

Keywords: Testis, epididymis, torsion, epididymitis, ischemia, tumor,

infection, hernia

Learning Objectives

At the end of medical school, the student should be able to:

1. Describe 6 conditions that may produce acute scrotal pain or

2. Distinguish, through the history, physical examination and
laboratory testing, testicular torsion, torsion of testicular
appendices, epididymitis/orchitis, testicular tumor, scrotal trauma
and
3. Appropriately order imaging studies to further refine the diagnosis
of the acute scrotum.
4. Determine which acute scrotal conditions require emergent surgery
and which may be handled less emergently or electively.

Introduction

The "acute scrotum" may be viewed as the urologist's equivalent to the

general surgeon's "acute abdomen." Both conditions are guided by similar
management principles:

 The patient history and physical examination are key to the

diagnosis and often guide decision making regarding whether or not
surgical intervention is appropriate.
 Imaging studies should complement, but not replace, sound clinical
judgment.
 When making a decision for conservative, non-surgical care, the
provider must balance the potential morbidity of surgical exploration
against the potential cost of missing a surgical diagnosis.
 A small but real, negative exploration rate is acceptable to minimize
the risk of missing a critical surgical diagnosis.
Differential Diagnosis of the Acute Scrotum

A list of potential medical conditions that can present as acute pain or

swelling of the scrotum are found in Table 1.

Table 1. Causes of Acute Scrotal Pain and Swelling

Ischemia:
Torsion of the testis (synonymous with torsion of the spermatic cord)
Intravaginal; extravaginal (prenatal or neonatal)
Appendiceal torsion (of the appendix testis or appendix epididymis)

Testicular infarction due to compressive hydrocele or hernia

Testicular infarction due to other vascular insult (cord injury,thrombosis)
Trauma:
Testicular rupture
Intratesticular hematoma, testicular contusion HematoceleInfectious conditions:
Acute epididymitis Acute epididymo-orchitis
Acute orchitis
Abscess (intratesticular, paratesticular, scrotal skin, cutaneous cysts)
Gangrenous infections (Fournier’s gangrene)
Infectious conditions:
Acute epididym itis
Acute epididym oorchit is
Acute or chitis
Abscess (intratesticular, intravaginal, scrotal skin, cutaneous cysts)
Gangrenous infections (Fournier's gangrene)
Inflammatory conditions:
Henoch-Schonlein purpura (HSP) vasculitis of scrotal wall
Fat necrosis, scrotal wall
Hernia:
Simple, or incarcerated, strangulated inguinal hernia, with or without associated testicular
ischemia
Acute on chronic events:
Spermatocele, rupture, hemorrhage or infection
Hydrocele, rupture, hemorrhage or infection
Testicular tumor with rupture, hemorrhage, infarction or infection Varicocele
Torsion

TESTICULAR TORSION
Figure 1. Bell clapper deformity. Normal testis lie is on the left and the
classic "bell clapper" lie is in the middle. The right side shows the bell
clapper variation.

The testicle is typically covered by the tunica vaginalis, creating a

potential space around the testis. Torsion can occur from within the tunica
vaginalis (intravaginal) or about the entire spermatic cord (extravaginal).
Normally, the tunica vaginalis attaches to the posterior surface of the
testicle and allows for very little mobility of the testicle within the scrotum.
Some patients have an inappropriately high attachment of the tunica
vaginalis, such that the testicle can rotate freely on the spermatic cord
within the tunica vaginalis (intravaginal testicular torsion) (Figure 1). This
congenital anomaly, called the “bell clapper deformity,” results in a
transverse as opposed to longitudinal lie of the affected testis; it can be
unilateral or (more commonly) bilateral and is a risk factor for a torsion
event. This congenital abnormality is present in approximately 12% of
human males.

Experimental evidence indicates that a 720° twist is generally required to

compromise flow through the testicular artery and result in ischemia,
however the degree of twist is different in each clinical
presentation. During testis torsion, the testicle twists spontaneously on
the spermatic cord, causing venous occlusion and engorgement, with
subsequent arterial ischemia and infarction.

In neonates, the testicle frequently has not yet descended into the
scrotum, after which it becomes attached within the tunica vaginalis. This
increased mobility of the testicle predisposes it to extravaginal (entire
cord) testicular torsion.

Testis torsion is the most common cause of testis loss in the US. The
incidence in males <25 years old is approximately 1:4000. Torsion more
often involves the left testicle. Among neonatal testicular torsion cases,
70% occur prenatally and 30% occur postnatally. The testis salvage rate
approaches 100% in patients who undergo detorsion within 6 hours of the
start of pain. However there is only a 20% viability rate if torsion persists
>12 hours; and virtually no viability if torsion persists >24 hours (Figure
2).

Figure 2. Testis histology during early (A) hemorrhagic phase and

chronic late (B) phases of testis torsion. Note the decreased seminiferous
tubule diameter and loss of germ cells in late relative to early phases.

Testicular torsion presents with the rapid onset of severe testicular pain
and swelling (Figure 3). Patients may also have abdominal pain, nausea,
or vomiting. The onset of pain may be preceded by trauma, physical
activity, or no activity (e.g. during sleep). It most often occurs in children
or adolescents, but this diagnosis should be considered in evaluating men
with scrotal pain of any age, as it may occasionally occur in men 40-50
years old. In this older age group, the diagnosis is often delayed or
missed due to a low suspicion because of age. Torsion should be in the
differential diagnosis for any sudden acute scrotal pain or swelling.

The classic physical examination findings with testis torsion are an

exquisitely tender testicle with a high, horizontal lie. Normally the testicle
has a vertical lie within the tunica vaginalis of the scrotum – that is, the
longitudinal axis of the testis is oriented vertically. With torsion and
twisting of the spermatic cord, the testis may assume an altered lie based
on the degree of twisting. After venous outflow is occluded, there is
swelling and occlusion of arterial flow. Early on, one may be able to
palpate the torsed cord and the testis below it; later in the course,
however, progressive edema and inflammation ensues, such that after
12-24 hours, the entire hemiscrotum appears as a confluent mass without
identifiable landmarks. At this stage, the physical examination may be
indistinguishable from that seen with epididymoorchitis. Importantly, with
torsion, signs of infection are usually absent: patients are usually afebrile,
free of irritative voiding symptoms such as dysuria, and have a normal
urinalysis and normal white blood cell count (WBC). (In later torsion,
however, an elevated WBC may be seen in response to the
inflammation.) Torsion of an undescended testicle will present differently
than that of a descended testicle. For example, it may mimic the
presentation of inguinal hernias or an acute abdomen, and physical
examination findings may be less pronounced, such as a lack of scrotal
swelling.

Figure 3. Example of acute scrotum highlighting hallmark signs of

testicular torsion, including color change and swelling (from Al-Salem AH:
Acute Scrotum. In: Atlas of Pediatric Surgery. Springer, Cham. (2020)).

With a high degree of suspicion, one may reasonably recommend

surgical exploration without delay. When the diagnosis is less clear,
the Testicular Workup for Ischemia and Suspected Torsion
(TWIST) score is a useful clinical decision tool used to characterize
torsion risk based on history and physical exam (Table 2). Some
clinicians, especially those who are not urologists, may not possess
extensive knowledge of the TWIST score, and so interdisciplinary
collaboration may offer an opportunity to increase utilization of this
predictive tool.

CRITERIA

 Testicular swelling (two points)

 Hard testis (two points)
  Absent cremasteric reflex (one point)
 Nausea or vomiting (one point)
 High riding testis (one point)

INTERPRETATION

 Score 0-2: Low risk

 100% negative predictive valuefor torsion

 Generally, no ultrasound or urological consultation required

 Score 3-4: Intermediate risk

 Ultrasound warranted

 Score 5 or above: high risk

 100% positive predictive valuefor torsion

Ultrasound not required, urgent urological consultation and surgery

required for testis salvage

Patients with intermediate risk TWIST scores should undergo scrotal

ultrasonography, if readily available, as this test is the single most useful
adjunct to the history and physical examination in the diagnosis of
torsion. The ultrasonographer should use Doppler flow to assess arterial
flow within (not simply around) the affected testis; if arterial flow is absent,
or decreased relative to the contralateral testis, then torsion is highly
likely. It is helpful to compare the flow patterns between both testes to
help make this diagnosis. Ultrasonography may also exclude significant
testicular trauma, show a hernia extending into the scrotum, and can
distinguish epididymitis from torsion by demonstrating increased flow to
the epididymis and adnexal structures along with preserved testicular
perfusion. Evaluation of intratesticular flow should include a comparison
of the contralateral testis, as well as the ipsilateral epididymis.
Sonographic findings should be considered within clinical context. For
example, a perceived increase in epididymal blood flow may be due to
decreased intratesticular blood flow. Similarly, a “complex mass” superior
to the testis might represent an inflamed epididymis or a torsed appendix
epididymis or appendix testis. The torsed cord with edema and
inflammation is difficult to distinguish from an inflamed epididymis in
torsion. Remember, testicular perfusion is the key to the ultrasound
diagnosis of torsion, and so should be considered by itself as well as
relative to adjacent structures. Bilateral testicular torsion, though rare, has
been reported. Tests such as nuclear testicular scans, CT or MRI, have
essentially no role in the contemporary management of acute testicular
processes.

When torsion is diagnosed, urgent surgical exploration and detorsion is

mandated, as testicular torsion is a true vascular emergency. Testicular
preservation is excellent when corrected within 4-6 hours of onset.
Beyond 12 hours, the risk of subsequent testis atrophy is significant with
detorsion. Testis salvage is often still appropriate if the testicular
appearance at exploration improves with observation following detorsion,
manually or otherwise. Manual detorsion is typically performed via the
“opening the book” maneuver, as most testes torse toward the septum of
the scrotum, however this should be considered an adjunct to definitive
treatment. In the acute setting (<24 hours of symptom onset), detorsion
should be attempted at the presenting institution when technically
feasible, as in some studies, salvage rates are lower for patients who are
transferred to another hospital.

During surgical exploration, the scrotum is entered and the affected

testicle delivered, then the tunica vaginalis is opened. The testis is
manually detorsed and wrapped in a warm, moist gauze. In patients with
torsion, it is assumed the bell-clapper deformity is bilateral, and thus the
contralateral testis is delivered, confirmed to be in proper orientation,
and then orchidopexy with permanent suture is performed to
prevent torsion on that side. The affected testis is reinspected for signs of
improved perfusion (“pinking up”) (Figure 4). If the testis appears viable,
then orchiopexy is performed by anchoring the tunica albuginea of the
testis to the overlying parietal tunica vaginalis and scrotal dartos muscle
with permanent suture.
Figure 4. Exploration of torsed testis. Note dark, cyanotic color of testis
following 30 minutes of detorsion suggesting nonviability.

In general, scrotal exploration is a procedure of low morbidity. A negative

exploration seldom results in long term complications. When weighing
conservative treatment with the loss of a potentially salvageable testis, it
is best to err on the side of exploration. In cases of "late torsion" or
"established torsion," exploration generally reveals a hemorrhagic, frankly
necrotic testis for which orchiectomy should be performed.

"Intermittent" testicular torsion is a well recognized entity in which a

classic torsion history is obtained, but physical examination and
ultrasound findings are normal. In such cases, it is reasonable to offer an
elective bilateral scrotal orchiopexy for the possibility of intermittent
symptoms becoming full fledged torsion.

TORSION OF TESTICULAR OR EPIDIDYMAL APPENDAGES

Figure 5. Illustration of the common appendices of the testis and

epididymis. The appendix testis is most commonly affected by torsion.

Small polypoid appendages are often found attached to the testis or

epididymis and are either Mullerian (appendix testis) or
Wolffian (appendix epididymis) duct remnants (Figure 5). Similar to testis
torsion, torsion of the appendix testis or appendix epididymis can also
present with the acute onset of scrotal pain and mass. In most cases,
however, the testis is palpable and has a normal lie, and systemic
symptoms like nausea and vomiting are less common. If encountered
early, the edematous, torsed appendage can often be palpated at the
upper pole of the testis. If the torsed appendage is ecchymotic, it can
usually be seen through the skin and represents the "blue-dot sign." Later
in its course, it can be more difficult to distinguish this entity from
testicular torsion or epididymitis, as global enlargement and edema of the
scrotal compartment may occur. Ultrasound is valuable in these cases to
identify normal blood flow to the testis.

Doppler ultrasound will demonstrate a normally perfused testis, often with

hypervascularity in the area of the appendage, which can be erroneously
attributed to epididymitis. This process is often self-limited, with the
infarcted appendage undergoing atrophy with time, but can occasionally
be intermittent. In general, pain control with over-the-counter pain
medications (e.g., NSAIDs) is sufficient.

Surgical exploration is generally not warranted, but if an exploration is

pursued, the appendage is simply excised and no orchidopexy is needed.

Trauma

PENETRATING AND BLUNT TESTICULAR INJURY

Testicular rupture results when there is laceration of the tunica albuginea

of the testis, such that testicular parenchyma may extrude. It may occur
from either blunt or penetrating trauma. As a general principle,
penetrating injuries to the scrotum should be surgically explored as
the risk of testicular injury is quite high with these injuries and the role of
ultrasound in the diagnosis of testicular rupture in this setting is limited.
Even penetrating injuries with a tangential trajectory have a high
likelihood of injuring the testis or cord structures. In cases of blunt
trauma, however, the incidence of testicular rupture varies widely, and
depends on the forces exerted, the mechanism of injury, and testis
mobility. Following blunt injury, the physical examination findings may
include swelling, tenderness or ecchymosis. If one can clearly palpate the
testis and it is entirely normal to palpation, rupture is unlikely. If there is
significant scrotal wall thickening from edema or hematoma, testicular
palpation may be difficult or impossible, and scrotal ultrasonography can
determine the degree of testis injury with a high level of accuracy. In
addition to demonstrating a break in the continuity of the tunica albuginea
or evidence of extruded parenchyma, ultrasound evidence of a marked
loss of internal homogeneity of the testis is highly predictive of testicular
rupture and warrants surgical exploration. Blunt injury may result in
testicular rupture, intratesticular hematoma, testicular contusion (bruising)
or hematocele (blood collection within the tunica vaginalis space). Among
these, only testicular rupture requires surgical repair, though surgical
exploration is indicated for large hematomas or imaging that fails to rule
out rupture. Large or painful hematoceles may benefit from drainage. For
intratesticular hematoma (intact tunica albuginea, localized hematoma
within an otherwise intact testis) or local tenderness (contusion),
observation, rest, cold packs and analgesics are appropriate therapy.

Surgical exploration for trauma is performed through incisions that

anticipate the structures at risk. For penetrating trauma, a vertical incision
may be easily extended into the groin to expose the spermatic cord. For
blunt trauma, a transverse incision over the injured scrotal compartment
is effective. After inspecting and draining the tunica vaginalis space, any
extruded testicular parenchyma is inspected, irrigated and resected or
retained and tunical lacerations repaired. The testicular compartment may
be drained, generally with a small Penrose drain. With trauma, most
testicular injuries are amenable to repair. Orchiectomy is indicated when
there is major injury to the spermatic cord with organ devitalization, and
destruction of parenchyma is so extensive that no significant tissue can
be salvaged.

Infections

EPIDIDYMITIS AND EPIDIDYMOORCHITIS

Although they may be difficult to distinguish on physical examination from

scrotal trauma or testis torsion, it is important to accurately diagnose
epididymitis and orchitis, as their management is entirely nonsurgical.
Epididymitis is usually caused by infections. In men <35 years old with a
history of sexually transmitted infection (STI) exposure, recent sexual
activity, epididymitis is often caused by chlamydial (C. trachomatis) or
gonorrheal (N. gonorrhoeae) infection, and is generally amenable to
treatment with ceftriaxone and doxycycline. In older men and those
with altered lower urinary tract function (e.g., significant benign prostatic
hypertrophy [BPH], a history of UTIs, or urethral stricture
disease), empiric therapy with fluoroquinolones should be considered. In
these patients, gram-negative enteric bacteria related to ascending
urinary infection are much more likely causes. In either case, initial broad-
spectrum antibiotics should be used until culture results direct further
therapy. There are also noninfectious or inflammatory forms of
epididymitis. These are due to the adverse effects of medications, urinary
reflux within the ejaculatory ducts, and sperm and fluid extravasation after
vasectomy. When epididymitis extends into the testis and causes
testicular tenderness and enlargement, it is termed epididymoorchitis.
There are several features in the patient history that may indicate
epididymitis, such as a history of previous sexually transmitted
infections (STI), recent sexual activity, irritative voiding symptoms,
BPH/incomplete emptying of the bladder, or UTI. The very sudden onset
of pain and swelling is more typical of torsion, while a more gradual,
progressive onset pain (often greater than 24 hours) suggests
epididymitis. On physical examination, epididymitis presents with
tenderness posterior and lateral to the testis (the usual location of the
epididymis). Scrotal ultrasound may show an enlarged, hypervascular
epididymis with normal or increased blood flow to the testis, which will
distinguish this condition from torsion or trauma. Abscess formation
within the epididymis or in the peri- epididymal tissues, can also be
detected by ultrasound. The diagnostic challenge occurs when trying to
distinguish advanced epididymoorchitis from late torsion. In both entities,
there is typically a confluent mass in the scrotum with edema and fixation
of the overlying scrotal wall that obliterate normal anatomic landmarks.
Furthermore, advanced epididymoorchitis can result in testicular ischemia
and infarction due to compression of the testicular vasculature from
epididymal inflammation. On ultrasound, this may present in a very
similar manner to testis torsion. In either case, the lack of testis blood flow
on Doppler ultrasound requires surgical exploration which allows these
conditions to be differentiated.

When diagnosed, epididymitis and orchitis are managed conservatively

with antibiotics, anti- inflammatories, analgesics, rest and scrotal
elevation. If abscess formation occurs, surgical drainage and/or
orchiectomy may be necessary.

SCROTAL WALL INFECTIONS

Figure 6. Fournier's gangrene of the scrotum. Note necrotic, black patch

of scrotal skin with large ulceration. (From: Aho T et al. (2006) Fournier's
gangrene. Nat Clin Pract Urol 3: 54–57)
Infectious conditions within the scrotal wall are also classified under the
acute scrotum and include cellulitis and fasciitis (e.g.,
Fournier’s gangrene). Scrotal wall cellulitides and abscess formation are
distinguishable from testicular conditions on physical examination: the
inflamed scrotal all often precludes palpitation, and when the testis can be
palpated, it is usually normal and nontender. Scrotal wall infections may
result from infected sebaceous cysts, folliculitis, or other dermatologic
conditions. Incision and drainage with gauze packing and broad-
spectrum antibiotics are appropriate for these superficial infections.
Fasciitis of scrotum and groin, termed Fournier’s gangrene, involves a
rapidly progressive, life-threatening infection of the genital soft tissues. It
is associated with predisposing issues including urethral perforation and
periurethral abscess and is most often seen in the immunocompromised
or diabetic patient. On physical examination, there can be diffuse
enlargement, thickening and erythema of the scrotal wall, groin and
perineum. There may be necrotic black or ecchymotic patches of genital
skin present (Figure 6). Patients may have altered mental status
that may make assessment of pain difficult, but in general, a patient with
necrotizing fasciitis experiences pain that is disproportionately more
pronounced than the physical examination findings.

The most diagnostic physical exam finding is crepitus, a spongy, cracking

feeling within the skin that indicates gas-producing microorganisms
underneath, that can be felt in the scrotum or perineum. When left
untreated, advancement of the infection along fascial planes will progress
over hours and result in overwhelming bacterial sepsis with an associated
high mortality rate. Therefore, broad-spectrum antibiotics that cover
aerobic and anaerobic organisms, and urgent and aggressive surgical
debridement are required to control the infection. In a clinically stable
patient, CT or MRI may be advantageous to identify a perirectal abscess,
rectal process, or for the tracking of air beneath in deeper tissues and
following fascial planes. At the time of surgical treatment, cystoscopy and
proctoscopy may be performed to exclude urethral and rectal
abnormalities. In patients with atypical presentations, a CT scan
demonstrating subcutaneous air is pathognomonic.

SCROTAL WALL INFLAMMATION

Henoch-Schonlein purpura (HSP) is a vasculitis of scrotal wall that

causes thickening and erythema in the absence of infection (Figure 7).
Idiopathic scrotal edema and filarial infections (rare in the US) can also
cause chronic, relatively painless, scrotal swelling. Lastly, scrotal edema
secondary to hypoalbuminemia, portal hypertension and
lymphadenopathy are also rare but significant conditions associated with
scrotal swelling that may occur under the aegis of the acute scrotum. In
most of these conditions, the history of a slowly progressive disease
process helps differentiate them from more classically acute conditions.
Treatment of the underlying, non-scrotal cause is most effective to relieve
the scrotal symptoms.

Figure 7. Characteristic scrotal erythema in Henoch-Schonlein purpura.

(From: Modi S et al.: Acute Scrotal Swelling in Henoch-Schonlein
Purpura: Case Report and Review of the Literature. Urol Case Rep.
(2016) 6:9-11.)

Inguinal Hernia
An acute inguinal hernia may also present as an acute scrotum. In this
case, pain and swelling involve both the scrotal contents and the groin
area. Although important to differentiate, it may be difficult to distinguish
an incarcerated inguinal hernia from other, less emergent, scrotal issues
such as hydrocele, scrotal trauma, or scrotal abscess. An incarcerated
inguinal hernia involves bowel that is obstructed and is a true surgical
emergency. In selected, less acute cases, groin and scrotal ultrasound or
pelvic CT scans can clarify the diagnosis before surgical exploration.
Hernia repairs that use polypropylene mesh for correction may be
associated with vas deferens obstruction and infertility later on.

Acute-on-Chronic Events

Other scrotal conditions that are chronic in nature can also present with
acute symptoms and include testicular neoplasms, spermatoceles and
hydroceles. In the case of testis tumors, patients may only become aware
of the mass after it has been present for many months, after it affects the
appearance of the scrotum. However, testicular tumors can present
precipitously if they undergo hemorrhage or necrosis, and produce
swelling, pain and soreness. In this case, a scrotal physical examination
reveals a firm, intratesticular mass and scrotal ultrasound demonstrates a
solid intratesticular mass which has a > 90% likelihood of being a germ
cell tumor. The suspicion of tumor is important for the approach to
exploratory surgery in the acute scrotum, as the correct surgical approach
to testis cancer is through an inguinal incision and not transscrotally. In
addition, the testis and its investments are dissected out intact, to
minimize tumor spillage during surgery and spermatic cord ligation is
done in the inguinal region to further contain the spread of cancer.

Other chronic scrotal lesions which can present acutely include

hydroceles (increased fluid within the tunica vaginalis space) and
spermatoceles (cystic dilation of the fine ducts that lead from the rete
testis to the epididymal head) that hemorrhage after trauma, or become
infected. In addition, a scrotal varicocele, a condition characterized by
dilated pampiniform plexus veins and that occurs in 15% of men at
puberty, can be present for years but become acutely symptomatic.
These dilated veins surround the spermatic cord. If the varicocele has
acute onset, is only right-sided, or persists in the supine position,
then retroperitoneal pathology must be excluded (i.e., IVC thrombus,
abdominal mass, etc.). A careful history, physical examination and
ultrasound examination is usually sufficient to diagnose these usually
benign acute on chronic events. Urgent surgical intervention is rarely
needed for drainage of a loculated infection or for a persistent
hemorrhage associated with hydroceles or spermatoceles.

Summary

 A full range of scrotal pathology must be considered in acute

scrotum
 Several conditions that result in acute scrotum require surgical
exploration, making evaluation of this condition very time-sensitive.
 A high value is placed on the history, physical examination and
ultrasound imaging for acute scrotum