Scrotal Emergencies

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Differential diagnosis

A diligent and focused history and physical examination of the male complaining of acute scrotal symptoms is the cornerstone of formulating an appropriate plan of action. One of the most challenging aspects of scrotal complaints is that a wide variety of clinical conditions may present in a similar fashion: a male patient complaining of an acute, painful, swollen, and tender hemiscrotum. Indeed, the differential diagnosis of the acute scrotum is extensive (Table 1).

For patients presenting with

History

The presence of systemic symptoms may provide additional diagnostic clues in the patient presenting with an acute scrotum. As noted, the vast majority of studies addressing the evaluation and management of the acute scrotum are derived from pediatric cohorts. Therefore, the information that follows is based on analysis of pediatric cases unless noted otherwise.

As a general rule, patients with testicular torsion are more likely to have associated systemic symptoms such as nausea and vomiting

Management in the emergency department

The key to managing acute GU problems is the timely recognition of conditions that threaten life or testicular viability. Most routine laboratory aids, such as blood work or urinalysis, cannot exclude testicular torsion.36 Certain laboratory tests may, however, be important in ruling in alternative conditions such as acute epididymitis.37

Testicular salvage rates are time sensitive. A meta-analysis of 1140 patients in 22 series demonstrated a greater than 90% salvage rate with surgery within 6

Epididymitis

Antibiotics are the mainstay of therapy for epididymitis. Antimicrobial selection is guided by patient demographics: younger (<35 years of age), sexually active males are treated with agents to cover Neisseria gonorrhoeae and Chlamydia trachomatis, such as single-dose intramuscular (IM) ceftriaxone with a 10-day course of oral doxycycline.37 Fluoroquinolones are no longer recommended for the treatment of gonococcal infections.64 Antimicrobials covering common urinary pathogens are recommended

Appendage torsion

Appendage torsion occurs most frequently in the prepubertal age group, likely resulting from the increased size of the pedunculated structures as a result of hormonal stimulation.68 Appendage torsion is self-limited. Treatment includes pain relief with nonsteroidal anti-inflammatory agents and limiting activity. Pain relief coincides with degeneration of the infarcted, necrotic appendage, which typically occurs within 1 to 2 weeks.69 Appendage torsion may recur, given appendage variability in

Fournier's gangrene

Fournier's gangrene should be considered in elderly, diabetic, or otherwise immune compromised males. Fournier's disease has also been reported in women and children.70, 71 Early surgical consultation and administration of broad-spectrum antibiotics is indicated in all suspected cases of Fournier's gangrene. Surgical debridement is imperative and remains the definitive treatment.72, 73 Computed tomography (CT) may be helpful in assessing the degree of extension.74 However, delays in recognition

Incarcerated inguinal hernia

An inguinal hernia may occur when there is a defect in the anterior abdominal wall musculature. Alternatively, a persistent embryologic communication (patent processus vaginalis) between the peritoneal cavity and the tunica vaginalis may result in an indirect inguinal hernia. A reducible hernia occurs when abdominal contents can freely (or with simple manipulation) move between the abdomen and the hernia sac. An irreducible, or incarcerated, hernia cannot return to its normal site spontaneously

Genitourinary trauma

Traumatic injury must be included in the differential of any GU complaint. Trauma to the GU system may be either blunt or penetrating (Table 3). The Société Internationale D’Urologie has published recommendations regarding the management of GU trauma.80 Of importance, trauma-induced testicular torsion has been reported.22 As such, consideration of testicular torsion in the differential diagnosis of blunt scrotal trauma is prudent.

Significant trauma to the scrotum and its associated structures

Summary

Male GU problems are frequently high-risk complaints from a medicolegal perspective.84 Definitive diagnosis for the patient presenting with an acute scrotum is not always feasible in the ED setting. However, recognition of GU emergencies takes precedence. Identification of testicular torsion is critical given its implications for future fertility. Additional emergent conditions include Fournier's gangrene, incarcerated or strangulated inguinal hernia, and any form of GU trauma until proven

Acknowledgments

The authors wish to acknowledge Dr Robert Schneider, who is board certified in both emergency medicine and urology, for his contributions and mentorship.

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