Acute scrotum syndrome is a group of urgent conditions accompanied by the accumulation of effusion in the tissues of the scrotum. Symptoms include enlargement of the scrotum, pain with irradiation in the groin, hyperemia of the skin, temperature reaction. The gold standard of diagnostics is ultrasound, which can be supplemented with Dopplerography and diaphanoscopy, with an unclear diagnosis or severe pain syndrome, MRI of the scrotum is performed. Treatment correlates with the cause of scrotal organ disease and can be conservative (antibiotic therapy) or surgical (organ-preserving operations, orchiectomy).
Acute scrotum syndrome combines urgent conditions in urology (torsion of the appendage of the testicle, trauma, orchoepididymitis (orchitis), abscess, Fournier gangrene, etc.), accompanied by a painful and edematous reaction. Acute scrotum syndrome can develop at any age, but it is registered more often in children, since boys mainly encounter testicular torsion in the first year of life. Testicular inversion accounts for 16-20% of all cases of acute scrotum in childhood, and hydatid torsion accounts for 95%. In men, the syndrome most often accompanies acute orchoepididymitis. Complication statistics are variable. The outcome of the disease largely depends on the speed of treatment.
Acute scrotum syndrome is considered as an urgent condition requiring immediate hospitalization. Predisposing factors include anatomical and physiological features (lack of stable fixation of the testicles in children), urological surgical interventions and medical manipulations. The main causes leading to scrotal edema include:
- Ischemia. Acute circulatory disorder, characteristic of twisting of the neurovascular bundle of the testicle, its appendage and hydatid (“suspension”) in a few hours can lead to necrotization. Pathology develops more often against the background of predisposing anatomical features in young children and with a direct blow to the scrotum. Sometimes the condition resolves on its own, but most patients require the help of a surgeon.
- Infections. Orchitis and orchoepididymitis are infectious in nature and can be caused by specific (Neisser’s gonococci, trichomonas, chlamydia) and non-specific microflora (E. coli, Klebsiella, staphylococci, streptococci), as well as viruses. The main predisposing factors are immunosuppression of any genesis, STIs or persistent chronic diseases of the urogenital tract. With the generalized spread of pathogens inside the fascia, Fournier gangrene may develop.
- Injuries. Injury to the perineum with damage to the testicles, appendages, and spermatic cords leads to an increase in the scrotum due to edema and the formation of a hematoma. Often there is a combined injury involving the penis, urethra, bladder, pelvic bones, which occurs in road accidents and as a result of a direct blow to the perineum. Hematocele – accumulation of blood in the vaginal membrane of the testicle – also changes the normal configuration of the scrotum.
- Other diseases. These include leukemic infiltration of the testicles, hemorrhagic Schenlein-Henoch vasculitis, varicocele, testicular tumors, acute spermatocele and hydrocele, allergic and idiopathic scrotal edema – a pain-free self-limiting condition characterized by hyperemia and pasty skin, fascia edema without the participation of deeper layers, testicles and their appendages.
In the pathogenesis of toxic, inflammatory and allergic edema, the main mechanism is a violation of microcirculation and an increase in the permeability of the capillary wall in the affected area. The release of vasoactive mediators and biogenic amines, prostaglandins, kinins and leukotrienes, as well as the formation of immune complexes with an allergic factor aggravates the pathological process. A decrease in the mechanical resistance to the flow of fluid from the vessels into the tissue develops with the loss of collagen and increased looseness due to increased activity of hyaluronidase. With ischemia as a result of the inversion of the hydatid or the twist of the spermatic cord, normal blood circulation is absent, and thrombosis is detected in the clamped vessels. The lack of oxygen and nutrients to the cells leads to necrosis.
Depending on the main pathogenetic factor, acute scrotum syndrome can be inflammatory (with the formation of exudate under the action of inflammatory mediators) or non-inflammatory genesis (with the formation of transudate – a liquid containing cellular elements and less than 2% protein). Scrotal edema is characterized by multifactorial, i.e., the involvement of several pathogenetic mechanisms. Most clinicians distinguish primary swelling of the scrotum, which occurs in all acute conditions, and secondary — with fluid overload of the vascular bed, for example, with cardiovascular insufficiency, nephropathy, etc. According to the mechanism of development , the following pathogenetic forms are considered:
- Hydrodynamic edema. One of the mechanisms for injury and inflammation of the testicle, appendage. Against the background of increased pressure in the microvessels (the primary reaction to pain), the resorption of interstitial fluid into the vascular bed with the formation of edema is disrupted.
- Lymphogenic edema. It is typical for the inversion of the testicle or the hydatid of the Morgania. Edema is formed against the background of impaired lymph outflow in the syndrome of prolonged compression.
- Membranogenic edema. The syndrome of edematous scrotum is caused by the accumulation of fluid and electrolytes, which occurs due to increased permeability of the vascular wall during the inflammatory process, allergic reactions.
- Osmotic edema. With inflammation, the osmolarity of the interstitial fluid increases due to the release of osmotically active substances from damaged cells, a decrease in their transport from tissue structures and an increased transition of sodium, potassium, calcium, glucose and nitrogenous compounds into the interstitial fluid.
Clinical manifestations depend on the cause, duration of existence, mechanism of swelling. Each nosology has its own symptoms, with a common increase in the size of the scrotum. Acute pain is caused by twisting of the neurovascular bundle responsible for the functioning of the testicle or its appendage. The skin of the scrotum initially turns red, a bluish hue speaks in favor of ischemia with tissue necrotization. The pain can be so strong that it is reflexively accompanied by vomiting, cold sweat, and a drop in blood pressure. The affected testicle is located slightly above the usual level. Pain can radiate to the groin area, perineum. The condition is accompanied by reactive dropsy due to disruption of the lymphatic drainage system.
Injuries to the organs of the scrotum, along with edema, are characterized by acute intense soreness, the formation of a hematoma, bluish skin color, an increase in the size of the scrotum. Infectious lesions are often preceded by hypothermia. Pain and swelling increase gradually, hyperemia is typical. There is an asymmetry of the scrotum on the side of inflammation. With orchoepididymitis, the appendage is gradually involved in the process, which is manifested by compaction in the form of a painful string in the groin area. There may be pathological discharge from the urethra. The temperature is raised to 39-40 ° C, chills are typical. With lightning-fast gangrene, inflammation spreads through the fascia and is manifested by significant swelling of the scrotum with severe pain, while the testicles are not involved in the process.
The causes of acute scrotum syndrome are determined by a urologist-andrologist based on the symptoms and results of a physical examination. When analyzing the history of the disease, the duration of manifestations and the characteristics of pain are taken into account. Surgical interventions performed in the past on the organs of the urogenital sphere and for inguinal-scrotal hernia are significant, because as a result of their conduct, the integrity of the lymphatic drainage system may be violated. Making a diagnosis implies:
- Palpation and diaphanoscopy. Palpationally, a mass can be felt in the testicle or appendage, mobile or soldered to tissues, with smooth or uneven contours, homogeneous or heterogeneous. With dropsy, allergic or angioedema, the testicles are not affected, and the large size of the scrotum is due to the accumulation of fluid between the membranes. In urgent conditions, palpation is difficult or impossible due to pain syndrome. With the help of diaphanoscopy, it can be assumed that the cause of the enlargement of the scrotum is fluid, vascular structure, cyst or tumor.
- Ultrasound of the scrotum organs. As a method of primary diagnosis, ultrasound is performed for any changes in the scrotum. According to the indications, with the help of a Doppler, it is possible to assess vascular malformations, measure the speed of blood flow. Allergic and angioedema on ultrasound look like diffuse swelling of the scrotum. Echography in Fournier gangrene can show the presence of fluid or gas in deep tissues. In difficult cases, an MRI of the scrotum may be necessary.
Differential diagnosis is carried out with a pinched inguinal-scrotal hernia, which is also characterized by pain syndrome, swelling and redness of the scrotum. Similar clinical manifestations may occur against the background of nephrotic syndrome, ascites, heart failure, reactive dropsy in testicular cancer, lymphedema. The pain in these conditions is less intense, due to stretching of the skin of the scrotum and fluid pressure. Body temperature is usually normal.
Treatment tactics depend on the established diagnosis and can be conservative or operative. The greatest difficulty is the determination of management tactics for the inversion of the testicle and its appendages, existing for several hours, since it is not always possible to find out the degree of tissue alteration as a result of ischemic disorders. Therapeutic measures for acute scrotum include:
- Pharmacotherapy. Drug therapy is carried out with uncomplicated orchitis and orchoepididymitis: antibiotics, anti-inflammatory drugs, analgesics are prescribed. To eliminate the consequences of ischemia with testicular torsion after detorsion, drugs that improve blood circulation are used, but conservative therapy has a better chance of success if started immediately from the moment of pain. Allergic edema implies the appointment of antihistamines.
- Surgical treatment. Surgical intervention is performed with testicular abscess, necrosis, phlegmon, Fournier gangrene, secondary purulent infection, rupture or bleeding with testicular dropsy, spermatocele. With all complications and urgent conditions, the operation is performed in an emergency. The purulent process involves drainage with the appointment of antibacterial therapy. When the testicle, appendage or hydatid is twisted, the surgeon assesses the degree of tissue necrosis and the ability to restore blood flow, otherwise orchiectomy is indicated. The management of a patient with an injury depends on its nature (bruise, crushing, injury, dislocation, etc.)
Prognosis and prevention
The prognosis is determined by the nature and severity of the pathology. The outcome of treatment of urgent conditions depends on the timeliness and completeness of therapy, for Fournier gangrene, the prognosis is serious. After removal of the testicle, some men have a decrease in fertility. Frequent episodes of orchoepididymitis can lead to the development of an obturation type of male infertility. Preventive measures include careful attitude to the organs of the scrotum: wearing protection when practicing traumatic sports, clothing according to the season, refusal of casual sexual relations, timely treatment of inflammatory diseases of the male genital area, adequate hygiene. Self-diagnosis is important – regular palpation and examination of the scrotum in order to detect pathological processes early.