Correct answer to Q3 is: Untreated or severe epididymo-orchitis
Discussion:
The acute scrotum is a syndrome characterised by acute onset painful hemiscrotumwhich can be accompanied by abdominal pain, fever or gastrointestinal upset such as nausea or vomiting. It is most commonly caused by torsion of the testis, torsion of epididymal appendage, epididymitis or epididymo-orchitis.
Patients presenting with sudden painful hemiscrotum with vomiting is typical for testicular torsion or torsion of epididymal appendage.
Duration of symptoms is shorter in testicular torsion (69% present within twelve hours) and torsion of the appendix testes (62%) compared to epididymitis (31%). In the early phase, location of the pain can lead to diagnosis. Patients with acute epididymitis experience a tender epididymis, whereas patients with testicular torsion are more likely to have a tender testis, and patients with torsion of the appendix testis feel isolated tenderness of the superior pole of the testis (1).
Apart from pain and hemiscrotalswelling, physical examination in patients with testicular torsion may reveal elevation of the scrotum without cremasteric reflex, and a testis sometimes in horizontal lie. The affected testis may be larger than the asymptomatic testis.
Doppler US is the modality of choice for evaluating testicular torsion. Ultrasound of the testis may demonstrate that the affected testis is enlarged, heterogeneous in echotexture, and without evidence of any blood flow. It is important to compare the affected testis with the normal side (2). Treatment is bilateral orchiopexy.
An important differential diagnosis is epididymitis, which is inflammation of the epididymis and may be extended to the testis, in which case it is called epididymo-orchitis.
Epididymitis and epididymo-orchitis are usually caused by a bacterial infection, often due to surgery, bladder catheter, urinary tract infection or sexually transmitted disease. The clinical spectrum ranges from mild tenderness to a severe febrile process with acute unilateral scrotal pain. US often shows that epididymis is swollen and heterogeneous, with hydrocele and scrotal wall thickening. Doppler US may demonstrate hyperaemia.
A complication of severe epididymo-orchitis is abscess formation. Doppler ultrasound shows a focal hypoechoic area with a surrounding hyperaemic rim. Treatment may include prolonged antibiotics, surgical debridement or even orchiectomy (3).
Conclusion
In conclusion, US is an important imaging tool in patients with acute scrotal pain.
Conflicts of interest
“The authors declare no conflict of interest.”
References
- C. Radmayr (Chair), G. Bogaert, H.S. Dogan, R. Koc ̆vara, J.M. Nijman (Vice-chair), R. Stein, S. Tekgül Guidelines Associates: L.A. ‘t Hoen, J. Quaedackers, M.S. Silay, S. Undre. EAU Guidelines on Paediatric Urology. https://uroweb.org/wp-content/uploads/EAU-Guidelines-on-Paediatric-Urology-2019.pdf
- Testicular torsion| Radiology Reference Article | Radiopaedia.org. Available online: https://radiopaedia.org/articles/testicular-torsion?lang=us (accessed on 18.01.2022).
- Testicular abscess| Radiology Reference Article | Radiopaedia.org. Available online: https://radiopaedia.org/articles/testicular-abscess (accessed 07. 05.2018)
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