History
• 19-year-old male with acute right
scrotal pain for the last 5 hours
• No fever, dysuria, nausea and
vomiting
• No previous pain episodes
• No history of trauma
• Past history: Unremarkable
Physical exam
• T = 37.2, P = 72, BP = 105/74
• Chest, abdomen, and extremities are
all normal
• Penis: Uncircumcised, no discharge
or lesions
• Left testis: Normal
• Right scrotum: Swollen,
erythematous and extremely tender
Exam
Laboratory
• U/A: 5 WBC, 0 RBC, Mod. Bacteria
• CBC: WBC 9.6, Hct 39
Differential Diagnosis
•
•
•
•
•
•
Spermatic cord torsion
Torsion of testicular appendage
Epididymitis / orchitis
Trauma
Malignancy
Idiopathic
Management
•
•
•
•
•
Epididymitis
Torsion of appendage
Torsion of cord
Trauma
Malignancy
- Antibiotics
- Observation
- Exploration
- Exploration
- Exploration
Imaging-Doppler Ultrasound
Management – Exploration
• Bell-clapper
Management – Orchiopexy
Epididymitis/Orchitis
• Etiology
– Sexually active
• N. Gonorrhea
• Chylamidia
• Ureaplasma urealyticum
– Prepubertal
• E. Coli
Infection: Management
• STD
– Azithromycin
– Metronidazole
• Prepubertal
– Trim/sulfa
– Cephalosporine
Torsion of Appendage
Torsion of Appendage
• Observation (if you can be certain of
the diagnosis)
• Exploration if you can’t rule out
spermatic cord torsion
Acute Scrotum – Summary
• Spermatic cord torsion most
common cause
• Doppler ultrasound most accurate
noninvasive imaging study
– 5% false negative
• Suspect spermatic cord torsion
– Immediate exploration
History
• 42-year-old white male w/ painful
erection >6 hours
• Past History: depression
• Medications: trazadone
Exam
• T = 37, P = 78, BP = 126/82
• Penis: erect with tumescence of
corpora cavernosa, soft glans and
ventrum
Management
• Aspiration / Irrigation
– Blood gas on aspirate
– pH = 7.4, pO2 = 38
• Phenylephrine Irrigation
– Monitor patient (BP, pulse)
History
• 26-year-old white male suffered
“crossbar” injury
• Erection >5 hours
• Past History: Negative
Exam
• T = 37, P = 78, BP = 126/82
• Penis: erect
• Aspirate - Bright red blood
– pH = 7.0, pO2 = 86
High-flow Priapism
• History of trauma
• Diagnosis:
– Duplex Doppler ultrasound
– Arteriography
• Management: Embolization