Scrotal swellings- Torsion and
Hydrocele
Testicular torsion
• Testicular torsion is a urologic emergency
which often results in the loss of a testicle if
not diagnosed and treated quickly.
• It occurs when the testis twists in the
scrotum, cutting off its blood supply.
• This is an extremely painful condition which
most commonly occurs in young males and is
the most common cause of a testicle loss.
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Types
• There are two types of testicular torsion:
extravaginal and intravaginal.
• Extravaginal torsion is diagnosed in newborns
and is caused by nonadherence of tunica
vaginalis to the dartos layer.
• As a result, the spermatic cord and tunica
vaginalis are rotated as a unit.
Cont’d
• Intravaginal torsion is usually diagnosed in
boys 12 to 18 years of age, but it can occur at
any age.
• The etiology of intravaginal torsion is
malrotation of the spermatic cord with in the
tunica vaginalis.
• Both extravaginal (newborn) and intravaginal
(adolescent) types of testicular torsion lead to
strangulation of blood supply to the testis
Risk factors
• Congenital
• Temperature (Winter Syndrome)
• Size -If one testicle is larger than the other due
to any cause it is more likely to twist on its
spermatic cord
• Trauma and aggressive sex
Clinical presentation
• Sudden severe pain in their testicle/s
• Lower abdominal pain.
• The concerned scrotum will be red and swollen.
• The patient may complain of nausea and vomiting
• Decreasing/disappearance of pain does not
necessarily mean that the torsion has corrected by
itself - the testis may be undergoing necrosis
P/E
• A swollen tender testicle that is raised in a red
scrotum
• The testicle may be lying horizontally in the scrotum
• No pain relief when the testicle is elevated (there
will be pain relief in epididymitis)
• Loss of the cremasteric reflex on the affected side
• The patient may have a fever
• Remember: Acute, tender enlargement of the testis
is torsion until proven otherwise.
Investigation
• Is a clinical diagnosis due to the speed at
which treatment should be commenced in
order to save the testicle.
• Ultrasound with colour Doppler scans are the
best investigations in terms of speed and
accuracy to help with the diagnosis of torsion.
• The Doppler scans show whether the testicle
has a patent arterial blood supply
Management
• Manual Detorsion - sometimes it is possible to
manually detwist the torsioned testicle.
• When the testicle is untwisted the pain
should be relieved.
• If not, try twisting the testicle the other way.
• If successful, check the testicles blood supply
using a colour Doppler ultrasound.
• Bilateral orchidopexy in the same admission
Cont’d
• Surgical Exploration - If the manual detorsion
is unsuccessful or there is doubt about the
diagnosis, then surgical scrotal exploration
within six hours.
• Untwist the spermatic cord and ;
If testis is not viable orchidectomy and
orchidopexy to the other testis
If viable, bilateral orchidopexy
Hydrocele
• A hydrocele consists of a collection of fluid
within the tunica or processus vaginalis.
• Although it may occur within the spermatic
cord, it is most often seen surrounding the
testis .
• Surgical correction is only required if the
patient has symptoms secondary to the size of
or discomfort associated with the hydrocele
Cont’d
• Communicating hydrocele of infancy and
childhood is secondary to a patent processus
vaginalis, which is continuous with the peritoneal
cavity, It is form of indirect inguinal hernia.
• Most communicating hydroceles spontaneously
close by 1 year of age, but persistent
communicating hydroceles and presence of
bowel content within the hydrocele sac may
require surgical correction
Types
• Hydrocele of tunica vaginalis
• Congenital communicating hydrocele
• Hydrocele of the cord
Investigation and management
• Clinically
History
P/E
• Scrotal US
• Surgical management
Hydrocelectomy
Inversion of tunica vaginalis
Questions???
