Torsion testis is an acute surgical problem that needs intervention within 6 hours. Clinically you can't differentiate from Acute epididymo-orchitis.

1. SCROTAL SWELLINGS
Case No:2
PROBLEM ORIENTED CASE BASED LEARNING
Dr.B.Selvaraj MS;Mch;FICS
Professor of Surgery
Melaka Manipal Medical college
Melaka Malaysia 75150

2. OVERVIEW
• Various causes(Differential diagnosis) of scrotal swellings
• Classical clinical vignette with probable diagnosis
• The diagnosis in detail- only one pathology in each episode
• Mind map of the diagnosis
• Tabular column of differential diagnosis depicting their
characteristic features to differentiate them from your
diagnosis
• References and feedback

3. Causes of Scrotal Swellings
ACUTE PAINFUL
• Torsion testis
• Acute epididymo-orchitis
• Torsion of testicular
appendages
CHRONIC PAINLESS
• Hydrocele
• Epididymal cyst
• Spermatocele
• Chronic epididymo-
orchitis
• Testicular tumor
• Varicocele

4. Classical Clinical vignette
Torsion Testis
• A 14-year-old boy presents with acute onset of right scrotal and
RLQ pain for the past 4 hours. He additionally reports nausea and
one episode of vomiting. He denies any similar past pain and
reports no history of trauma.
• O/E: the skin overlying the right side of the scrotum appears to be
slightly erythematous and edematous. The right testicle appears to
be lying significantly higher in the scrotum as compared to the left
testicle.
• The entire right testicle is exquisitely tender to palpation, whereas
the left one is nontender
• He has an absent cremasteric reflex on the right.

5. Torsion Testis- Etiopathogenesis
• Twisting of testis along with spermatic cordStrangulationNecrosis
• Common in neonates and in puberty
• Inversion of testis
• Strong muscular exertion or blunt trauma can trigger it
• Undescended testis undergo torsion frequently
• High insertion of tunica vaginalis- bell clapper deformity-predisposes
• There are 3 types of torsion- Extravaginal, intravaginal and mesorchial
• Extravaginal in neonates, intravaginal in adolescents

6. Torsion Testis- Types
In Neonates In Adolescents
Bell clapper
deformity

7. Torsion Testis- Clinical Features
• Sudden severe pain in hemiscrotum or both sides
• Nausea & vomiting
• Scrotal skin edematous and erythematous
• Testis exquisitively tender
• Affected testis at higher level because of twisting Deming’s sign
• Normal testis lying horizontally Angel’s sign
• Pain not relieved on elevation of scrotum Prehn’s sign
• Cremastric reflex absent in affected side

8. Torsion Testis- Clinical
Features

9. Torsion Testis- Clinical
Features

10. Torsion Testis- Clinical
Features

11. Torsion Testis- Differential Diagnosis

12. Torsion Testis- Doppler USG

13. Torsion Testis- Doppler USG
Central testicular blood flow Normal
Testis
No Central testicular blood flow but
excessive peripheral blood flow

14. • Ipsilateral side Exploration, detorsion and fixation orchiopexy
Detorsion is away from median raphae of scrotum like opening a
book
• Contralateral side Exploration and fixation orchiopexy
• In doubtful cases and nonavailability of Doppler USG Better to
explore rather than unduly delay the treatment
• Testicular salvage rate is 100% if surgery is done within 6 hrs
and it is 20% if surgery is delayed > 24 hrs
Torsion Testis- Treatment

15. • Hydatid of testis & epididymis Remnant of obliterated
Mullerian ducts
• Sudden Swelling and redness of hemiscrotum
• Tender Testis
• ‘Bluedot sign’ +ve
• Cremastric reflex intact
Torsion of Testicular appendages

16. Torsion of Testicular appendages
“Blue dot sign”

17. • Explore & Excise torsed appendages in early cases
• In delayed cases >48 hrs conservative treatment with
antibiotics & anti inflammatory drugs
Torsion of Testicular appendages
Treatment

18. • Inflammation of epididymis & Testis due to infection or
trauma
• Sudden onset of pain in a hemiscrotum
• Commonly associated with UTI or trauma
• Thickened & Tender epididymis
• Pain relief by elevation of hemiscrotum Prehn’s sign
• Can be treated conservatively with antibiotics and
antiinflammatory drugs
Acute epididymo-orchitis

19. Acute Epididymo-orchitis
Doppler USG
USG Scrotum
• Thickened Epididymis
• Reactive Hydrocele
• Thick scrotal wall
Doppler USG
• Excessive blood flow to
Epididymis
• Normal testicular parenchymal
blood flow

20. Testicular Torsion- Mindmap

21. Scrotal Swellings- Algorithm

22. Scrotal Swellings Ex & Px Hx Sx Dx Tx
1. Hydrocele Primary-Idiopathic
Secondary- under
lying pathology
Painless big
swelling; not
reducible
No cough impulse
Get above swelling+
Transilluminant+
Clinical
In doubt- USG of
scrotum
Lord’s operation
Jaboulay’s
operation
2. Epididymal
cyst &
Spermatocele
Degenaration of
epididymis, occlusion
of pathway
Swelling in
scrotum resembles
3rd testis
Testis palpable
separately; Chinese
lantern appearance
Clinical
USG of scrotum
Conservative
Excision
3. Varicocele Idiopathic
Absence of valves in
testicular vein
Worm like in upper
scrotum; infertility
Disappears on lying
down; Bag of worms
appearance
Clinical
USG color doppler
Varicocelectomy
Inguinal or
Retroperitoneal
4. Testicular
torsion &
Epididymo-
orchitis
Abnormal fixation and
lie of testis
UTI & trauma
Severe pain&
swelling scrotum
Nausea & vomiting
Tender hemi scrotum;
cremasteric reflex
absent
Clinical
USG color doppler
Explore,detorse,
orchiopexy or
orchidectomy
Conservative
5. Testicular
carcinoma
UDT, Kieinfelter’s
Germ cell- Seminoma
& Non seminoma
Painless heavy
swelling
Not reducible
Hard in consistency
Testis felt separately
Clinical; No FNAC
USG OF scrotum
High orcidectomy
with or without
RPLND+ RT+CT
D/D for Scrotal Swellings (Compare &
Contrast)
(Vertical
Reading)

23. References
• Hunt & Marshall’s clinical problems
in surgery 2nd edition
• Clinical surgery made easy- a
companion to PBL by Mohan De
silva 1st edition
• 100 cases in surgery 2nd edition
• Case files surgery 4th edition
• Clinical scenarios in surgery-
decision making 1st edition
• Surgery- a case based clinical
review 1st edition
• Surgery Review by Carlos Pestana
• Clinical surgery pearls by
Dr Dayananda Babu 2nd edition
• NMS casebook surgery 2nd edition
• General Surgery- Correlations &
clinical scenarios 1st edition
• Surgery review by Makary 3rd edition
• Short practice of surgery by Bailey
and Love 26th edition
• Shelf life surgery 1st edition

24. Feedback & Suggestions

25. Thank You
To watch the video version go to
Channel
Surgical Educator in You Tube
https://www.youtube.com/watch?v=HqHEf0krIng