ACUTE SCROTUM; Scrotal Emergency Conditions

It started as a knot in the pit of his stomach, immediately he pulled away from her after the vigorous sexual encounter.
Then it progressed to an excruciating pain around the left side of his scrotal sac, which seemed to be moving upwards.
Few minutes later, the left hemi-scrotum of the 21 year old seemed to have assumed a higher position than the right, and was inclinedd at an odd angle.
By the time he got home, he was feeling nauseous and vomiting his guts out, and his scrotum was visibly swollen, and painful to touch.
He'd been having little episodes of pains such as this one, now and then, after a vigorous sexual encounter, a vigorous workout routine, or that time Henry kicked him playfully in the groin. But none had lasted this long, they all lasted barely a minute or so, and was not this Painful.
2 hours and tons of analgesics later, he knew he had to see a doctor ASAP as they pain was becoming incapacitating.

Wikimedia commons

WHAT IS AN ACUTE SCROTUM?
This is a painful scrotal condition that constitutes an emergency, and for which an urgent surgical intervention may be needed to relieve symptoms and effect cure.
It has diverse causes, ranging from ischaemic, through infectious, to traumatic causes. While some are relatively unserious, others have the potential to damage the testis beyond repair, with a potential risk of infertility looming.

STRUCTURE AND CONTENTS OF THE SCROTUM
To better understand the several causes, and why acute scrotal conditions are important surgical/medical emergencies, perhaps it is best to remind us about the important contents of the scrotum.
The scrotum​ is a pouch of skin in the midline of the groin area, and on either side of the penis. It contains the testicles, epididymis, and vas deferens [which are important for sperm production, maturation, and transport respectively] all wrapped up in layers of fascia.
It also contains the spermatic cord, which suspends the testicles within it [the scrotum], serving as a conduit conveying blood vessels, nerves, the sperm duct, and lymphatics, to and from the body.
Acute scrotal conditions may arise from any of these structures, and may constitute considerable harm to any of them.

Wikimedia commons

GENERAL FEATURES OF AN ACUTE SCROTUM
There are a myriad of symptoms and signs, which can be used to identify each of the several acute scrotal conditions.
However, two symptoms are common to almost all of them. And these are;

• Scrotal pain
  and
• Scrotal swelling

Presence of these two, is an indication to seek for an urgent medical help.

COMMON CAUSES OF ACUTE SCROTUM
Testicular Torsion
As described above, the testicles are suspended from the body by the spermatic cord, much like an orange tied to a thread and suspended from a fixed point.
Testicular torsion occurs when the spermatic cord twists on itself, rotating the testis on its axis. This cuts of the blood flow to the testis constituting an emergency, as if left untreated, it could lead to death of the testis within​ 6 to 12 hours!
The symptoms include scrotal pain and swelling, a high-riding testis positioned at an odd angle, nausea and vomiting [just like in the case above]. Signs of infection [fever, painful urination, pus in urine, etc] are usually absent.
It is commoner in children, and young adults. Other risk factors include trauma, vigorous exercise [including vigorous sex], cold, recurrent testicular pain. The major risk factors are usually present from birth, and include a "bell-clapper deformity" and a long mesochium [Google for details please].
Treatment is Surgical, and involves detorsion [untwisting the testis] and fixing [to prevent future recurrence] of the testis.

EPIDIDYMO-ORCHITIS
This is inflammation, usually of INFECTIOUS origin, of the Epididymis and/or Testis [Orchium].
It usually affects sexually​ active men, and the most implicated organisms are CHLAMYDIA and GONORRHEA.
The symptoms include, scrotal pain and swelling, and symptoms of infection including: fever, nausea, vomiting, anorexia, painful urination, frequent urination, and presence of pus in urine.
Risk factors include urinary tract obstruction, UTI, STI, and risk factors for STIs like multiple sexual partners and unprotected sex.
It does not require surgical intervention. Treatment is usually with broad spectrum antibiotics.

Wikimedia commons

COMPLICATED INGUINO-SCROTAL HERNIA
Inguino scrotal hernia are very common conditions in which the intestines herniate, or protrude, through a defect in the abdomen, and enter into the scrotum. This makes the scrotum to become swollen.
Usually, such herniated intestines can return to the abdomen, on their own, and without hassles. In such a way that the person would be having recurrent episodes of PAINLESS scrotal swelling that resolves [or "reduces"] on its own.
It becomes COMPLICATED, when the intestine herniates and refuse to go back on their own [that is become irreducible]. With time, they become incarcerated [adherent to the walls of the scrotum]. Then they become strangulated and obstructs.
When this happens, the blood flow to the intestines are cut off, they become necrotic [dead], and infected. This lead to a very painful, and swollen scrotum, with signs of infection [fever, nausea, vomiting, anorexia], and/or obstruction [ persistent vomiting, swollen tummy, and inability to pass stool].
This is a SURGICAL EMERGENCY!

Wikimedia commoms

FOURNIER'S GANGRENE
Wew! This is the mother of all evils. Kidding. But trust me, you don't want to have Fournier's gangrene.
It is a form of necrotizing fascitis , affecting the scrotal skin and fascial layers [literally this means it eats deep into the scrotum], which erodes these structures leading to an extensive, deep, ugly, and foul-smelling ulceration.
It is of INFECTIOUS origin, and is usually caused by numerous microbes acting in concert. If left untreated, it could progress rapidly into full blown sepsis, and DEATH, within 24 hours!
It is seen commonly in the elderly, and in young people with diabetes, HIV, and chronic alcoholism.
It presents initially as a painful scrotal swelling, with discoloration of the skin, and crepitus [crackling feel, when touched, as if filled with air, just like a pop waterproof]. It later progresses to a necrotic ulcer. The person would have signs of infection [fever, nausea, vomiting, anorexia], and will be looking REALLY SICK.
Treatment involves AGGRESSIVE use of intravenous antibiotics, and surgical debridement [cutting off of dead tissues​, to allow new ones grow].
Others

• Torsion of testicular appendix
• Testicular rupture
• Hematocele
• Etc.
  
  Wikimedia commons

CONCLUSION
Acute scrotum are emergency scrotal conditions usually characterized by pain and swelling.
They​ are considered emergencies, not just because of the excruciating pain they cause, but because of potential damage to the vital structures in the scrotum, the risk of infertility, and the ultimate risk of death, if left untreated.
Any scrotal swelling accompanied by pain of sudden onset MUST be examined by a doctor, for proper diagnosis and prompt and appropriate intervention​.
EVERY MINUTE COUNTS!

References

• Testicular pain
• Acute epididymitis
• Fournier gangrene
• Inguinal hernia