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AUA M EDICAL S TUDENT C URRICULUM This document was amended in December 2021 to reflect literature that was released since the original publication of this content in May 2012. This document will continue to be periodically updated to reflect the growing body of literature related to this topic . T HE AC U T E SCR O TUM K E Y W O R DS : Te s tis, e p ididy m is, tor s ion, epi d i d y m itis, isch e m ia, tu m or, infection, hernia L E A R N IN G O B JE C T I V ES : At the end of m edical school, t h e student should be able to: 1. Describe 6 conditions that m ay prod u ce acute s c rot a l pain o r swelling. 2. Distinguish, through the history, physical ex a m ination and l a boratory testing, testicular torsion, tor s ion of testi c u lar ap p endices, e p i d idymiti s , te s tic u lar tu m or, s crotal tra u m a and hernia. 3. Appropriately order i m aging studies to m a ke the diagnosis of the acute scrot u m . 4. D eter m ine w hich acute s crot a l con d itions r e quire e m ergent surgery and which m ay be handled less e m ergently or electively. I NTR O D U CTION: The “acute s crotu m ” m a y be vie w ed as the ur o l o gist’s equi v a lent to the g eneral surgeon’s “acute ab d om en.” Both conditions are guid e d by s i m ilar m anage m ent principl e s : - The patient history and physical exa m ination are key to t h e diagnosis and often guide decision m a king regarding whether or not s u r g i c al i n terve n tion is appropriate. - I m aging studies should c o m pl e m en t , but not replace, sound clinical ju d gm ent. - When m aking a decision for conservati ve , no n - surgical care, the provider m ust balance the pote n ti a l m orbidity o f sur g ical e x plor a tion a g ain s t the potent i a l cost of m issing a surgical diagnosis. - A s m all but real, negative explo r ati o n rate is a c c eptable t o min i m ize the risk of m issing a critical s u rgical d iagn o sis. D I FF E R E NTI A L DIA G NO SIS O F THE AC UTE S CR OT UM A list of potential m edical conditions that can pr e sent as acute pain or s w elling of the scrot u m is found in Table I. Table 1: Causes of Acute Scrotal Pain and Swelling Ische m ia: Torsion of the testis (synon y m ous with torsion of the spermatic cord) Intra v agin a l; extra v agin a l (pre n at a l o r neonatal) Appendiceal torsion, testis or e p idid ym is Testicular infarction due to compressive hydrocele or hernia Te s ticular

i nf arction due to other vascular insult (cord injury, thr o m bosis) Trau m a: Testicul a r rupture Intr a te s tic u l ar he m atoma, t e s tic u lar contu s i o n Hematocele 1 2 Infectiou s conditions: Acute epi d idy m itis Acute epi d idy m oorchitis Acut e orchitis Abscess (i n t rate s ticul a r, int r avagin a l, scrot a l skin, c u t a neous cyst s ) Gangrenous infections ( F ournier’s gangrene) Inflam m ato r y conditions: Henoch - Schonlei n purpur a (HSP ) vasculiti s o f scrota l wall Fat necro s is, scrot a l wall Hernia: Incarcerated, strangulated i nguinal hernia, with or wi t hout associated testicular ischemia Acute on c h ronic e v ent s : Sper m atocele, rupture or he m o rrhage Hydrocele, rupture, he m orrhage or infection Testic u lar t u mor with r u pture, he m orrhage, in f a rc tion or in f e c tion Varicocele While the differential d i agnosis is broad, an acc u rate h ist o ry and physical exa m ination can frequently precisely define the condition. Often, carefully chosen i m aging studies can co m p l e m ent clinical judg m ent and expedite the r apeuti c decisions . A discussio n o f th e most i m portant and common conditions that cause ac ut e scrota l pai n o r swellin g follows. T ORSI O N Testicular torsion The testicle is typically covered by t h e tunica vaginalis, creati n g a potential space arou n d the testis. Torsion can occur from within the tunica vaginalis or about the entire spermatic cord . Normally, the tu n i ca vagin a lis attaches to the posterior s u rface of t h e te s ticle a n d allows fo r very little m obility of the testicle within t h e s crotu m . So m e patients have an ina p propri a t e ly high attach m ent of the tunica vaginalis, such that the t e sticle can rotate f r eely on t h e s per m atic cord within the tunica vaginalis (intravaginal testicular torsion) (F i gure 1). This congenital ano m aly, called the “bell clapper defo r m ity, ” consists of a transverse as opposed to longitudinal lie of the affected t esti s ; it can be unilateral or bilateral and is a risk factor for a torsion event . This conge n ital abnor m ality is prese n t in ap p roxi m ately 12% of hu m an males. F i g u re 1. Bel l c l app e r de f or m ity . N o r m al testi s li e i s o n t he lef t an d t h e classi c “ b ell cla pp e r ” li e i s in t h e m i dd le . T h e rig ht s i de s h o ws a bel l c l apper v a r i a ti on. 3 Experi m ental evidence indicates that 720° twist is required to co m pro m ise flow through the testicular artery and result in ische m ia , however the degree of twist is different in each clinical presentation . In neonates, the testi c le f requen t ly has not yet descended into t h e sc

r o tu m , a f ter which it bec o m es attach e d within t h e tunica v agi n alis. T h is i n crea s ed mobility of the te s ti c le p r edisposes it to e xtrava g inal testicul a r to r sion. During testis torsion, the testicle twi s ts spontaneously on the sper m atic cord, causing venous occlusion and engorge m ent, with subse q uent arterial ische m ia and infar ction. Testis tor s i o n is the m o st common cause of tes t is loss in the US. The inci d ence in m ales 25 years old is approxi m ately 1:4000. T o rsion m o re often involves the left testicle. A m ong neonat a l te s t icul a r t o rsi o n case s , 70% occur prenatally and 30% occur postnatally. T h e testis salvage rate approaches 100% in patients who undergo detorsion within 6 hours of the start of pain. However there is only a 20% viability rate if torsion persists �12 hours ; an d virtuall y no viability if torsion persists �24 h ours (Fig u r e 2). F i g u re 2. Tes ti s h i s t o l ogy d u ri ng e a r l y (A) he m or r hag i c p hase a n d c h ro n i c lat e (B ) ph ase s o f testi s t o rsio n. N o te t he de c reas e d s e m i n i fer o us t u bu l e dia m e t er and l oss of g e rm cells in late relati ve t o ear l y p h a ses. Testicular torsion presents with th e rapi d onse t o f sever e t esticular pain and swelling (Figure 3) . The onset of pain m ay be preceded by tra um a, physical acti v ity, o r by no acti v ity (e.g. duri n g sleep). It most often occurs in children or adolescents, but this diagnosis sho uld be considered in evaluating m en with scr o tal pain of any age, as it m ay occasionally occ u r in m en 40 - 50 years old. In t h is age group, t h e diagnosis is often dela y ed or m issed due to a l o w suspicion because of age. Torsion should be in the differential for an y sudden acute scrot a l pain or swelling. The classic physical exa m ination findings with testis torsion are an exquisitel y tende r testicle with a high, horizontal lie. Nor m a lly the testicle has a vertical l i e within the tunica vaginalis of the scr o t um – that is, the longitu d inal axis of the testis is o r ie n ted ve r ti c ally. W ith tor s ion and twisting of the sper m atic cord, the te s tis m ay assu m e an altered lie based on the degree of twisting. After venous outflow is occluded , ther e i s swellin g an d occlusio n o f arteria l flow. Early on, one m ay be able to palpa t e the torsed cord and th e testi s belo w it ; later in the course, however, progressive ede m a and inf l ammation ens u es, such that after 1 2 - 24 hours, the entire he m iscrotum appears as a confluent m a ss without identifiable land m arks. At this stage, the physical exa m ination m ay be indistinguishable from that seen with epididy m oorchitis.

I m portantly, with tor s io n , signs of in f ection are usuall y absent : patient s a r e usually afebrile, free of irritative voiding sy m pto m s such as dysuria, and harbor a nor m al urinalysis and nor m al white blood cell count. (In later torsion, however, an elevated WBC m ay be seen in response to the inflam m ation). Torsion of an undescended testicle will present differently than that of a descended testicle. For example, it may mimic the presentation of inguinal hernias or an acute abdomen , and there may not be scrotal swelling. 4 F i g u re 3 . Example of acute scrotum highlighting hallmark signs of testicular torsion, including color change and swelling (from Al - Salem AH: Acute Scrotum. In: Atlas of Pediatric Surgery. Springer, Cham. (2020) ). W ith a high degree of suspicion, one m ay rea s onably recommend surgical exploration without delay. When the diagnosis is less clear , the TWIST score is a useful clinical decision tool used to characterize torsion risk based on history and physical exam. Patients with intermediate risk TWIST scores should undergo s crotal ult r as onography , i f readily available, as this test is the single m o st useful adjunct to the history and physical exa m ination in the diagnosis of torsion. The ultrasonograp h er should use Doppler flow to assess arterial f low within the a f f ected testis; if arteri al flow is absent, or decreased relative to the contralateral test i s , then torsion is highly likely. It is helpful to co m pare the flow patterns between both testes to help m ake this diagnosis. Ultrasonography m ay also exclude significant testicular trau m a, s how a hernia extending into t h e scr o tu m , and can di s ting u ish epi d id ym itis f rom torsion by d e monstrating incr e ased f l ow to the e p ididy m is and adnexal structures along with preserv e d testicular perfusi o n. Evaluation of intratesticular flow should includ e a comparison of the contralateral testis, as well as the ipsilateral epididymis. Sonographic findings should be considered within clinical context. For example, a perceived increase in epididymal blood flow may be due to decreased intratesticular blood f low. Similarly, a “co m plex m ass” superior to the testis m ight repre s ent an infla m ed epididy m is or a torsed appendix, epididymis, or testis. T he torsed c o rd with ede m a and in f lammation is di f f icult to distinguish f rom an infla m ed epididy m is in torsion. R e m e m b e r, te s tic u lar perfusion i s th e key to the ultrasound diagnosis o f torsion . Test s suc h as nuclear testicular s c ans, CT or MRI, have essentially no role in the conte m pora r y m anage m e nt of acute testicular processes. When torsion is diagnosed, urgent surgical exp l oration and detorsion is m andat

ed, as testicular torsion is a true vascular e m erg e ncy. Testicular preservation is excellent when corrected wit h in 4 - 6 hours of onset. Beyond 12 hours, the risk of s ubsequent testis atrophy is significant with d etorsion. T estis salvage is often still appropriate if the testi c ular appearance at exploration i m proves with observation following detorsion , manually or otherwise. Manual detorsion is typically performed via the “opening the book” maneuver, as most teste s torse toward the septum of the scrotum, however this should be considered 5 an adjunct to definitive treatment. In the acute setting (24 hours of symptom onset), detorsion should be attempted at the presenting institution when technically feasible, as sal vage rates are lower for patients who are transferred to another hospital. The definitive treatment for testicular torsion is scrotal exploration. A f ter shar p ly entering the scrotu m , the tunica vaginalis is opened. Then the testis detorsed and wrapped in a war m , moist gauze. In patients with torsion, it is assumed the bell - c lapper deformity is bilateral, and thus t he contralateral sid e the n under goes orchidopexy with permanent suture to prevent tors i on on that side. The affected testis is r e i n spected f or s igns o f i m p r ove d perfusio n (“pinkin g up ”) (Fig u r e 4 ). If the testis appears v ia b le, or the timefra m e suggests t h at s al v age is reas o n able t h en o rchiopexy is perfor m ed by anchoring the tunica albuginea of t h e testis to the overlyi n g parieta l tunic a vaginalis and scrotal dartos m uscle with permanent suture . Fi g ur e 4 . Ex p l or atio n of torse d testis . N o t e dark , cyan o ti c c o lor of testi s f o llowi ng 3 0 m i nu te s o f d et o rsio n s u g g estin g n o nvia b ility. In general, scrotal exploration is a procedure of low m orbidity. A negative exploration seldom results in l o ng term complic a tions. W h en we i ghing conser v a tive tre a t m ent with t h e loss of a potentially salvageable testis, it is best to err on the side o f exploration . I n ca ses of “late torsion” or “esta blished torsion , ” exploration generally re v eals a h e m o r rhagic, fran k ly necr o tic testis for which orchiecto m y should be perfor m ed. “Inter m itte n t” testicular torsion is a well - recognized entity in w h ich a classic t o rsion history is obtained, but physical exa m inat i on and ultrasound findings are nor m al. In such cases, it is reasonable to o ff er an elective bil a te r al s crot a l orc h i o pexy f or the possibility o f inter m itte n t sy m p to m s beco m ing full - fledged torsion. Torsio n o f testicula r o r epididyma l appendages S m all polypoid appendages are oft

en found attached to the testis or epididy m is and are either Mullerian or W olffian duct re m nants (Figure 5 ). S i m ilar to testis torsion, torsion of the appendix testis or ap p endix epi d i d y m is can al s o present with the acute o nset of scr o tal pain and m ass. In most cases, however, the testis is palpable and has a nor m al li e . If encountered early, the ede m atous, torsed appendage can often be palpa t ed at the upper pole of the testis. If the torsed appendage is ecchymotic, it can usually be seen through the skin and represents the "blue - dot sign." D oppler ultrasound will de m onstrate a nor m ally perfused tes t is, often with hypervascularity in the area of the appendage. This process is often self - limited, with the infarcted appen dage undergoing atrophy with ti m e. 6 Fi g ur e 5 . Ill u s t rati on o f t h e com mon ap p en d i ce s o f t h e testi s and e p i d i d y m is . Th e ap p en d i x testi s i s m o s t c o m m on l y affecte d b y t o rsio n. If exploration is pursu e d, the appendage is si m ply excised and no orchidopexy is needed. Later in its course, it can be m ore difficult to distinguish this entity f rom testic u l ar to r sion or epididy m itis, as global enlarge m ent and ede m a of the scrotal co m p ar t m ent m ay occur. Ultrasound is valuable here to identify nor m al blood flow to the testis. TRA U MA Penetrating and blunt testicula r injury Testicular rupture results when t h ere is laceration of t h e tunica albuginea of the testis, such that testicular parenchy m a may extrude. It m ay occur from either blunt or penetrating trau m a. As a general principle, penetrating injuries to the scr o tum should be surgically explored . T he risk of testicular injury is quite high w ith t h ese i n juries and the role of ultrasound in the diagnosis of testicular rupture in this setting is limited . Even penet r ating inju r i e s with a tan g enti a l trajectory have a high likelihood of injuring the testis or cord structures . In cases of blunt trau m a, however, the incidence of testicular rupture varies widely, and depends on the forces exerted, the mechanism of injury, a n d testis m obility. F o llowing blunt i n j u ry, the phy s ical exa m ination findings m ay include swelling, tenderness or e c chymosis . I f on e ca n clearl y palpate the testis and it is entirely nor m al to palpation, rupture is unlikely. If there is significant scrotal wall thickening from ed e m a or he m atoma, testicular palpat i on may be difficult or i m possible, and scrotal ultrasonography can deter m ine the degree of te s tis injury with a high level of accuracy . In addition to demonstrating a br eak in the continuity of the t unica albuginea or evidence of extruded parenchy m a, ultrasound eviden

ce of a m arked loss of internal ho m ogeneity of the testis is highly predictive of testicular rupture and warrants surgical e xploration. Blunt injury m ay r e su lt in testicular rupture, intratesticular hematoma, testicular contusion (bruising) or hematocele (blood collection withi n the tunica vaginalis space). Among these, only testicular rupture requires surgical repair , though surgical exploration is indicated for large hematomas or imaging that fails to rule out rupture . Large or painful he m atoceles may benefit from drainag e . For intratesticular he m ato m a (intact tunica albuginea, localized he m ato m a wit h in an otherwise intact testis) or local tenderness (contusion), observation , rest , col d pack s an d anal gesics are appropr iat e therapy. Surgical exploration for trau m a is perfo r m ed th roug h incision s tha t anticip ate the structures at risk. For penetrating trau m a, a vertical incision m ay be easily e x tended into the groin to expose the sper m atic cord. For blunt trau m a, a trans v er s e incision o v er the inj u r e d scrot a l c o mpart m ent is effective. After inspecting and d raining the tunica vaginalis space, any 7 extruded testicular parenchy m a is inspected, irrigated and resected or retained and tunical lacerations repaired. The testicular compart m ent m ay be drained, general l y with a s m all Penrose drain. W ith trau m a, m o st testicular i n juries are a m enable to repair. Orc h i e cto m y is indicated when t here is m ajor inj u ry to the spermatic cord with organ devitalization, and destruction of parenchy m a is so extensive that no significant tissue can be salvaged. INFECTIONS Epididymitis and epididymoorchitis Although they m ay be difficult to distinguish on physical exa m ination from scrotal trau m a or testis t o rsio n , it is i m portant to accurately d iagno s e epi d idy m itis and o rchitis, as their m anage m ent is entir e ly n onsurgic a l. Epididy m itis is usu a lly caused by i n f ections. In m en 35 years old with a history of sexually transmitted infection ( STI ) exposure , recent sexual activity , epididy m itis is often caused by Chla m ydia or gonococcal infection, and is generally a m enable to treatment with ceftriaxone and doxycycline . In older m en and those with proble m s such as significa n t benign prostatic hypert r oph y (BPH) , a history of UTIs, or urethral stricture d isea s e, enteric, gram negati v e bacteria related to ascending urinary infection are m u ch m o re likely causes and warrant the empiric use of a fluoroquinolone , such as levofloxacin . I n eith e r ca s e , initial b ro a d - spectrum antibi o ti c s should be used until culture results direct further therapy . There are also noninfectious or inflammatory for m s of epididy m itis. The s e are due to the a

dverse effects of m edications, u rin a ry re f lux within the e jac u latory ducts, and sperm and fluid extra v asati o n after vasecto m y. W h en epididy m itis e x tends i n to the t e stis a n d causes testicul a r ten d e r ness and enlarge m ent, it is t e r m ed epididy m oorchitis. The r e are se v eral features in the p a tient history that m ay indicate epididy m iti s , such as a h istory of previous STI, recent sexual activity , irritative voiding sy m p to m s , BPH/incomplete emptying of the bladder, or UTI. The very sudden onset of pain and swelling is m ore typica l o f torsion , w h il e a m or e gradual, progres s ive onset pain (often greater than 24 ho u rs) suggests epididy m iti s . On physical exa m ination, epididy m itis presents with tenderness posterior and lateral to the testis (the usual location of the epididy m is). Scrota l ultrasoun d m a y sho w an enlarged, hyper vascular epididy m is with nor m al or increased blood flow to the testis, which will d isting u ish t h is condition from torsion or trau m a. Ab s cess for m a tion within the epididy m is or in the peri - epididy m al tissues, can also be detected by ultrasound. The diagnostic challenge occurs when trying to distinguish advanced e p ididy m oorchitis from l a te torsion. In both entities, there is typic a lly a c on f luent m a ss in the sc r o tum with ede m a and f i xation of the overlying scrotal wall tha t obliterate nor m al anato m ic land m arks. Fur t her m ore, advanced epi d i d y m oorchitis can res u lt in te s tic u lar ische m ia and in f arction due to co m p ression of t h e te s ticular vasculature from epididy m al inflammation. On ultrasound, this m a y present in a very si m ilar m anner to testis torsion. In either case, the lack of testis blood flow on Doppler ultrasound requires surgical exploration which allo w s these condition s t o b e differentiated. When diagnosed, epi d i d y m itis and o rchitis are managed con s ervatively w ith a n tibi o tics, anti - inflam m ato r ies , analgesics, rest and scrotal ele v ation. If ab s cess for m ation occurs, surgical drainag e and/o r orchiect o m y m ay be necessary. 8 Scrotal wall infe c tions Infectious conditions w i thin t h e scrotal wall are also class ifie d unde r th e acut e scrotu m and include cellulitis and fasciitis (gangrene). Scr o t a l wall c ell u litides and a b scess f or m ation are distinguishable from testicular condit i ons on physical exa m ination, as the testis is usually palpably nor m al and nontender, if it can b e palpated w ithout co m p ressing the infla m ed scrotal wall. Scrot a l wall in f ections m ay result f r o m in f ec t ed sebaceous cysts, folliculitis, or other der m atologic conditions. Incis i on and drainage with gauze packin g an d broad - spectrum

anti b iotics a re pre s c r ib e d f or these s uper f ici a l c o nditions. F a s ciitis of scr o tum and groin, ter m ed Fournier’s gangrene, involves a rapidly progressive, life threaten i ng infection of t h e g e nit a l so f t tissu e s. It is associ a ted w ith predisposin g issue s includin g ureth ral perforation and periurethral abscess and is m ost often seen in the immunocompro m ised or diabetic patient. On physical exa m ination, there can be diffuse enlarge m ent, thickening and erythe m a of the scrotal wall, groin and perineu m . There m ay be necrotic black or ecchy m otic patches of genital s k in prese n t (Figure 6 ). F i g u re 6 . F o ur n i er ’ s ga n gr e n e o f t he sc r o tu m . N o t e necr o tic , blac k patc h o f scrota l s k i n wi t h lar ge ulcerat i o n. (F r o m : Aho T et a l . ( 2 00 6) F o ur n i er ' s g a n gre ne Na t Cli n Prac t Ur ol 3: 54 – 5 7) The m ost diagnostic is the finding of crepitus, a spongy, cracking feeling w ithin the skin that indicates gas - producing m icroorgan i s m s underneath that can be felt in the scrotum or perineu m . Wh en le f t untre a ted, g e nit a l gangr en e will p ro g ress ov e r h o urs and r e sult in ov e rwhel m ing bact e ri a l se p sis with an a ssociated high m ortality rate. Therefore, broad spectrum antibiotics that co v er aerobic and a n aerobic organis m s, and urgent and re p eated s u rgical drainage and debride m ent are required to control the infection. In a clinically stable patient, CT may be advantageous to identify a perirectal abscess, rectal process, or for the tracking of air beneath in deeper tissues and following fascial planes. At the ti m e of surgical treat m ent, cystoscopy and proct oscopy m ay be perfor m ed to exclude urethra l an d rect al abnormalities. Scrotal wall inflammati o n Henoch - Schonlein purpura (HSP) is a vasculitis of scrotal w a ll that causes thickening and erythe m a in the abse n ce of infe c tion (Figure 7 ) . Idiop a thic s crot a l ede m a and f ila r ial in f ections ( r are in the US) can also cause c h ro n ic, r e lativ e ly painl e ss, s c rot a l swelli n g. Lastly, s c rot a l ede m a secondary to hypoalbu m ine m ia, portal hypertens i on and ly m p hadenopathy are also rare but significant conditions that m ay o ccur under the aegis of the acute scrotum. In m ost of these conditions, the history of a slowly progressive disease process helps differentiate them from more classically acute conditions. T reat m ent of the underlying, non - scrotal cause is m ost e ff ective to r elie v e the s c rot a l sy m pto m s. 9 F i g u re 7 . Characteristic scrotal erythema in Henoch - Schonlein purpura . (F r o m : Modi S et al . : Acute Scrotal Swelling in Henoch - Schonlein Purpura:

Case Report and Review of the Literature. Urol Case Rep. ( 2016 ) 6:9 - 11. ) INGUINAL HE R NIA An acute in g u inal hernia m ay also present as an a c ute scr o tu m . In this case, pain and s w elling involve both the scrot a l contents and the groin area. Al t hough i m portant to differentiate, it m ay be difficult to distinguish an i n carcerated inguinal h e rnia from other, less e m ergent, scrotal issues such as hydrocele, scrotal trau m a, or scr o tal abscess. An incarc e rated inguinal hernia involves bowel that is obstructed and is a true surgical e m erg e ncy. In selected, less acute cases, g roin and scrotal ultrasound or pelvic CT sca n s can clarify the diagnosis before surgical exploration. Hernia repairs that use polypropylene m esh for corr e ction m ay be associated with vas deferens obstruction a nd infertility later on. ACU TE ON C HR O NI C E V E NTS Other scrotal conditions that are chroni c i n natur e ca n als o p resent with acute sy m pto m s and include testicular neoplas m s, spe r m a tocele s and h ydrocele s . In the ca s e of testis tu m ors, patie n ts m ay only b e co m e aware of the m ass after it has b een pre s ent for m any m onths, after it affects the appeara n ce of the scrotu m . However, testi c ular tu m o rs can present precipitousl y i f they undergo hemorrhage or necrosis, a n d produce s w elling, pain and soreness. In t h is case, a scrotal physical exa m ination reveal s a fir m , intratesticular m ass and scrotal ultrasound de m onstrates a solid intratesticular m ass which has a� 90% likelihood of being a germ cell tu m or. The suspicion of tu m or is i m porta n t f or th e approac h t o explora tory surgery in the ac u te scrotu m , as the correct surgical approach to tes t is cancer is through an i nguina l incisio n an d not trans c rotall y . In addition, the t e stis a n d its i n v est m ents are dis s ected o u t intact, to m ini m ize tu m or spill a ge during s u rgery and s p er m atic cord lig a tion is d one in the i n guinal regi o n to further co n t ain the spread of cancer. Other chronic scrotal lesions which can prese n t acutely include hydroce l es (increased fluid within t h e t u nical v agin a lis sp a ce) a n d sper m atoceles (cystic dilat i on of the fine ducts that lead f rom the rete te s tis to t h e epididy m al head) t h at he m o rrhage after trau m a, or beco m e infected. In addition, a scrotal varicocel e , a c o ndition characterized by dil a ted pampiniform plexus veins and that occurs in 15% of m en at puberty, can be present for yea r s bu t beco m e acutely sy m p to m atic. These dilated veins surround the spermatic cord. If the varicocele has acute onset, is only right - sided, or persists in the supine position, then inferior vena caval (IVC) obstruction must be excluded

(i.e., IVC thrombus, abdo minal mass, etc. ). A careful history, 1 0 physical exa m ination and ultrasound exa m ination is usually sufficient to diagnose these usually b e nign acute on chronic e v ents . Urgen t surgi cal intervention is rarely needed for drainage of a loculated inf e ction or for a persistent he m orrhage associated with hydroceles or sper m atoceles. SUMM A RY  A full range of scrotal pathology m ust be considered in acute scrotum cases.  Several co n ditions th a t r esult in ac u te scrot u m r e quire s u rgi c al exploration , m a kin g this a very ti m e sensitive condition.  A high val u e is place d on the history, physical exa m ination and ultrasound i m aging for acut e scrotu m diagnoses. R EFE R EN C E S : Meacham RB: Potential for vasal occlusion among men after hernia repair using mesh. J ournal of Andrology . (2002) 23:759 - 761. Joyner B & Walsh T: Evaluation of the Pediatric Patient with a Non - Traumatic Acute Scrotum: AUA Update Series (2005), Volume 25, Lesson 12. Kim SH et al.: Significant predictors for determination of testicular rupture on sonography: a prospective study. J ournal of Ultrasound Med. (2007) 26:1649 - 1655. Lin EP et al.: Testicular torsion: twists and turns. Semin Ultrasound CT MR. (2007) 4:317 - 328. Callewaert PR et al . : New insights into perinatal testicular torsion. Eur J Pediatr . (2010) 169 :705 – 712. Sheth KR et al . Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score. The Journal of urology . (2016) 195: 1870 - 6. Kwenda EP et al . : Impact of hospital transfer on testicular torsion outcomes: A systematic review and meta - analysis. J Pediatr Urol . ( 2021 ) 17 :293.e1 - 293.e8. Tracy CR et al.: Diagnosis and management of epididymitis. Urol Clin North Amer . (2008) 35:101 - 108. Morey AF et al . : U rotrauma Guideline 2020: AUA Guideline. J Urol. ( 2021 ) 205 :30 - 35. Dupond - Athénor A et al. : A multicenter review of undescended testis torsion: A plea for early management. J Pediatr Urol. ( 2021 ) 17 :191.e1 - 191.e6. 1 1 AUTHORS 2021 Kathleen Kieran, MD, FACS, FAAP, MSc Seattle, WA Disclosures: Nothing to Disclose Brendan Kiely Wallace, BS New York, NY Disclosures: Nothing to Disclose 2018 Elizabeth Takacs, MD Iowa City, IA Disclosures: Nothing to Disclose 2016 Seth Cohen, MD Arcadia, CA Disclosures: WebMD, Health Publishing; American Urogynecologic Society, Leadership Position; MicrobeDx, Consultant or Advisor William Gans, MD West Palm Beach, FL Disclosures: Opko, Investment Interest 2012 Bruce Slaughenhoupt, MD Madison, WI Disclosures: Nothing to disclose © 20 21 American Urological Association Education and Research, Inc.® All Rights Reserved