Idiopathic Scrotal Edema

Fig. 29.22 A clinical photograph with idiopathic scrotal edema

•Over 75 % of cases occur in boys less than 10 years of age.

•Two thirds of cases are unilateral.

•Idiopathic scrotal edema is characterized by:

–The rapid onset of significant edema without tenderness.

–Painless erythema and induration of the scrotum.

–Edema and erythema may extend to the phallus, groin, and lower abdomen.

–The patient is usually afebrile.

–Patients may complain of pruritus.

–All diagnostic tests are negative.

•The etiology of this condition remains unclear.

•An allergic reaction is the most likely cause.

•Sonography plays an important role in excluding testicular torsion, epididymitis, and torsion of a testicular appendage and confirming the diagnosis of acute idiopathic scrotal edema.

•Treatment consists of bed rest and scrotal elevation.

•Analgesics are rarely needed.

•Most cases resolve spontaneously within a few days and do not require specific treatment.

•There is a 20 % recurrence rate.

29.6Testicular Trauma

•Testicular injury is uncommon and usually results from either a direct blow to the scrotum or a straddle injury.

•Traumatic damage to the testes results mostly from forceful compression of the testis against the pubic bones.

•Scrotal trauma can also result in intratesticular hematoma, hematocele or laceration of the tunica albuginea (testicular rupture).

•Color Doppler ultrasonography is the imaging technique of choice.

•Testicular rupture requires immediate surgery and repair.

29.7Other Causes of Acute Scrotum

•Schönlein-Henoch purpura:

–A systemic vasculitis of unknown etiology.

–It is characterized by (Figs. 29.23 and 29.24):

•Nonthrombocytopenic purpura

•Arthralgia

•Renal disease

•Abdominal pain

•Gastrointestinal bleeding

•Scrotal pain

–The onset can be acute or insidious.

–Hematuria may be present.

–The syndrome has no specific treatment.

•Incarcerated inguinal hernia:

–This should be suspected in a child who has a history of intermittent groin swelling.

–The usual presentation is with an irreducible painful and tender inguinal or inguinoscrotal swelling.

–In those with strangulated hernia, there may be an associated scrotal swelling and redness (Figs. 29.25 and 29.26).

–This may be due to bowel congestion and ischemia or sometimes localized bowel perforation.

–An incarcerated or strangulated hernia requires urgent surgical intervention.

Figs. 29.25 and 29.26 A clinical and intraoperative photographs of a child who presented with a strangulated right inguinal hernia. Note the associated scrotal swelling, and redness secondary to intestinal ischemia

•Hydrocele:

–A hydrocele occurs because of a patent processus vaginalis.

–Most hydroceles resolve spontaneously.

–The usual presentation is that of a scrotal swelling that transilluminate and usually does not cause pain (Figs. 29.27 and 29.28).

29.8Splenogonadal Fusion

•Splenogonadal fusion is a rare congenital malformation that results from an abnormal fusion between the primitive spleen and gonad.

•Splenogonadal fusion is a rare, benign, congenital anomaly thought to occur between the fifth and eighth weeks of intrauterine life where immature splenic tissue adheres to the developing gonad, epididymis or vas deferens.

•The splenic tissue is subsequently pulled in a caudal direction with descent of the gonad.

•Karaman and Gonzales in 1996 reviewed 137 cases of splenogonadal fusion and surprisingly 37 % of the patients had orchiectomy because of suspicion of a testicular tumor.

•This is of great importance and to obviate this physicians caring for these patients should be aware of this and intra-operatively if there is doubt concerning the nature of the

VARICOCELE

Fig. 29.29 A clinical photograph showing a left varicocele

swelling, intra-operative frozen section biopsy should be performed to avoid unnecessary orchiectomy.

•Splenogonadal fusion occurs more commonly in males with a male-to-female ratio of 15:1. This figure may of course be inaccurate due to the relative inaccessibility of the ovary to clinical examination.

•It is seen nearly always on the left side.

•Splenogonadal fusion is common in children and adolescents.

–The number of cases reported in patients <10 years of age account for 50 % of the total cases reported.

–The number of cases reported in patients <20 years old account for 70 %.

•Splenogonadal fusion is commonly asymptomatic discovered incidentally during routine herniotomy or orchidopexy.

•Splenogonadal fusion may presents as an asymptomatic testicular mass.

•Many of these cases however go passed unnoticed or discovered at autopsy.

•Other manifestations may include acute testicular pain and swelling caused by ectopic splenic tissue infections.

•In the pediatric age group, these patients commonly present with a scrotal swelling and may rarely present with an acute scrotal pain as a result of torsion or involvement of splenic tissue with other pathological conditions such as mumps, malaria, leukemia, trauma and infectious mononucleosis.

•Not uncommonly splenogonadal fusion is associated with other anomalies or discovered during the evaluation of these associated anomalies. This is more so with the continuous type which is known to be associated with other associated anomalies in as much as 33 % of the cases.

•There are two types of splenogonadal fusion:

–Continuous

–Discontinuous

Fig. 29.30 A clinical intraoperative photograph of splenogonadal fusion diagnosed in a child with unusual testicular swelling

•In continuous splenogonadal fusion there remains a connection between the main spleen and gonad.

•In discontinuous splenogonadal fusion, ectopic splenic tissue is attached to the gonad, but there is no connection to the main spleen.

•The continuous form occurs when the normally located spleen is attached to the gonad by a discrete cord.

•In the discontinuous type the splenic tissue is attached to the gonad and completely

separated from the normal spleen (Fig. 29.30).

•Both types occur with equal frequency and the discontinuous type may be discovered incidentally during herniotomy or orchidopexy or present as a scrotal swelling. Awareness of this is of great importance to avoid unnecessary orchiectomy mistaken it for a testicular tumor.

•Treatment is surgical excision and every attempt should be made to preserve the gonad at the time of dissection and excision which should not be difficult since true fusion with the gonad is rare.

•Although there have been few reports of an association of testicular neoplasms with splenogonadal fusion, it appears that this is a coincidental finding rather than an association as these tumors occurred in adults with undescended testes.

•The diagnosis of splenogonadal fusion should always be kept in mind and included in the differential diagnosis of testicular swelling in infants and children.