The acute scrotum

In boys and adolescents, the acute scrotum usually results from one of three diseases: torsion of the spermatic cord, torsion of the appendix testis, or epididymitis. A rapid diagnosis of torsion of the cord, if present, is essential, and as soon as this diagnosis is made, arrangements must be made for timely surgical correction. Although a diagnosis for the acute scrotum in this age group can sometimes be made on the basis of the history, pathognomonic signs, and basic laboratory analysis of the urine and a urethral discharge, in the usual case diagnosis requires a Doppler ultrasound examination (which if positive for torsion makes the diagnosis), a radionuclide scan (for cases negative or indeterminate for torsion on the Doppler examination), or, as a last resort, scrotal exploration. In men, by far the most common cause of the acute scrotum is epididymitis, with the torsions being much less common. In heterosexual young men with epididymitis, N. gonorrhoeae and C. trachomatis are the most likely etiologic organisms; in homosexual men and older men (and boys), E. coli, Pseudomonas sp., and the gram-positive cocci are the most common pathogens. Ceftriaxone plus tetracycline is the initial antimicrobial regimen of choice in heterosexual young men; in the absence of evidence of a sexually transmitted pathogen, one of the antimicrobials effective against common urinary tract pathogens is the initial antimicrobial of choice in all other patients. When torsion of the cord is suspected in adult male patients, the Doppler examination and the radionuclide scan (if the Doppler is negative or indeterminate) can again make the diagnosis or rule it out.