What is the treatment for scrotum swelling?

Treatment of Scrotal Swelling

The treatment for scrotal swelling depends on the underlying cause, with ultrasound being the first-line imaging modality to differentiate between emergent conditions requiring surgery and those requiring medical management. 1

Diagnostic Approach

• Scrotal ultrasound with Doppler is the primary imaging modality for evaluating scrotal swelling, with high sensitivity (96-100%) and specificity (84-95%) for detecting conditions like testicular torsion 1
• The three most common causes of acute scrotal pain and swelling are torsion of a testicular appendage, epididymitis, and testicular torsion, accounting for 85-90% of cases 1
• Rapid and accurate diagnosis is essential as testicular torsion requires surgical intervention within 6-8 hours to prevent testicular loss 1

Treatment Based on Etiology

Testicular Torsion

• Surgical emergency requiring immediate exploration and detorsion within 6-8 hours of symptom onset 1
• Characterized by sudden onset of severe pain, absence of cremasteric reflex, and decreased or absent blood flow on Doppler ultrasound 1
• Surgical management includes detorsion, bilateral orchiopexy if the testicle is viable, or orchiectomy if necrotic 1

Epididymitis/Epididymo-orchitis

• Most common cause of acute scrotal pain and swelling in adolescent boys and adults 1
• Treatment regimens based on likely causative organisms:
  • For gonococcal or chlamydial infection (typically in men <35 years): Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg orally twice daily for 10 days 1
  • For enteric organisms or in men >35 years: Ofloxacin 300 mg orally twice daily for 10 days or Levofloxacin 500 mg orally once daily for 10 days 1
• Adjunctive measures include bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 1
• Failure to improve within 3 days requires reevaluation of both diagnosis and therapy 1

Torsion of Testicular Appendage

• Most common cause of acute scrotal pain in prepubertal boys 1
• Conservative management with rest, scrotal support, and analgesics is typically sufficient 1
• Can be identified by the "blue dot sign" (visualization of the infarcted appendage through the skin), though this is only visible in 21% of cases 1

Idiopathic Scrotal Edema

• Self-limiting condition, more common in children 1
• Treatment is supportive with scrotal elevation and anti-inflammatory medications 1

Fournier's Gangrene

• Necrotizing infection requiring immediate surgical debridement, broad-spectrum antibiotics, and intensive care 2, 3
• Early recognition and aggressive surgical debridement of all necrotic tissue is crucial for survival 3

Hydrocele

• If symptomatic or large, surgical correction may be indicated 1
• Small, asymptomatic hydroceles may be observed 1

Follow-up Considerations

• Patients with epididymitis should be reevaluated if symptoms don't improve within 3 days 1
• Persistent swelling or tenderness after completion of antimicrobial therapy requires comprehensive evaluation for other conditions including tumor, abscess, infarction, or testicular cancer 1
• Men with a history of cryptorchidism should be monitored for increased risk of testicular cancer (3.6-7.4 times higher than general population) 1

Pitfalls and Caveats

• Testicular torsion can be missed if relying solely on clinical presentation, as symptoms may overlap with other conditions 1
• The absence of urinary symptoms or pyuria does not exclude epididymitis 1
• Scrotal edema can rapidly develop and obscure physical examination findings, making early imaging crucial in unclear cases 1
• Failure to recognize Fournier's gangrene can lead to rapid progression and mortality; any necrotizing infection of the scrotum requires immediate surgical intervention 3