What are the symptoms of scrotal compartment syndrome?

Symptoms of Scrotal Compartment Syndrome

Scrotal compartment syndrome is characterized by acute scrotal pain, swelling, and redness of sudden onset, which requires immediate medical attention to prevent testicular loss due to impaired microcirculation and resulting hypoxia. 1, 2

Key Clinical Manifestations

• Acute scrotal pain of sudden onset, typically developing within minutes to 1-2 days 3
• Scrotal swelling and redness 3
• Testicular tenderness on examination 4
• Possible fever and systemic symptoms in advanced cases 4
• Dull purple appearance of the affected testicle in severe cases (visible during surgical exploration) 1, 2

Pathophysiological Signs

• Impaired microcirculation in the testicle due to increased venous resistance or extraluminal compression 2
• Elevated tissue pressures (above 30 mmHg) within the testicular compartment 1, 2
• Progressive hypoxia leading to testicular ischemia if not promptly addressed 1, 2
• Potential for ischemia-reperfusion injury with resulting oxidative stress 2

Associated Findings on Examination

• Possible absence of the cremasteric reflex in cases related to testicular torsion 5
• Pain not relieved by elevation of the testicle over the symphysis pubis (negative Prehn sign) in torsion-related cases 3
• Possible "blue dot sign" if related to torsion of testicular appendage (though this is only seen in 21% of cases) 3

Diagnostic Findings

• Ultrasound with Doppler is the first-line imaging modality, showing 3:

  • Decreased or absent blood flow to the affected testicle 3, 4
  • Enlarged, heterogeneous testis that may appear hypoechoic 3
  • Possible ipsilateral hydrocele and skin thickening 3
  • "Whirlpool sign" (twisted spermatic cord) if related to testicular torsion 3

• Early manifestations may include 3:

  • Diminished arterial velocity
  • Decreased diastolic flow
  • Increased resistive index
  • Later progression to absent or reversed diastolic flow

Potential Complications if Untreated

• Testicular necrosis and loss 1, 2
• Impaired fertility 2
• Increased risk of infection 6
• Potential for systemic inflammatory response in severe cases 4

Important Clinical Pitfalls

• Symptoms may overlap with other conditions such as epididymitis, testicular torsion, or torsion of testicular appendage, making diagnosis challenging 3
• False-negative Doppler evaluations can occur in partial torsion or spontaneous detorsion 3, 4
• False-positive Doppler evaluations can occur in infants and young boys who normally have reduced intratesticular blood flow 3, 4
• Delay in diagnosis beyond 6-8 hours significantly increases risk of testicular loss in cases related to torsion 3
• Early presentation may not show all classic symptoms, potentially leading to missed diagnosis 3