What is the best approach to document and manage swelling and erythema of the scrotum and penis?

Documentation of Scrotal and Penile Swelling and Erythema

Document the anatomic location, size, laterality, associated symptoms (pain, fever, urinary symptoms), duration of symptoms, presence of trauma, and testicular position/perfusion status on physical examination. 1

Essential Documentation Elements

History Components

• Onset and duration: Record exact time of symptom onset, as delay beyond 6-8 hours significantly increases risk of testicular loss in torsion cases 2, 3
• Pain characteristics: Document presence, severity, and timing (sudden onset suggests torsion; gradual onset suggests infection) 3, 4
• Trauma history: Any recent injury, including minor trauma during intercourse 1, 5
• Systemic symptoms: Fever, urinary symptoms, or constitutional symptoms 2, 6
• Sexual history: Recent sexual activity (relevant for infectious etiologies) 2

Physical Examination Documentation

• Anatomic specificity: Document exact location—"superior scrotum," "distal penile shaft," "glans penis"—rather than vague terms 1
• Laterality: Specify unilateral versus bilateral involvement 1
• Measurements: Record diameter of swelling in centimeters 1
• Skin changes: Document erythema, ecchymosis, skin thickening, or perforation 5, 3
• Testicular examination: Record testicular position (high-riding suggests torsion), cremasteric reflex presence, and ability to palpate testicular contours 5, 4
• Associated findings: Presence of inguinal lymphadenopathy, penile discharge, or leg edema 1

Immediate Diagnostic Workup

First-Line Imaging

• Ultrasound with Doppler is mandatory for evaluating scrotal edema when diagnosis is unclear, with high sensitivity for distinguishing etiologies 2, 3, 6
• Both grayscale and color Doppler should be performed to assess testicular perfusion 2
• Document specific ultrasound findings: testicular blood flow (present/diminished/absent), testicular contour integrity, heterogeneous echotexture, hydrocele, and "whirlpool sign" 5, 3

Laboratory Studies

• Urinalysis should always be performed 4
• White blood cell count and inflammatory markers if infection suspected 7, 6

Critical Clinical Pitfalls

• False-negative Doppler evaluations can occur in partial torsion or spontaneous detorsion 2, 3
• Early presentation may not show all classic symptoms, potentially leading to missed diagnosis 2, 3
• 30-50% of palpable inguinal lymphadenopathy in penile lesions is due to inflammatory changes rather than malignancy, requiring 6-week antibiotic trial or fine-needle aspiration before definitive intervention 1
• Failure to improve within 3 days of treatment requires reevaluation of both diagnosis and therapy 2

Documentation Template Structure

Document in this algorithmic format:

1. Chief complaint with timeline: "Acute scrotal swelling and erythema for 12 hours"
2. Anatomic description: "Bilateral scrotal edema extending to superior scrotum with erythema of distal penile shaft"
3. Measurements: "Right hemiscrotum 8 cm diameter, left 6 cm"
4. Pain assessment: "Severe pain, 8/10, sudden onset"
5. Testicular examination: "Right testis high-riding, absent cremasteric reflex, left testis normal position"
6. Vascular status: "Doppler ultrasound shows absent right testicular blood flow"
7. Working diagnosis and urgency: "Suspected right testicular torsion—surgical emergency"

This structured approach ensures medicolegal completeness while facilitating rapid clinical decision-making for time-sensitive conditions like testicular torsion or compartment syndrome. 2, 5, 3