What are the evaluation and treatment options for chronic right scrotal atrophy?

Chronic Right Scrotal Atrophy: Evaluation and Management

For chronic right scrotal atrophy, perform scrotal ultrasound with Doppler to identify the underlying cause (varicocele, prior torsion, trauma, infection), and if the testis is non-functional and causing chronic pain, consider orchiectomy as definitive treatment. 1

Initial Diagnostic Evaluation

Scrotal Ultrasound with Doppler

• Perform high-resolution grayscale and color Doppler ultrasound as the first-line imaging modality to assess testicular size, parenchymal echotexture, and vascular perfusion 2, 3
• Measure testicular volume using automatic measurement options based on the formula of a rotating ellipsoid or three perpendicular measurements 3
• Evaluate for heterogeneous echotexture of parenchyma, which may indicate prior ischemic injury or inflammation 2
• Assess arterial and venous flow patterns with spectral Doppler in the upper, mid, and lower poles of each testicle 2
• Compare findings to the contralateral normal testis as an internal control 2

Key Differential Diagnoses to Evaluate

Prior testicular torsion with ischemic atrophy:

• Look for history of acute scrotal pain that may have spontaneously resolved (missed torsion) 2
• Ultrasound findings include small, heterogeneous testis with diminished or absent blood flow 2
• Early exploration and repair of testicular torsion prevents ischemic atrophy, but chronic atrophy indicates missed or inadequately treated torsion 2

Traumatic injury:

• Obtain history of blunt or penetrating scrotal trauma, even if remote 2
• Testicular rupture that was not surgically repaired can lead to ischemic atrophy 2
• Traumatic dislocation of the testis can result in partial atrophy of seminiferous tubules and impaired spermatogenesis 4

Chronic epididymo-orchitis or lymphocytic orchitis:

• Evaluate for history of genitourinary infection, sexually transmitted infections, or recurrent epididymitis 2, 5
• Idiopathic lymphocytic orchitis can manifest as testicular pain and atrophy with unremarkable conventional investigation results 5
• If pyospermia or signs of infection are present, consider infectious workup 2

Varicocele:

• Examine for palpable varicocele on physical examination 2
• Color Doppler ultrasound can identify spermatic cord veins if examination is difficult 2
• Do not routinely perform abdominal imaging for an isolated small or moderate right varicocele 2
• However, consider abdominal imaging for new onset or non-reducible varicocele, especially if large, to exclude retroperitoneal pathology 2

Acquired cryptorchidism (secondary ascent):

• Determine if the testis was previously descended but has now ascended and cannot be manipulated back into the scrotum 6
• Germ cell damage begins after 15-18 months with progressive loss of fertility potential 6
• Even with successful orchiopexy, lifelong surveillance for testicular cancer is needed, with relative risk 2.75-8 times higher 6

Testicular tumor:

• Swelling and tenderness that persist after antimicrobial therapy should be evaluated comprehensively, including consideration of tumor 2
• Biopsy may be needed if diagnosis is uncertain or lesions do not respond to standard therapy 2

Management Based on Etiology

If Testis is Non-Salvageable or Causing Chronic Pain

• Perform orchiectomy for definitive treatment of chronic scrotal content pain when the testis is atrophic and non-functional 2, 5
• Orchiectomy was effective in resolving chronic pain in a patient with idiopathic lymphocytic orchitis and testicular atrophy 5
• For testicular rupture that is non-salvageable, orchiectomy is indicated 2

If Chronic Pain Without Clear Structural Pathology

• Consider spermatic cord block as a diagnostic and potentially therapeutic intervention 1
• Microdenervation of the spermatic cord is emerging as a reasonable and effective outpatient surgical technique for chronic scrotal content pain 1
• Successful results appear to be predicted by a temporary but complete response to a spermatic cord block 1
• A trial of oral steroids may be considered for inflammatory causes, though the effect may be temporary 5

If Varicocele is Identified

• Treatment of varicocele may be considered if it is contributing to symptoms or fertility concerns 2
• Clinical (non-palpable) varicoceles identified only on ultrasound should not be treated 2

Important Clinical Pitfalls

• Do not order imaging studies routinely for retractile testis or cryptorchidism evaluation, as they rarely assist in decision-making 6, 7
• Recognize that chronic orchialgia is frequently idiopathic, and many patients will see multiple physicians during evaluation 1
• The term "chronic scrotal content pain" is more appropriate than "chronic orchialgia" since pain may involve the epididymis, vas deferens, or adjacent paratesticular structures 1
• For bilateral nonpalpable testes in a phenotypic male, immediate specialist consultation is required to rule out disorders of sex development 7