Anatomical Approach to Scrotal Emergencies: A New Paradigm for the Diagnosis and Treatment of the Acute Scrotum

摘要

Acute scrotal pain is a common reason for emergency room visits in men of all ages, but especially in children and young adults. Differentiating those etiologies that require immediate surgical intervention from those that can be treated medically is often challenging. Excluding testicular torsion and avoiding unnecessary surgery although difficult in the past is easier now with advances in ultrasound and other diagnostic techniques. In this paper we suggest an anatomical approach to the acute scrotum by partitioning the contents of the scrotum and spermatic cord into distinct zones. It is postulated that this will facilitate physical and ultrasound exam making pre-surgical diagnosis more accurate. Zone I extends from the internal ring through the inguinal canal to the end of the spermatic cord. Zone II comprises the scrotum, subcutaneous tissues and the tunica vaginalis. Zone III encompasses the testicle with associated appendage and Zone IV includes the epididymis with its appendage. All pathological conditions affecting each zone and the resulting presentation of the acute scrotum are discussed. Introduction Acute scrotal pain is a common reason for emergency room visits in men of all ages, but especially in children and young adults. Differentiating those etiologies that require immediate surgical intervention form those that can be treated medically is often challenging. Early surgical exploration was universally recommended in the past when testicular torsion could not be confidently differentiated from other common etiologies, such as, epididymitis or torsion of an appendage. This methodology promoted unnecessary surgery in many patients that could otherwise have been treated conservatively. With advances in ultrasound and other imaging techniques, it may be possible to make a rapid definitive diagnosis of a benign disorder thus avoiding surgery or unnecessary antibiotics. In this paper we suggest an anatomical approach to the acute scrotum by partitioning the contents of the scrotum and spermatic cord into four distinct zones. It is postulated that this will facilitate physical and ultrasound exam making pre-surgical diagnosis more accurate.Anatomical Zone Classification ParadigmPathological conditions of the contents of the inguinal canal and scrotum can produce symptoms that make localization of the disease process difficult. We suggest the following paradigm of zonal classification of the anatomical constituents in order to aid in the management and treatment of the acute scrotum (Figure 1). Following, a comprehensive review of all disease processes affecting each zone is presented.