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It's okay. Hi, everyone. I'm just going to give us another five minutes. Whatever you want to join, and then we can start five past eight. Yeah. Yes. Oh, yeah. Great. Okay, so that's five minutes past eat. We'll go ahead and start use of for you. You that? Yeah. Right ago. Cool. So thank you, everyone for joining, joining us today for another world by sessions in the urology Siris with mindedly. Um, today's topic is going to be talking about the acute scrutiny. Um, so we go to the next slide, please? Okay. Great. So, uh, just before we go ahead and started, like to give a quick message for one of our sponsors on this is CBD me. So they've designed a cool application, Basically, which you can use to log in or what? Teaching pretty portfolio on. It's designed for people who you registered with the GMC or the intimacy. You Any of this wall of health care professional? You k on? Do you can find it on your android? And I us APs so mindedly have the discount? Sort of. You're interested. You can get 50% off. Just used the QR code provided on do know I'll go ahead and 100 over two you use if you use today's presente. Well, thanks, Doc. Um so money would use if I am a CT two pediatric surgery in Arbor Dean ground. So what we're gonna talk about today is the acute scrotum and learning outcomes there the recognition of the acute scrotum thief or ensure diagnosis and the management of acute scrotal emergencies. And this quite important topic because the acute scrotum is a common presentation to refer iasi of healthcare practitioners. Come comes to primary care to surgeons, pediatricians, um, general surgeons, urologists, pediatric surgeons, etcetera. So, um, presents any obesity as well, So it's good to have on idea about. And what are the various presentations? So we'll start off with testicular torsion. So stick interactions is probably the most important thing when you need to know about, um, it's an acute urological emergency, and the most common and relevant type is inter vaginally torsion, and will will delve into a little bit, but not too much detail about that on gets essentially where you've got an abnormal attachment of the Tunica vaginalis to the lower pole of the testes. Um, so I'm not going to spend a huge amount of time talking about the anatomy. But if you remember, you've got multiple layers of the scrotum. Onda, if you've got a high, narrow attachment of the Tunica VAGINALIS on onto the testes than this complete dispose, dispose of having a portion. Okay, so, um, in terms of the epidemiology, So there's a by motile um, source of, uh, peek. So the first peak is in the perinatal period, and this is what's called an extra vaginal testicular torsion, which is not going to be very relevant to most of you. Um, and it tends to be identified a routine baby check, and the one that's more relevant is thie is the intravaginal torsion on this most commonly occurs in pre puberty or puberty or other boys where there's rapid testicular growth during that puberty phase. Um, essentially, it outgrows the very abnormal high attachment in some Ah, and some young people on predisposes them to torsion so you can see they're run anywhere from Htwe of 2 17. And by that 16, the incident starts to drop. Okay, eso a little bit more about the pathophysiology. So if you look at the diagram of the normal testes. You see it because the spermatic cord and you've got the lining around the testes, The Tunica vaginalis. Um and you've got a normal, longer chewed in law in the lie of the testes is quite important. Um, because if you've got an abnormal life, you are more likely to develop a torsion. So if you look the middle diagram, um, this is a picture of a torsion where you can see that the spermatic cord is twisted around. And essentially, what that means is that you've got on obstruction to the arterial inflow, um, and to the venous outflow to the testes on. Obviously, if if this goes on for too long and returned to get worried about six plus hours, then there's a high risk of of losing the testes and needed gonna work a deck to May with an extra vaginal torsion. And it's essentially it's in the name. So the whole complex from outside the Tunica Vaginalis torts on this has a different path of physiology than than the intervaginally. This is the one the new national portion that we, um, that I've touched upon on do usually we need to look at other reasons. Um, some things that just testicular tumors. Okay, um, if there's any questions about that, Zack just let me know, and I can clarify anything that's fine. Perfect. So I'll just continue to move on. So clinical presentations. So, very classically, it's sudden onset out of the blue. Severe unilateral testicular pain associated with nausea, vomiting. The pain is radiating to the lower optimism on the same side of the testes that's affected. You'll have erythema. You'll have swelling and sometimes, and this is important the location to be a history of trauma. And you'll have little kids in school and primary school or whatever kicking each other in the bulls. And, um, you can't dismiss it as just a bit of pain from the trauma, because sometimes the trauma is, um, is the source of trigger for this to happen. Um, so just bear that in mind in the back of your head. If there's a history of trauma to stick it, A torsion is very important differential to help. The extra vaginal is identified, a routine baby checks and you get an injury. Should marble like swelling on again, it's there's no as much urgency about that because the testes is already dead and is normally a different underlying pathology, um, that you'll need to deal with so on physical examination. You'll have heavy scrotal area thema, and this is important because if you've got everything that that's spreading to the other side or into the perineum or the groin to the Penis, you need to be thinking about about different things. Um, different differential diagnosis. And some of them are more benign than others. Um, particularly in elderly diabetic patients. Um, you need to be thinking about for years. Gangrene, necrotizing fasciitis. That sort of thing needs to be in your head, but with younger Children who have not got any risk factors for any of that, things like idiopathic scrotal, a demon need to be in the back of your mind as well. We won't go into that too much. You'll get a high riding testes that's very important, and you'll get loss of the rugae, which were normal folds in the scrotum, um, on disses. This is a clean, clinical finding, really, to to differentiate a a tortilla testes from others. Testicular pathology. That's less serious. Um, you have loss of the car. Miss Derek Reflex. So it's important to just bear in mind where you're examining your patients with chronic steroid reflexes essentially, where you've had, Um, if you stroke the inner thigh, you'll get a contraction of the Cremaster muscle and the fibers of monster attached. Sporadic cord essentially will pull the testes up, but examining someone in a cold room in a cold any examination room that you're not really going to be able to appreciate a cremasteric reflex. Um, a good trick is to get the patients to cough. And if you can see movement of the testes upwards, um, they're not sometimes fairly reassuring, and you can also get swelling, which is a late sign, And it's usually because you've got a reactive hydrocele, and that means that it's probably been going on for quite a while. And you'd be really worried about the viability of the testes, a diet point, this some pictures just to demonstrate. And the differences between intravaginal on extra vaginal itch or shin um, so you can see um, the intra vaginal one is 30. Um, it looks like a boy who's got more developed external genitalia and you can see that high riding testes in the wall of the regain that I was mentioning before, and it looks like there's an abnormal lie. So if you look at the left testis, it looks like there's a more longer tube in a lie as opposed to a more horizontal abnormal. I, um, off the right testis eso This is strongly suggestive of of distinct tore her shin. Um, on the other side you're seeing in urination is picture of in the unit on Deacon. See, because they got what appears to be a physiological phimosis, you can easily see the mediations with the Penis. You most likely won't be able to retract up for a skin which is normal at that age group. Um, but the interesting part is the right testis where you've got a an injury should dark and And when you tell patients marble like testes on disses invaluable, this isn't viable. Um, so you need to look at underlying reasons for this, um, most important, being a testicular tumor. Um, and this is this is the only This is the only time where imaging radiological imaging is really useful. Because the stick a tourist thing is a clinical diagnosis, and I can't stress that enough, Okay, since the next slide. So you have to stick attrition, clinical diagnosis, so that if you only take away one thing from today's lecture, it's that distinctive rhetorician is a clinical diagnosis. You don't waste time trying to get investigations. And if you call a Brady oh, just ask for an ultrasound scan. In most circumstances, they won't be particularly happy. Um, um, which I completely agree with, um So it's useful in the new nation torsion because you want to exclude, um ah, tumor and as the underlying pathology that might have caused this distinct your portion. Um, but if you're if you're fairly certain from a good history in a good clinical examination, um, that the patient has two or shin, then you need to proceed. Surgical management. Okay, so the surgical management is essentially you need to do an immediate scrotal exploration on, but there's various approach is classically people used to sometimes do a midline incision on describe him. But we're moving away from nuts. Even general surgeons. So certainly pediatric surgery, we definitely will most certainly wouldn't do a midline incision. We would do, um, a transverse incision over there affected hemiscrotum on diffuse needed to explore the other side to do another transverse incision on. These tend to be along the lines of the regains, so they feel they healed very nicely and make small incisions was opposed to making very traumatic incision in the middle. Um, and then you detour still affected testes on What you do is you. You be warm it with lots of warm swabs, and you're waiting for it to pick up again, especially if it's looking particularly dusty. But there's a possibility that it's not going to be viable, particularly if, um, the time to surgery was and was quite prolonged, usually about 6 to 8 hours plus, in which case you need to do an orchidectomy. Um, but if you've made in time, you do an orchiopexy with just interesting means that you're fixing the testes, and the two most common techniques are, um, so what the urologists will do is something called a three point fixation and general surgeons, particularly in DJ Ages or places where there is no urology service, Um, which is which essentially means you suture the testes that three points into the surrounding fascia. Um, what we do in pediatrics is what we created a pouch in the dark. Oh, Slayer. And we put the testes in there, um, and allow adhesions to form and not actually fixes it quite nicely. Um, you do have to explore the contralateral size and fix it. And the reason for that is the, um quite a high proportion of these patients who have had, um, testicular torsion will have had what's called a bell clapper deformity, which is where you have this abnormal, high attachment high and very narrow attachment of the Tunica vaginalis from the testes. So it's happened on one side because of this is more than likely to happen on the other side as well. You need to go pick up the other side. Um, so, yeah, delays of more than six hours dramatically reduce the likelihood of salvage. This is why you don't waste time with radiological investigations. And if the timeline is very short with these symptoms and you've got any diagnostic uncertainty, then you will never be criticized for taking this patient's disease here. Okay, so here's some pictures of of what it looks like. Intraoperatively, um so that the new national one is is interesting to look at, But again, it's not the most relevant one in the world for you. But it's obviously very abnormal looking, um, testes search May There may be something else going on there. I'm not too sure. Um, but on the left, you can see that there is, um the testes is twisted around. It's access, and you can see the spermatic cord is is tortured, and the testes is looking very blue and dusky, so that needs to be detoured. It'd and warmed up with swabs. And I'm not sure that test that particular test. This is going to be valuable if I'm perfectly honest. Okay, so there's other differential diagnosis to bear in mind. Obviously, testicular torsion is thie most important of them, because if you, um don't exclude it or deal with that appropriately, you're going to lose testes on got could be quite devastating. And most people they've got another another functioning testes for a variety of reasons. You don't want that to happen. Physiological, psychological. So on. Um, so another thing to think about on this is really only a a pediatric issue is torsion of testicular appendages. Okay, so during Embryologically development, there's multiple of his digital remnants of the wolf in or the museum nephric um Leary Energy The pyramids in Africa Duct systems, which essentially to the, um, development of the reproductive and you're a new truck systems on the most commonly affected is the high dosage of more gag Knew she was thought to be, and the Embryologically remnant of would have developed into the flow peon Shoob in the boy before they became boy. Essentially. And it's a 22, 15 millimeter long mushroom shaped structure just prone to torsion. Um, and essentially, what happens is that this this little to stick your appendage ports on its own access. And that leads to the release of sight of kinds and inflammatory mediators, which will cause any scrotal, a rhythm, a edema. You can get a bit of a reactive hydrocele. You'll get pain. Does this sound familiar? So it sounds quite similar to to stick in your torsion, and it's very important mimic in the pediatric population, so you can usually differentiate them on clinical examination. On normally, there's a more insidious timeline with this, so you'll tend to get a child who will say that Oh, I started to have this pain a couple of days ago, and it's been getting worse and worse, and I wasn't going away. And they only told their parents after a day or two, it's been embarrassing, Um, and just because they may have presented with with a torture to stick your appendage on the ah particular instance does not mean that they couldn't come back in with the torsion. So you need to tell them, um, that if they have two sick of your pain again, they need to come back in a certain on clinical examination. You normally have a normal lives, and they'll be focally tender in the upper pole of the testes near the epididymis, which is where this most common, um, calm and the torches to stick your appendix. The high dosage of more gag names and Italian surgery discovered this. Oh, are described this, um so the focally tender there. But the rest of the test is tense, not be tender, as opposed to the testicular torsion, where the entire complex will be exquisitely tender and the district record of sporadic cord would be quite tender as well. But you'll have no court tenderness in a portion of the high dosage of more cognitive eso. This is just another thing to bear in mind and and we do see this fairly frequently. They are mimic of distinct rhetorician, and you feel much better. They're seeing these patients. So if you see a patient and you're not sure whether this is what's going on, just send them in to the nearest appropriates BDA trick surgery or urology ears General Surgery Department because they do need assessment by someone experienced in seeing these patients. Cool. Uh, this is the blue dot sign that you classically see. So as I mentioned you, get this release of cytokine is inflammatory mediators. When you have these testicular appendages, torch on their own access. And sometimes you'll get this blue dot sign where the scrotum is blue, precisely over where this tortured appendages. And but it is important to bear in mind that you don't always get this. You can have a tortured testicular appendage and not have a bleed outside. In fact, the blue dot sign isn't super common, so I wouldn't rely on that to make your diagnosis. Okay, um, another differential diagnosis to bear in mind for acute scrotal pain is epididymo orchitis And again you'll get an erythematous swollen heavy screws. Um, but you will have associate it lower urinary tract symptoms, and we need to do is send that urine for microalbumin culture and sensitivity and treat with appropriate broad spectrum antibiotics until you have your sensitivities back. In case you need to give different antibiotics, you do need to take a sexual history. And that's why this is this almost does not exist in pre puberty. Kill non sexually active Children. And if it does, um, happened to occur. Um, you know, Children can't sometimes get viral or ky cysts and things like this. Which company mimics of testicular torsion? Um, but if they have the bacterial epididymo-orchitis, then you need to think about whether they might have another lying renal truck to normally. Um, the first line investigation would be an ultrasound scan of the of the Rio trucked. Okay, so in summary, the acute scrotum is not uncommon. Clinical presentation it presents to primary care and, um, and a variety of surgeons on careful history and physical examination is all you need to make your diagnosis again. If you're not particularly experienced on, and there's any diagnostic uncertainty. Then you do need a surgical assessment because these patients might need to go ahead and have a scrotal exploration. So it's very important that you make your decisions quickly because if you've got to stick your torsion, the viability of the testes is not very long. It's about 68 hours. Um, you need to get these patients to theater very quickly. Um, and other causes of testicular pain can be managed medically. So something else just to quickly mention but have not touched on us that you can have, Um, you can't have intermittent testicular torsion. And so and classically, this will present is the testes for tours and you'll have pain. And then a one tours and it was settled. So don't automatically think that if the pain is settling that it's going to be something benign, and there's a possibility that it is an intermittent or shin. So you need to bear that in mind. So again, if you know, you know, very experienced in this union. Urgent surgical. Um opinion. Perfect s Oh, this is quite a nice diagram. So, uh, everything up. So you get acute pain and swelling if you have to stick in your torsion again. It's a surgical emergency that needs intervention. Usually within six hours, the Doppler ultrasound will demonstrate decreased blood flow. But again, we don't want to be doing old percent scans. You want to be taking those patients first, little exploration, and you'll get twisting of the testes in the spermatic cord resulting in the scheme. Yeah, because you've got that's impaired. Arterial in flow and impaired venous outflow. Perfect. Any questions for me? Great. Thank you very much. You said that was really useful. Um, I'm just gonna give you guys two minutes in case anyone would like to pop a question on the chat box, and I'll relay that to use it. So I have a question here from Dean. Consum one. Still get a torsion even after anorchidism pexy? No. Yeah, very, very, very, very unlikely. I've never seen it before. Never heard of it before, right? Okay, because the justices fixed in place. So how is it going to twist around? Count up anyone else Have any questions they'd like to put in the box before we go? I think it is a good sign if I'm not getting too many questions. Right. Okay. And I think in that case, we'll move onto the next slide. Um, cool. So thank you very much, everyone for joining and thank you. Use it again for a great session. So, um, this is the QR code for the feedback form. If you guys could go ahead on Do do that and you can get yourself some certificate. Um, obviously, if you have any questions that you think godly to run, feel free to email us on the address provided, and we'll be happy to send it across to use if you could send you an answer. Um, make sure you guys join us next time. Next time sessions gonna be discussion with one of the urology consultants, another dean And he's going to tell us about basically his experience is a consultant. And how you guys can get into urology of that something you'd be interested in. So thank you very much on, but I'm gonna pop the feedback link in the chat box for anyone who would like to go through through that weight. All right. Have a good evening and thank you very much again. Use it. Thank you. Thank you.