RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA
ANNEXURE 2PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / NAME OF THE CANDIDATE AND
ADDRESS. / DR. ANANDA MURTHY K.T
AMMA VILLA, 96/2,
MOGARAHALLI,
SRIRANGAPATNA (TQ),
MANDYA (DIST) – 571438
2. / NAME OF THE INSTITUTION. / MYSORE MEDICAL COLLEGE AND RESEARCH INSTITUTE -
570021
3. / COURSE OF STUDY AND SUBJECT / M.S. GENERAL SURGERY
4. / DATE OF ADMISSION / 05/06/2013
5. / TITLE OF THE TOPIC / “ DIAGNOSIS AND MANAGEMENT OF ACUTE SCROTUM IN K. R .HOSPITAL,MYSORE” –A CLINICAL STUDY.
/
6.BRIEF RESUME OF THE INTENDED WORK
6.1 NEED FOR THE STUDY:Acute scrotum is a clinical syndrome can be defined as “any condition of the scrotum or intrascrotal contents requiring emergent medical or surgical intervention”, because acute scrotal pathology can result in testicle infarction and necrosis , testicular atrophy, infertility, persistent testalgia, and significant morbidity.It poses one of the more challenging clinical dilemmas in field the of surgery . Distinguishing benign conditions from the acute scrotum is the key to managing these patients.
The correct diagnosis of the acute scrotum is not always obvious, but a thorough history, physical examination and use of basic laboratory studies can aid in distinguishing benign from surgical conditions.However, patients may present with an atypical history and symptoms. Clinical symptoms and physical examination are often not enough for definite diagnosis due to pain and swelling that limit an accurate palpation of the scrotal contents.Similarity of presentation and physical finding of different causes limits the accurate diagnosis. Radiological techniques helpful but may delay diagnosis. Operation may be needed for both diagnostic and treatment purposes.Ultimately, the most important question to be addressed is whether the testicle is adequately perfused.
6.2REVIEW OF LITERATURE:
· DIFFERENT CAUSES OF THE ACUTE SCROTUM
Ø Ischemia:
Torsion of the testis (,Intravaginal, extravaginal),Appendiceal torsion of testis or epididymis, Testicular infarction due to other vascular insult .
Ø Trauma:
Testicular rupture, Intratesticular hematoma, testicular contusion, Hematocele.
Ø Infections:
Acute epididymitis, Acute epididymoorchits, Acute orchitis
Abscess, Gangrenous infections( Fournier’s gangrene).
Ø Inflammations:
Henoch-Schonleinpurpura (HSP) vasculitis of scrotal wall
Fat necrosis, incect bites.
Ø Hernias:
Incarcerated, strangulated inguinal hernia, with or without associated testicular ischemia.
Ø Acute on chronic events:
Spermatocele rupture or hemorrhage, Hydrocele rupture, hemorrhage or infection ,Testicular tumor with rupture or hemorrhage, infarction or infection of varicocele.[1,2]
· A full range of scrotal pathology must be considered in acute scrotum cases.Several conditions that result in acute scrotum require surgical exploration, making this avery time sensitive condition.A high value is place on the history, physical examination and ultrasound imaging forscrotum diagnosis.[3,4]
· Acute scrotal condition has many etiologies, some of which can have disastrous consequences if not diagnosed and treated properly. A prompt diagnosis is often required, especially if torsion of the testicle is considered likely.[5]
· Diagnosing acute scrotal pain and swelling in children andadolescents is urgent and often difficult. In acute epididymitis nonoperative therapy is indicated.. Scrotal exploration is the diagnostic (andusually therapeutic) procedure of choice.[6]
· Testicular torsion must be considered in any patient who complains of acute scrotal pain and swelling. Conditions that may mimic testicular torsion, such as torsion of a testicular appendage, epididymitis, trauma, hernia, hydrocele, varicocele and Schönlein-Henochpurpura, generally do not require immediate surgical intervention.Urinalysis should always be performed, but scrotal imaging is necessary only when the diagnosis remains unclear. [7]
· The testis is ischemic in only about 20% of cases.The clinical approach to the acute scrotum must begin with a standardized, rapidly performed diagnostic evaluation. Dopperultrasonography currently plays a central role. Its main use is to demonstrate the central arterial blood supply and venous drainage of the testis. The resistance index of the testicular vessels should also be determined.[8]
· Epididymitis was the commonest cause of acutescrotum. The majority of patients withepididymitis were managed conservatively. The accuracy of ultrasonography was only 72.7% in testiculartorsion, but was good in epididymitis. careful clinical evaluation, by anexperienced examiner, provides the correct diagnosis in acute scrotum rather than ultrasonography. It is of utmost importance to exclude testicular torsion in thosewho are younger than 16 years and whose pain durationis less than 24 h.[9]
· Ultrasonography b-mode and colour Doppler ultrasonography has become the imaging modality of choice for evaluating acute scrotal diseases in emergency room. Ultrasound, is a valid method for the study and for the immediate diagnosis in the emergency room of thesepathologies.[10]
· Acute pain in one testicle in patients under age 25 is considered a surgical emergency. Failure to correct spermatic cord torsion with testicular ischemia within 2 to 4 hours can result in loss of testicular function and testicular atrophy. Thirty percent of seminomas, teratomas, and embryonal cell carcinomas of the testes also present with unilateral pain and tenderness of a testicle.[11]
· Urinalysis should be performed to rule out urinary tract infection in any patientwith an acute scrotum suggests infection . A white blood cell count is not helpful and should not be routinely obtained.Until recently, no imaging studies were useful in confirming the cause of an acutescrotum. Immediate surgical exploration was thus the standard approach when torsion was suspected. The physical examination should include inspection and palpation of the abdomen, testis, epididymis, scrotum and inguinal region, but scrotal imaging is necessary only when the diagnosis remains unclear. [12]
· Fournier’s gangrene is a infectionof the skin and fascia of the scrotum and perinealtissues. It occurs most frequently in middle agedpatients and is usually associated with obesity and diabetes. It is rapidly progressive and requiresquick intervention and radical surgicaldebridement for treatment. The initialtreatment is multiple broad-spectrum antibioticsand immediate evacuation.[13]
· 6.3 OBJECTIVES OF STUDY:
1. To ascertain the various etiologies and differential diagnosis of causes in acute scrotum.
2. To ascertain the role of imaging studies in the diagnosis .
3. To ascertain the various modalities of treatment in management.
7. MATERIALS AND METHODS
7.1SOURCE OF DATA
Data will be collected through preformed proforma among the patients visiting surgical opd and patients admitted at the general surgery department of K R Hospital,mysore with acute scrotal pain and swellings or any other patients referred for such complaints during some other ailment during the period from January 2014 to january2015.
7.2. METHOD OF COLLECTION OF DATA
History, physical examination , laboratory investigations ,imaging studies, operative findings and post operative consequences (including mortality) will be entered in preformed proforma and analysed. Patients will be followed for one month (two days once) or for longer period whenever necessary.
A total of 50 cases will be studied.(based on about 4-5 acute scrotum cases visits surgical opd in K R hospital ,per month)
Ø Inclusion criteria:
· patients with acute pain and swellings in the scrotum
· above age of twelve completed years
· history duration < two weeks
Ø Exclusion criteria :
· Patients with painless scrotal swelling (history duration >2 weeks)
· history duration >2 weeks
TYPE OF STUDY : cross sectional study
STUDY PERIOD: January 2014 to june 2015
SAMPLE METHOD: convenience sampling
7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so describe briefly. Yes[patients only],
1. Blood investigations - Hb, TC,DC,BT,CT,Platelet count,ESR
2. Random Blood Sugar
3. Blood urea, SerumCreatinine.
4. Urine routine(albumin ,sugar, microscopy)
5. Ultrasonography of scrotum
6. Colour Doppler of scrotum
7. Orchidopexy.
8. Orchidectomy.
7. 4 Has the ethical clearance been obtained from your institution ?
Yes, ethical clearance has been obtained from the ethical committee of Government medical college, Mysore.
8. LIST OF REFERENCES
1) Lin EP et al.: Testicular torsion: twists and turns. Semin Ultrasound CT MR. (2007)4:317-328.
2) Tracy CR et al.: Diagnosis and management of epididymitis. UrolClin North Amer (2008)35:101-108.
3) Kim SH et al.: Significant predictors for determination of testicular rupture on sonography: a prospective study. J Ultrasound Med.(2007)26:1649-1655.
4) Joyner B & Walsh T: Evaluation of the Pediatric Patient with a Non Traumatic Acute Scrotum: AUA Update Series (2005), Volume 25, Lesson 12.
5) CAPT M. Melanie Haluszka, MC, USN, LCDR Brian K. Auge, MC, USN, and LT Timothy F. Donahue, MC, USNR, National Naval MedicalCenter, Bethesda (1999).
6) PHILIP J. KNIGHT, M.D., LOUIS E. VASSY, M.D.; The Diagnosis and Treatment of the Acute Scrotumin Children and Adolescents (1984), vol.200. No.5;664-673
7) LARIS E. GALEJS, MAJ, USAF, MC, U.S. Air Force Medical Center, Wright-Patterson Air Force Base, Dayton, Ohio EVAN J. KASS, M.D., William Beaumont Hospital, Royal Oak, Michigan. Diagnosis and Treatment of the Acute Scrotum. 1999 Feb 15;59(4):817-824.
8) DtschArztebl :The Acute Scrotum in Childhood and Adolescence. Int. 2012 June; 109(25): 449–458.
9) FawziAbul, Hilal Al-Sayer, NarayanaswamyArun. The Acute Scrotum: A Review of 40 Cases Med PrincPract 2005;14:177–181
10) D’Andrea et al. US in the assessment of acute scrotum. Critical Ultrasound Journal 2013, 5(Suppl 1):S8
11) Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rdedition. Boston: Butterworths; 1990.Chapter 186
12) Laris E. Galejs, Evan J. Kass;Diagnosis and Treatment of the Acute Scrotum, Feb 15, 1999
13) Jones R B Hirschmann J V, Brown G S Treamann J A,Fournier”s syndrome :necrotizing subcutaneous infection of the male genitalia. J Urol 1979;122:279-282
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