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ABSTRACT Introduction: Acute appendicitis is the most common surgical disease of the abdomen in clinical practice, affecting mainly young adults. It has a wide variety of clinical presentations, due to the anatomical variation of the cecal appendix. Its presentation as acute scrotum and scrotal abscess is quite rare and atypical, occurring mainly in young male patients with patent processus vaginalis. Case presentation: An 18-years-old male patient attended the emergency unit complaining of diffuse abdominal pain, fever and hyporexia for four days followed by inflammatory signs in the scrotum. He was taken to the operation room after diagnosis of scrotal and abdominal sepsis. During scrotum exploration, pus was found inside the right hemiscrotum coming down from the groin and communicating with the abdominal cavity. The laparotomy found perforated appendicitis and peritonitis leading to the scrotal abscess. The abscess was drained, appendectomy was performed and the scrotal and abdominal cavity were washed with saline solution. Despite postoperative complications such as pneumonia and intra-abdominal abscess, the reported patient recovered and was discharged in the 44th postoperative day. Conclusion: Acute appendicitis can mimic acute scrotum and surgeons must have a high index of suspicion of this complication for diagnosing. This unusual clinical presentation may be challenging and can delay the diagnosis leading to perforated peritonitis.

RESUMO Introdução: A apendicite aguda é a doença cirúrgica mais comum do abdome na prática clínica, afetando principalmente adultos jovens. Tem uma grande variedade de apresentações clínicas, devido à variação anatômica do apêndice cecal. Sua apresentação como escroto agudo e abscesso escrotal é bastante rara e atípica, ocorrendo principalmente em pacientes jovens do sexo masculino com túnica vaginalis patente. Apresentação do caso: um paciente do sexo masculino de 18 anos de idade compareceu à unidade de emergência queixando dor abdominal difusa, febre e hiporexia por quatro dias que se seguiram de sinais inflamatórios no escroto. Ele foi levado para centro cirúrgico após o diagnóstico de sepse de origem escrotal e abdominal. Durante a exploração da bolsa escrotal, secreção purulenta foi encontrada do lado direito oriunda do canal inguinal e comunicando-se com a cavidade abdominal. Durante a laparotomia observou-se sinais de apendicite aguda perfurada e peritonite levando ao abscesso escrotal. O abscesso foi drenado, a apendicectomia foi realizada e as cavidades escrotal e abdominal foram lavadas com solução salina. Apesar de complicações pós-operatórias como pneumonia e abscesso intra-abdominal, o paciente recuperou-se bem, recebendo alta hospitalar no 44° dia pós-operatório. Conclusão: A apendicite aguda pode simular o escroto agudo e os cirurgiões devem ter um alto grau de suspeição dessa complicação para o diagnóstico. Esta apresentação clínica incomum pode ser desafiadora e retardar o diagnóstico levando à peritonite por perfuração.

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PURPOSE: We assessed reproductive and testicular function in adult rats after testicular torsion created before, during and after puberty, and with vs without resveratrol or arginine treatment. MATERIALS AND METHODS: Age matched rats were divided into groups, including simulated surgery without testicular torsion, 720-degree testicular torsion for 4 hours, testicular torsion with resveratrol treatment and testicular torsion with arginine treatment. To study reproductive function at age 12 weeks each rat mated with 3 females. The males were sacrificed at age 14 weeks. Spermatozoids were collected from the epididymal tail and evaluated for concentration, motility and viability. Testicular samples were collected for morphological analysis. RESULTS: Reproductive function was not altered by testicular torsion but antioxidants improved potency. Compared to sham operated and contralateral samples all spermatozoid parameters from testicular torsion samples were inferior. Resveratrol and arginine did not improve spermatozoid quality or quantity in torsed testes but contralateral samples were improved by each drug. The seminiferous epithelium of rats submitted to testicular torsion during puberty was least affected. Each antioxidant partially to totally prevented the morphological alterations found in rats with untreated testicular torsion. Rats submitted to testicular torsion before puberty that were treated with antioxidants showed the fewest changes. CONCLUSIONS: Testicular morphology was altered less in rats when torsion occurred earlier in life, that is during puberty. Treatment with antioxidants improved contralateral spermatozoid production and some fertility parameters. Each antioxidant also prevented testicular morphology alterations after testicular torsion. Prepubertal rats benefited most from antioxidant treatment.

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Mammalian spermatogenesis is a complex biological process occurring in the seminiferous tubules in the testis. This process represents a delicate balance between cell proliferation, differentiation, and apoptosis. In most mammals, the testicles are kept in the scrotum 2 to 7°C below body core temperature, and the spermatogenic process proceeds with a blood and oxygen supply that is fairly independent of changes in other vascular beds in the body. Despite this apparently well-controlled local environment, pathologies such as varicocele or testicular torsion and environmental exposure to low oxygen (hypoxia) can result in changes in blood flow, nutrients, and oxygen supply along with an increased local temperature that may induce adverse effects on Leydig cell function and spermatogenesis. These conditions may lead to male subfertility or infertility. Our literature analyses and our own results suggest that conditions such as germ cell apoptosis and DNA damage are common features in hypoxia and varicocele and testicular torsion. Furthermore, oxidative damage seems to be present in these conditions during the initiation stages of germ cell damage and apoptosis. Other mechanisms like membrane-bound metalloproteinases and phospholipase A2 activation could also be part of the pathophysiological consequences of testicular hypoxia.

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Acute scrotum is a common entity found in pediatric emergency rooms all over the world. This is a syndrome in which fast and accurate diagnosis is vital to perform an effective treatment of the underlying disease. Testicular torsion is the first diagnosis that has to be discarded. Torsion of appendix testis and epididymitis or orchitis must also be considered. If clinical signs are compatible with testicular torsion, and especially if the condition has not passed the six hours threshold, surgical exploration has to be perform at once. Radiological tests cannot delaysurgical exploration. Detorsion must be achieved as soon as possible to prevent irreversible ischemia and necrosis of the testicle that could lead to an orchiectomy. Once the torsion is relieved, the testicle must be placed in warm, moist sponges to test for adequate perfusion. If the testicle has acceptable blood supply, both testicles have to be fixed to prevent similar events in the future. If health providers are familiarized with the clinical presentation of these conditions, testicular torsion and other causes of acute scrotum could be diagnosed and treated rapidly and therefore important complications, such as fertility impairment, could be prevented.

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Mammalian testes are highly sensitive to oxidative free radical damage. Acute scrotum is a clinical syndrome mainly caused by torsion of the spermatic cord that constitutes a surgical emergence affecting newborns, children and adolescents. This syndrome often leads to infertility of the ipsilateral (torted) and contralateral (not torted) testis, an outcome that makes surgical intervention mandatory. There is a controversy involving the effects of ischemia and reperfusion on ipsilateral and contralateral testes after unilateral torsion and detorsion of the spermatic cord. Conflicting reports have led to two distinct and opposite recommendations regarding surgical intervention: detortion and preservation of the ipsilateral testis, or ipsilateral orchiectomy to preserve contralateral fertility. Early detortion surgery in humans preserves fertility, but after prolonged torsion periods followed by preservation of the ipsilateral fertility of both testis is jeopardized. Lowered contralateral blood flow after unilateral testicular torsion is associated with reactive oxygen species (ROS) overgeneration and therefore with the corresponding tissue damage. Reperfusion time appears to be determinant of contralateral testes damage due to the consequent oxidative insult that accompanies the rise in ROS following ischemia-reperfusion. Nevertheless, more investigations on the molecular mechanisms and the antioxidant status in testis are necessary to ascertain the contribution of ROS to the tissue damage produced by spermatic cord torsion in experimental animals and humans.

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Os autores relatam sua experiência com 26 casos de torção do cordão espermático em dois hospitais universitários, de janeiro de 1992 a dezembro de 1997. O presente estudo foi realizado com o objetivo de avaliar dados como idade, sinais/sintomas e relação entre demora do tratamento e perda do testículo. O diagnóstico diferencial também é discutido. Concluem que em casos duvidosos a exploração cirúrgica precoce é necessária para excluir torção do cordão espermático e para prevenir a perda testicular

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La denominación de escroto agudo incluye a todas las condiciones patológicas que producen dolor intenso y súbito casi siempre acompañado de inflamación de la bolsa escrotal; las principales causas son: torsión testicular; torsión de apéndices testiculares, hernia inguinal encarcelada y estrangulada, trauma testicular y orquiepididimitis. El escroto agudo constituye 0.13 por ciento de las consultas en una unidad de urgencias pediátricas. Sólo en la mitad de los casos el cuadro clínico es "clasico" y mientras no exista un estudio con sensibilidad y especificidad de 100 por ciento se propone que todos los pacientes con escroto agudo deben ser explorados quirúrgicamente; el tratamiento definitivo dependerá de la patología y su pronóstico de fertilidad estará en relación directa con el tiempo del tratamiento. La finalidad de la presente comunicación es proporcionar información esencial a pediatras y médicos en general que manejan niños, pues son ellos quienes tienen el primer contacto con el enfermo. Se pretende facilitar el establecimiento de un diagnóstico e instituir un tratamiento definitivo con la consecuente disminución de los problemas de fertilidad secundarios a la torsión no recuperada

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The fertility potential of 54 men aged between 19 and 42 years, who had undergone unilateral orchidectomy was evaluated. In all cases the remaining testis was of normal volume and consistency. The patients were divided into four groups according to the cause of the orchidectomy: group I--cryptorchism (n = 19), group II--testicular torsion (n = 14), group III--testicular cancer (n = 12) and group IV--accidental (n = 9). The time between orchidectomy and seminal analysis varied from 6 months to 30 years (median 5 years). All semen samples were examined at the same laboratory, and no differences in sperm concentration were found among the groups. 53% in group I, 57% in group II, 50% in group III, and 56% in group IV had sperm counts of less than 20 million/ml. Our results suggest that unilateral orchidectomy leads to a considerable decrease in fertility potential, whatever the reason for it.

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