DISCUSSION

The acute scrotum is an acute painful scrotal swelling affecting the scrotum or any of its contents 1 In our one year prospective study, the acute epididymitis (35.6%) is the commonest cause leading to acute scrotum followed by epididymo-orchitis (31.35%) then trauma (11%), testicular torsion (9.3%), scrotal wall abscess (5.1%), Fournier gangrene (3.4%).the frequency of different disease cause acute scrotum in shown in( Chart 1).In a study conducted by Cass et al., ( 72.57%) of cases was caused by epididymitis 8 . In another a study conducted by Abul F,Al-Sayer H, Arun N a review of 40 patients managed for acute scrotum reported that acute epididymitis (60%) was the commonest pathology of acute scrotum, followed by testicular torsion(27.5%), torsion of the appendages(10%), and Acute idiopathic scrotal edema(2.5%).9Where in a study reported by NA Watkin et al., testicular torsion was the most common disorder leading to acute scrotum (39.5%).10 .In another series reported by NH Moharib et al., testicular torsion was the commonest aetiology (33.92%) 11.Volkan Sarper ERIKCI et al, study reports the Epididymo-orchitis (44%), strangulated inguinal hernia, Testicular torsion and torsion of testicular appendage (32%)(22%)(2%)respectively.12 Tabari et at reports that testicular torsion (31%) as most common cause of acute scrotum followed by incarcerated inguinal hernia (30%), torsion of testicular appendage (27%) Epididymo-orchitis (7%), Idiopathic scrotal edema (4%), scrotal hematoma (1%).13Anderson et at al describe testicular torsion (45%) as most common cause of acute scrotum in their study,Torsion of appendix testis (35%), Epididymo-orchitis (15%), Idiopathic scrotal edema (3%)14.Our study is similar to some of the previously reported studies in the incidence of pathological causes where the acute epididymitis (35.6%) is the most common cause of acute scrotum while some studies are different .The age incidence was shown in the (table 1). in this study The incidence was occurred between eleven and forty years with a peak  incidence in the age group 21-30 years , 21-30 years 24.6% followed by31-40years then11-20 22.03%. the age incidence for Acute epididymitis was maximum in the 21-30 years (26.2%)with mean age of presentation33.8 years. acute epididymo-orchitis was maximum in the 21-30 years (27%)with mean age of presentation 40.1 years was differs from the reported by NA Watkin (21.3 years).14 the mean age of Fournier gangrene presentation was 53.75 years .In sutdy conducted by Yan-Dong Li et al. 51.6 years was the mean age of presentation of FG. 15 57.9 ± 13.5 years was reported by Ruiz-Tovar J et al. 2013 as a mean age Fournier’s gangrene.16 also (51.3 years) reported by RB Jones et al. .17 The mean age of incidence for for Fournier’s gangrene was 53.75 years, that correlates with the result reported studies.Barker and Raper in their study in cases of Torsion testis, noted that none of the patient was less than 14yrs18, where as in our study(63.6%) was in11-20 years and 20.8 years is the mean age of presentation of testicular torsion one patient was below 10 yrs , truma 1-10 years (38.46% )mean age 22.7years In comparison with other studies, our study showed an late age of presentation of testicular torsion and acute epididymo-orchitis.
Duration of symptoms was widely varied . The shortest duration of symptoms in this study was 1.15 hours and longest duration was 14 days. In the study reported by Thorsteinn et al., the shortest duration of symptoms was 3 hours and longest was 21 days.19 . The average duration of pain from onset till presentation in case of epididymo-orchitis was 2.4 days, whereas it was 4 days in a study conducted by Ricardo et al.20 . The average duration of symptoms from onset till presentation in case of Fournier’s gangrene was 3 days in our study. In our study there was history of UTI and dysuria in 42% of cases.other predisposing factors are shown in (chart 4), urethral catheter (3.36%), urethral stricture (.84%), Previous history (10.92%), LUTS/PBH (6.72%), paraplegic (3.36%), meatal stenosis (.84%) and trauma (10.92%).
Ricardo C. Del Villar study reported that , history of similar complaints in the past was found in 2 cases of epididymitis and in 6 cases of torsion testis. history of trauma was in 7 cases of epididymitis and in 3 case of torsion testis. Dysuria were present in 7 cases of epididymitis and in 1 case of torsion. 20 Arshad Mehmood Malik et al. 2010 and B. Fallet al. 2009 stated idiopathic cause in 32.8% and 25.5% cases respectively.21.In our study patient presented with history of fever in 46.2%, nausea 10.9%, vomiting10.9%, abdominal pain7.6%, urethral discharge13.5%, sinus discharge4.2%, haematuria0.84%, hematospermia0.84%, redness31.3%, ecchymosis7.6%, tendderness84.7%, cord note1.69% (Table 2).The Investigations show, an increase in total leucocyte count in 70 (58.8%) cases and normal count in 40 (33.6%) cases (chart 8). Thorsteinn Gislason showed that leucocytosis was present in 44% cases22, The urine examination showed significant pus cells in 68 (68.48%) and negative pus in 50 (50.84%) cases.84 cases (71.2%) were managed conservatively with bed rest, scrotal supports, oral or intravenous antibiotics, and analgesics (Chart 9). In 34 cases (29%) Surgical Treatment was carried out (Chart 10). In eleven cases of testicular torsion, orchiopexy was done in sex cases where five was with viable testis and trial to preserve testis was done in one ischaemic testis. Orchidectomy was done in four (36%) ischaemic testis and one case managed with manual detorsion immediately then treated with orchiopexy later. In sex cases of scrotal wall abscess five was treated with incision and drainage under local anesthesia and one where testis was involved treated with orchidectomy. Debridement was carried out in four cases of Fournier gangrene followed by secondary simple suturing in one case and grafting in other cases was done. Orchidectomy was done in one case of testicular abscess .And one case of infected sebaceous cyst treated surgically under local anesthesia.In one series of 209 scrotal explorations, the overall rate of testicular salvage was 75%.Relief of torsion within 4 h resulted in complete viability; up to 16 h, 89% of testes were salvaged, but this decreased to 25% after 16 h23. However, the testis was preserved in 3 cases in which continuouspain had been present for more than 24 h and where the testis was still twisted at the time of surgery. These values for testicular viability confirm that surgery should always be an emergency procedure4 Teoman Eskitasc?o?lu et al. 2014 reported the average debridement in their study to be 1.55 ± 1.15 with a range of 1-8 debridements. Serial debridement was done in 30% patients with 75% patients were debrided within 24 hours of the admission24. In this study, recurrence has occurred in two cases epididymitis and one case epididymo-orchitis in a range of one month and scrotal wall abscess in one case after two months, no postoperative complication was reported .The average hospital stay in conservatively managed patients was 3.62 days and six cases managed as an outpatient. Avarage hospital stay for patients operated was 4.7 days and four cases were managed as an outpatient. Maximum hospital stay was in Patients with Fournier’s gangrene 29 days with average hospital stay 17.75 days.

CONCLUSION
The commonest cause of acute scrotum was the acute epididymitis (35.6%) followed by epididymo-orchitis (31.35%), Acute scrotal swellings are common in young aged males( 21-40 years).the acute scrotum is slightly more in right side. Scrotal pain , swelling, tenderness and fever are the most common presentation. The predisposing factor for acute scrotum are mainly UTI, Previous history , LUTS/PBH , trauma ,urethral catheter, urethral stricture, paraplegia and meatal stenosis. Conservative treatment are effective with good outcome, surgical exploration when indicated is the best diagnostic and therapeutic option with no serious complication.