Short Reports Acute scrotum in Nigeria: an 18-year review NH Mbibu MBBS FWACS H Y Maitama MBBS E A Ameh MBBS FWACS LM Khalid MBBS FWACS (Nig) L MAdams MBBS Department of Surgery, Ahmadu Bello UniversityTeaching Hospital Zaria, Nigeria Correspondence to: Dr NH Mbibu, Urology Unit E-mail: ssrs.njsr@skannet.com § 3.5 .§ 3 .E Jij 2.5 G 2 s 1.5 '0 .... 1 0.5 0 TROPICAL DOCTOR, 2004, 34, 34-36 Fig.1 The number of casespresenting with testicular torsion per month between 1986-1991 in Zaria, Nigeria Table 1 Causesof "acute scrotum" in Zaria between 1986-1991 Introduction The 'acute scrotum' is a common urological emergency affecting males of all ages'. Early recognition and prompt management is required to avoid complications, including testicular infarction and infertility/v'. Testicular torsion has been noted as the most common cause of acute scrotum in Zaria affecting adolescents. It significantly increases during the harmattan season, a period of cold air and low relative humidity'. The seasonal frequency and the association of cold weather with torsion have been noted in other studies in Canada, Dublin and Japan4--7. Infarcted testes caused by incarcerated inguino- SUMMARY One hundred and seventy-eight patients presenting with an acute scrotum during a period of 18 years (1978-1997) were reviewed retrospectively. Fifty per cent had testicular torsion, with a mean age of 23 years (range 3 weeks-55 years).Torsion was significantly more common in the cold harmattan season (October-early March). The salvage rate of torted testes was 52%. Ingui- noscrotal hernia was the cause of testicular infarction in 10% and is an important contributor to male infertility. Twelve per cent of cases of suspected torsion were found to have epididymo-orchitis, at exploration. Twenty-three (13%)patients presented with scrotal gangrene (Fournier's gangrene) which did not result in testicular loss.There was significant morbidity following intervention by non- doctors, and misdiagnosis from unsuspecting physicians. The acute scrotum affecting young patients isa significant cause of male infertility and morbidity in Zaria. Early recognition, prompt treatment and re-education of those who may provide the first line care for such patients will reduce the morbidity and pathologic consequences following neglect. Patients, methods and results The records (case notes, operation notes and discharge summaries) of patients presenting with acute scrotum who had scrotal surgery between 1978-1997 (1984 excluded), have been reviewed. The authors personally managed patients in the last 5 years of the study period. Scrotal surgery was performed in 321 patients - 178 (55%) patients presented with acute scrotum. The causes are listed in Table 1. scrotal hernia and trauma are rarer causes of testicular loss3.5. The initial presentation of the acute scrotum may be confusing and misdiagnosis and delay in commence- ment of appropriate treatment may be a major cause of morbidity. This study reviews the presentation, morbidity, and the influence of cold and low relative humidity on some aspects of the acute scrotum. Testicular torsion Testicular torsion was seen in 90 (50.6%) patients presenting with acute scrotum. The mean daily relative humidity and air temperature for each month were- obtained from the meteorological department of the Institute of Agricultural Research in Zaria from 1978- 1997. Testicular torsion was most common in October- early March (harmattan season) (see Figure 1 for 1986- 1991), a period of cold air and low humidity. The data were analysed using the r-test, for seasonality (P = 0.05, statistically significant). A review of the data in three equal 6-yearly periods showed a persistent peak from November-March, with a modest peak noted between May and September, which is a period of mean low relative temperature and high relative humidity (see Figure 2 for the 6 year period 1992-1997). This suggests that low relative humidity and low air temperature play complementary roles in causation of testicular torsion, but low air temperature appears to playa more important role than mean relative humidity. The age range of patients was 3 weeks-55 years (mean 23 years). Eighty-eight per cent were aged 11-25 years. Torsion was more frequent on the right side with a ratio of 3:2 (R:L). Three patients had torsion of a solitary testis following previous neglected torsion of the contralateral testis. One patient had torsion of the right appendix testis. There was delay in surgical intervention in 43 patients (47.8%) resulting in gangrene and testicular loss. Forty-seven No. of testes removed due to gangrene 2 59 43 14 Causes No. Testicular torsion 90 Strangulated inguinosuotal hernia 38 Idiopathic scrotal gangrene (Fournier's) 23 Epididymo-orchitis 21 Trauma 5 Idiopathic scrotal oedema 1 Total 178 34 Tropical Doctor January 2004, 34