Wednesday, May 16, 2012

Overview of Acute Scrotal/Testicular Pain

History & Physical Exam

  • Pain? Acute onset suggests torsion, epididymitis, or torsion of the appendix testis/epididymis
  • Trauma?
  • Change in size? Valsalva = hydrocele
  • Sexually active? Epididymitis in adolescents
  • Difficulty voiding? Think mass, cord lesion, UTI
  • Flank pain or hematuria? Referred pain from a kidney stone
  • Abdominal pain, nausea/vomiting? Torsion
  • Setting the stage
    • Get a chaperone if you or patient are uncomfortable
    • Have the patient stand if possible
    • If you suspect a varicocele examine the patient supine as well
    • Respect the patient’s privacy!
  • Don’t forget to examine the;
    • Inguinal folds
    • Penis and urethra
    • Pubic hair
    • Testicular position (left is lower)
    • Testicular lie

Testicular torsion

  • Surgical emergency!
  • The testicle twists on the spermatic cord
    • Venous compression then…
    • Edema of testicle and cord then…
    • Arterial occlusion then…
  • 1/4000 males < age 25
    • Bimodal -  neonatal and puberty
    • 65% between ages 12-18 years
    • Likely due to increasing testicle volume
  • Bell clapper deformityTestis is not fixed to the tunica vaginalis posteriorly and it is free to rotate and is at increased risk of torsion.Incidence is approximately 1/125 and usually present bilaterally.
  • Presentation
    • Abrupt onset of pain <12 hours
    • Associated N/V, lower abdominal pain
    • In a retrospective review only 8% had pain prior to this episode (Kadish, 1998)
  • Exam
    • Edema of scrotum
    • Testis – tender and slightly elevated, may have a horizontal lie
    • Cremaster reflex is absent
  • Torsion is ideally a clinical diagnosis
    • If suspected tell your Attending and call Urology ASAP
  • Ultrasound
    • Sensitivity 69-100%
    • Specificity 77-100%
  • Nuclear medicine scans are very sensitive and specific – but not readily available
  • Surgery
    • If viable – detorsion of affected testis and fixation (orchiopexy) of both testis
§                    Viability rates
Within 4-6 hours 100%
12-24 hours 20%
>24 hours 0%

  • Sequelae
    • Males may have increased risk of infertility even when viable de-torsed testis is left in scrotum because of immune-mediated injury to contralateral testis
    • Other studies have failed to show that anti-sperm antibodies are present
  • Intermittent torsion
    • 80% have bell clapper deformity
    • Pain is brief and resolves quickly (minutes)
    • Eaton et al, 26% had nausea and vomiting, 21% pain awakened patient from sleep
  • Neonatal torsion
    • A topic that could have its own talk
    • Many cases occur in utero

Torsion of the appendix testis and appendix epididymis

  • Vestigial structures
    • Appendix testis: Müllerian system
    • Appendix epididymis: Wolfian system
  • They torse easily
    • Boys 7-12 years of age
    • Pain is usually less severe
  • The ‘blue dot sign’ is the pathognomonic physical finding
    • Due to infarction/necrosis of the appendix
    • A reactive hydrocele may also be seen
  • Diagnosis
    • Usually clinical if you see a ‘blue dot sign’
    • Get an Ultrasound in cases where you can’t r/o torsion
  • Management
    • Analgesics
    • Rest
    • Scrotal support
    • The pain typically resolves in 5-10 days


  • Etiology
    • Sexually active? Chlamydia, gonorrhea, E.coli, viruses
    • Prepubertal? Viruses, E. coli, mycoplasma
  • Presentation
    • Pain and swelling localized to the epididymis
    • Testis has a normal lie
    • 50% have scrotal edema
    • The scrotum is sometimes red
    • Cremaster reflex is present
    • Positive ‘Prehn sign’ (not reliable)
    • Patient may have dysuria
  • The work-up
    • Clinical exam
    • Ultrasound
    • Urinalysis
      • Obtain in ALL patients with suspected epididymitis
    • STD testing
      • Get gc/chlamydia DNA of urine if sexually active
      • Syphilis and HIV testing
  • Prepubertal boys
    • Antibiotics are NOT always indicated
    • Treat if.. Pyuria >3-5 wbc, positive U/C, or underlying UTI risk factors  - TMP/SMX or Cephalexin for 10 days
  • Teenagers (Pro-Tip: think about STDs)
    • Ceftriaxone 250mg IM x1 then doxycyline 100mg bid x10 days
    • For enterics AND negative STD…
    • 10 days of ofloxacin 300mg bid or levofloxacin 500mg qday
  • Tx also includes rest, NSAIDs, and scrotal elevation

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