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
Epididymitis
- 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
