82. Testicular pain

Question 1

Index conditions.

Answer 1

Torsion of the testis (or testicular appendage)
Trauma to testis
Epididymo-orchitis (bacterial, viral)
Referred pain from renal colic, etc.

Question 2

Most common causes of acute scrotal pain by age.

a) Pre-pubescent (age 7 - 12)
b) Post-pubescent/adolescent
c) Adult

Answer 2

a) Torsion of testicular/epididymal appendage
b) Testicular torsion
c) Epididymo-orchitis / torsion (very rare above age 30)

Question 3

Typical history 1:
- History of similar episodes of self limiting pain. Precipitants may be related to forceful contraction of the cremasteric muscle secondary to trauma, physical exertion, an erection or sudden coldness.

Answer 3

Torsion of testis

Question 4

Conditions associated with epididymo-orchitis:

a) Main group
b) Others

Answer 4

a) STIs

b) Mumps (fevers and parotid gland swelling) and vasculitides such as Buergers syndrome and HSP

Question 5

Differentials: referred pain

a) Differential NOT to miss in the elderly (more likely presenting with abdominal/back pain)
b) Other possible referred pain differentials

Answer 5

a) Abdominal aortic aneurysm rupture

b) Appendicitis, renal colic

Question 6

Differential: Fournier’s gangrene

a) what is it?
b) more common in whom?
c) presents how?

Answer 6

a) Necrotising fasciitis of the genitals and perineum (a urological emergency).
b) It is more common in diabetes and vasculopaths.
c) Presents with severe pain and rapidly spreading necrotic cellulitis.

Question 7

Investigations

a) Initial
b) Imaging

Answer 7

a) A-E (unwell?, septic, haemodynamically unstable, etc.), urinalysis, STI swabs
b) Doppler (do not delay surgery if torsion suspected!), Surgical exploration

Question 8

Management.

a) Testicular torsion
b) Epididymo-orchitis
c) Appendage torsion

Answer 8

a) - URGENT urology referral
- Surgery (within 4 - 6 hours ideally): de-torsion and fixation (orchidopexy); removal if unsalvageable testis (orchidectomy)

b) - Rest, NSAIDs, safety net
- STI advice + contact trace
- ABx (e.g. IM cef STAT + doxy oral 10-14 days)

c) Rest, ICE, NSAIDs (diagnosis of exclusion)

Question 9

Testicular torsion.

a) What is it?
b) Main risk factor
c) Signs o/e (vs. epididymo-orchitis)
d) Easing of pain may indicate…?

Answer 9

a) Torsion of the spermatic cord, causing occlusion of testicular blood vessels and ischaemia, resulting in loss of the testis (germ cells are the most susceptible).
b) High insertion of tunica vaginalis (bell-clapper testis)

c) - Red, swollen, tender testis (usually unilateral)
- High-riding or transverse testis lie
- Testis may appear retracted
- Absent cremasteric reflex (present in epididymitis)
- Pain increased on lifting testis (decreased in epididymitis)

d) Onset of necrosis

Question 10

Cremasteric reflex.

a) Elicited how
b) Normal response
c) Afferent nerve
d) Efferent nerve
e) Spinal level
f) Causes of absent reflex

Answer 10

a) Stroking superior and medial part of the thigh
b) Contraction of cremaster muscle, causing instant retraction of ipsilateral testis
c) Femoral branches of the ilioinguinal and genitofemoral nerves
d) Genital branch of the genitofemoral nerve
e) L1 - L2

f) - Testicular torsion
- Upper and lower motor neuron disorders
- Spinal lesion at L1-L2.
- ilioinguinal nerve damage during a hernia repair

Question 11

Testicular torsion vs. torsion of appendage

Answer 11

• Age: appendage (pre-pubescent: 7 - 12 years) vs torsion of testis (12+)
• Systemic symptoms are common in testicular torsion
• ‘Blue dot sign’ (ie. tender blue nodule on the upper pole of the testis) in appendage torsion