Acute Scrotal Pain: Epididymitis & Testicular Torsion

Question 1

Describe the symptom onset of epididymitis versus testicular torsion.

Answer 1

Epididymitis: Acute or chronic
Testicular torsion: VERY ACUTE!

Question 2

Describe the cremasteric reflex with epididymitis versus testicular torsion.

Answer 2

Epididymitis: +
Testicular torsion: -

Question 3

Besides symptom onset and cremasteric reflex, how do epididymitis and testicular torsion differ?

Answer 3

Epididymitis:
- Tender epididymitis
- Culture/swab + if STI present

Testicular torsion:
- Testicular swelling
- High-riding testicle
- Urologic EMERGENCY!!!

Question 4

What is the definition of epididymitis?

Answer 4

Inflammation of epididymis, usually resulting from ascent of:
- pathogen
- urine from urethra
- prostate

Question 5

What are the most common noninfectious etiologies of epididymitis?

Answer 5

• Reflux of urine through ejaculatory ducts and vas into epididymis
• Prolonged sitting (car/plane trip, desk job, etc)
• Heavy lifting, upper body workouts
• Long distance runners
• Underlying congenital defect

Question 6

What are the most common infectious etiologies of epididymitis?

Answer 6

Infectious etiology = VERY UNCOMMON!
(unless STI present)

75% =
- C. trachomatis (most common)
- N. gonorrheae

Question 6

Describe the assessment findings associated with epididymitis.

Answer 6

• GRADUAL development of pain (hrs - days)
• Epididymis (located posterior to testicle):
  - Very tender
  - Enlarged
  - Indurated
• Urethral discharge (suspect STI)
• Dysuria

Question 7

What diagnostic tests should be done for suspected epididymitis?

Answer 7

• UA:
  
  • Normal if noninfectious
  • Suspect infectious if pyuria
    (WBCs or pus in urine)
• Urethral swab if discharge present
• Ultrasound if acute onset
  (to rule out testicular torsion)

Question 8

How should noninfectious epididymitits be managed?

Answer 8

Noninfectious/No severe pain:

• Conservative management:
  
  • Rest
  • Oral fluids
  • Scrotal support
  • Ice
• NSAIDs/analagesics

Question 9

How should infectious epididymitis be managed?

Answer 9

Infectious (based on culture):

• Ceftriaxone 500 mg IM
• If chlamydia +, then:
  Doxycycline 100 mg BID x 10 days

Question 11

What is the expected course of epididymitis?

Answer 11

• Improvement within 3 days
  (not fully recovered but better)
• Infection and pain resolve over 2 - 4 weeks with appropriate treatment

Question 12

Describe testicular torsion.

Answer 12

Twisting of testis and spermatic cord resulting from testicular ischemia if not corrected

Question 13

Describe the presentation associated with testicular torsion.

Answer 13

• Sudden onset of testicular pain
  (may occur after vigorous exercise or
  testicular trauma)
• Absent ipsilateral cremasteric reflex
• Tender, high-riding testicle *
• Testicular swelling
• N/V
• Awakening in middle of night
  (common in children)

NOTE: Normal cremasteric reflex = testicle rises when inner thigh is stroked on same side/ipsilateral

Question 14

How should testicular torsion be managed?

Answer 14

• Immediate urological referral for correction
• Clock starts at time when pain started
• Duration of torsion determines if testicle
  remains viable:
  - MUST correct in < 4 - 6 hours
  - IRREVERSIBLE damage after 12 hours