Acute testicular pain (module 6)

Question 1

typical presentation for testicular pain

Answer 1

peri pubertal male
younger patients <18 tend to have testicular torsion
older patients (sexually active and/or bladder outflow obstruction) tend to have epididymo-orchitis

but torsion should still be excluded in every case

Question 2

DDx of acute testicular pain

Answer 2

testicular torsion
epididymo-orchitis
torted appendix of the epididymis/testis (hydatid of morgagni)
trauma (ruptured testicle, haematoma, other)
other (hernia, referred pain from renal colic/hip/back pathology)

Question 3

how to tell testicular torsion and epididymo-orchitis (EO) apart

Answer 3

both present with acutely painful and swollen testicle
you have to differentiate between a vascular issue (torsion) versus and inflammatory (EO) one

Question 4

prehn’s sign

Answer 4

when the pain is worse on standing
means it is epipididymo-orchitis

Question 5

torsion indicators on history

Answer 5

paediatric patient
sudden onset severe
no difference with posture
vomiting frequent

Question 6

EO indicators on Hx

Answer 6

sexually active (STI) or elderly (UTI)
gradual onset
worst on standing (prehn’s sign)
urinary symptoms or discharge
systemic upset
Hx of unprotected intercourse
Hx of voiding difficulties

Question 7

signs on examination that indicate torsion

Answer 7

afebrile
high riding tender
horizontal lie
cremaster reflex lost
U/A normal

Question 8

bell clapper configuration

Answer 8

high fusion of the tunica vagnalis means the tesicle lies loose in bell clapper configuration
enables testicle to twist around on its blood supply
bell clapper testicles test to be high riding with a horizontal lie

Question 9

what is the treatment for testicular torsion?

Answer 9

urgent referral to urology
surgical exploration of BOTH testes after detorting torted testicle
viability of the testis is assessed after warming with saline packs

Question 10

if the testis is viable after de-torsion

Answer 10

3 point fixation (orchidopexy) is performed to pin testicle and tunica vaginalis onto darts muscle of the scrotum
contraleterral side is also explored and fixed
failure to treat the contralateral side will result in future torting of the untreated side

Question 11

what should you do if the testis is not viable after de-torting

Answer 11

orchidectomy and then fixation of the contralateral side

Question 12

prognosis for testicular torsion

Answer 12

best results within 6 hours
reduced viability 6-24 hours
few testis viable after 24 hours

Question 13

for best results, testis must be de-torted within

Answer 13

6 hours

Question 14

long term effects of torted testis

Answer 14

fertility may be mildly impaired after an episode of torsion
hormonal function is usually normal
affected testis may atrophy if viability was borderline or ischaemia prolonged

Question 15

what are the four main mechanisms through which epididimoorchitis occurs

Answer 15

1. sexually transmitted infection (esp. gonorrhoea, chlamydia)
2. urinary tract infection eg. patient may have voiding difficulties
3. virus eg. mumps, rare with vaccination
4. chemical/reflux of urine - occurs in extreme straining eg. weightlifters

Question 16

if there is no clinical suspicion of torsion, what should the patient have investigated?

Answer 16

MSU for MC + S (to check for UTI)
first stream urine for chlamydia/gonococcal PCR (STI)
U/S scan of the scrotum

Question 17

what might you be looking to achieve by doing an ultrasound of the scrotum?

Answer 17

exclude testicular cancer
assess blood supply, access formation and confirm signs of infection

Question 18

treatment for epididymo-orchitis

Answer 18

bed rest
scrotal support
anti-inflammatories
analgesia
inpatient IV-Abs

Question 19

when might a urology consult be required during treatment for epipidymo-orchitis

Answer 19

uncertainty about diagnosis
intractable pain
failure to improve on oral Abs
sepsis
U/S indicates abscess or infarction

Question 20

how long does it take for swelling to improve in epididymo-orchitis

Answer 20

may take several weeks

Question 21

long term sequelae for epididymo-orchitis

Answer 21

most resolve with no long term sequelae

occasionally complications may occur
- testicular atrophy
- abscess
- infarctions
- cellulitis/fasciitis

Question 22

torsion vs. epididymo-orchitis table

Answer 22