Ch. 52 - Scrotal Pain Flashcards
A 13 y/o boy presents with acute onset RLQ and scrotal pain for the past 4 hrs. +n/v, denies any similar past pain and reports no hx of trauma.
On physical exam, skin overlying R side of scrotum appears to be slightly erythematous and edematous. The R testicle appears to be lying significantly higher in the scrotum as compared to the L testicle. The entire R testicle is exquisitely tender to palpation, whereas the L one is nontender. He has an absent cremasteric reflex on the R.
What is the most likely dx?
Testicular torsion
Testicular torsion
Tender and swollen testicle that is displaced superiorly;
mass may be felt in spermatic cord, ABSENT CREMASTERIC REFLEX
+n/+v
Torsion of testicular or epididymal appendage (appendix testis)
Common cause of acute painful hemiscrotum in a child; the epididymal appendage (appendix testis) is located at the head of the epididymis; blue-dot sign = classic finding
Onset of pain is more gradual; CREMASTERIC REFLEX MAINTAINED
Epididymitis and/or orchitis
Scrotal pain relieved by supporting the scrotum
Dysuria
Induration
Classically from mumps (more common bacterial)
Acute epididymitis is treated with abx, but possibility of missing a dx of testicular torsion is so dreadful that sonogram is done to r/o
Hydrocele
- Fluid in tunica vaginalis
- Will transilluminate
- Increase in size with valsalva
- Often spontaneously resolve by 1 y/o
Varicocele
- Tortuous dilation of pampiniform plexus
- DOES NOT TRANSILLUMINATE
- Inc. in size with valsalva
- Described as a “bag of worms”
Appendicitis
- Anorexia
- Vague periumbilical abdominal pain
- Vomiting
- Localized RLQ pain (McBurney’s point)
- Rovsing’s sign
- Psoas sign (hip extension)
Fournier’s Gangrene
Severe necrotizing infection in perineal and scrotal region occuring most commonly in uncontrolled diabetic patients and immunocompromised
Testis tumor
Presents as firm, painless testicular mass that cannot be transilluminated; seminomas (germ cell tumors) are most common type and are malignant
Which type of testicular trauma is most common?
Blunt testicular trauma = 85% of cases (of these, sports-related injuries = most common)
- Usually unilateral
Penetrating trauma can involve both testes
What is the cremasteric reflex?
What would cause an absent cremasteric reflex?
Elevation of ipsilateral testicle by cremasteric muscle in response to stroking motion at medial aspect of upper thigh
Sensory fibers from femoral branch of genitofemoral nerve (L1-L2) are stimulated –> sensory input travels to spinal cord, synapses with motor n. from genital branch of genitofemoral nerve (L1-L2) –> activate cremasteric muscle –> ipsilateral elevation of testis
Absent with:
- UMN and LMN disorders
- Spinal cord injury at L1-L2
- Testicular torsion (almost always absent)
What is Prehn’s Sign? Is it reliable?
Positive when pts report pain relief with elevation of scrotal contents
Clasically, pts with epididymitis have +Prehn’s sign, while testicular torsion pts have -Prehn’s sign
However, Prehn’s sign is NOT reliable distinguishing feature b/w testicular torsion and epididymitis, as a +Prehn’s sign does not exclude diagnosis of testicular torsion
What is the Blue-Dot Sign?
Pathognomonic sign for torsion of testicular or epididymal appendage (appendix testes)
Palpation of testes reveals small firm and tender nodule near head of epididymis that appears to have a blue discoloration
What are the four cardinal sx and signs of testicular torsion?
- +N/V
- Testicular pain duration < 24 hrs
- Superiorly displaced testicle
- Absent cremasteric reflex
What are the important differences between testicular torsion and appendix testes torsion?
What congenital defect predisposes children to developing testicular torsion?
Bell-clapper deformity?
Congenital defects of processus vaginalis can lead to failure of testes to attach to inner lining of scrotum –> inc. risk of developing testicular torsion later in life
In particular, pts with bell-clapper deformity are at increased risk for testicular torsion –> occurs when there is a failure of normal posterior anchoring of the gubernaculum, testes, epididymis –> testes freely rotate and swing within tunica vaginalis of scrotum similar to gong (clapper) inside of a bell –> deformity usually present in both testicles, placing both at risk for torsion
Mgmt if suspicion for testicular torsion is high?
No labs.. prompt surgical intervention to restore blood flow to the testis
Mgmt if suspicion of testicular torsion is low?
Urinalysis to r/o UTI or epidymo-orchitis (may also present with scrotal pain)
Imaging should only be obtained with equivocal clinical findings and when performance of imaging will not significantly delay treatment. Doppler (blood flow) ultrasound (imaging) = modality of choice
In trauma setting, what are the most important things to look for during doppler U/S?
To determine if tunica albuginea (capsule that surrounds each testis) is violated (testicular rupture) –> warrant surgical repair in acute setting
Mgmt:
In the setting of testicular torsion, what is the optimal timing from initial evaluation to definitive mgmt?
Dx requires immediate surgical consultation with urologist for intervention
Timing is SO IMPORTANT!!!
100% viability when detorsion was achieved within 4-6 hrs
20% viability with detorsion after 12 hours
0-10% viability if detorsion was performed after 24 hrs
Orchiopexy vs Orchiectomy
Orchiopexy = testicle fixed to scrotum to prevent retorsion
Orchiectomy = testicle removed (necessary if testicle is necrotic)
Does loss of testicle from torsion affect fertility?
Only one testicle needed for fertiliy… in majority of pts who lose a testicle, fertility is not affected. On occasion, testicular necrosis and loss from torsion can lead to formation of antisperm antibodies with a subsequent decrease in sperm count and decrease in motility
