Clinical Case #3 Testicular Torsion - Pearson Flashcards
What does a thorough male genital exam consist of?
Inspect: Skin, Foreskin (retract), Glans, Meatus, Scrotum (include undersurface)
Palpation: Penis, Scrotal contents: each testis, epididymis, spermatic cord
Hernia Eval: Inspect groin area and then palpate the external inguinal ring
Cremasteric Reflex – rub inner thigh and look for ascension of testis
Digital rectal exam of the prostate
What is the DDx for male groin pain?
Contusion/trauma (ecchymosis)
Groin muscle strain (ROM, strength, resistance)
STI, UTI or other infection
Testicular Torsion
Hernia (incarcerated=jailed/stuck OR strangulated=blood supply is compromised), Inguinal: Indirect=through inguinal ring, Direct=through weakness in floor of inguinal canal, Femoral: more likely to incarcerate or strangulate
Hydrocele: NOT painful, trans illuminate, fluid filled sac surrounding testicle. Common in newborns. ?trauma, infection, malignancy, inflammation in adult males?
Varicocele: Enlargement of veins (pampiniform plexus) within the scrotum. Prevalence greater on L side. Often harmless, but keep in mind as a potential cause of decreased fertility in males.
Femoral nerve impingement = Hip flexion/knee extension, loss of patellar reflex
Malignancy = lump or painless presentation, young adult (teens-30s)
Lymphadenopathy/Lymphadenitis: ?Infection, inflammation, malignancy
Referred pain from: Hip, Pylonephritis, Renal colic, Regional ileitis, Appendicitis
Atypical/self-inflicted (i.e. vacuum)
What are the possible infectious causes of male groin pain?
UTI = Increased risk: BPH, uncircumcised, anal intercourse, kidney stones, catheters, diabetes, congenital anomalies
STI
Urethritis = Think UTI bugs vs. STI bugs vs. chemical irritant, pain with intercourse, pain with ejaculation
Epididymitis = Most common infections are STI bugs in young men, UTI bugs in older males/children. Zebra=TB
Pain localized to superior aspect of testicle.
Prostatitis = Acute vs chronic
Cellulitis
Orchitis = Can be epididymo-orchitis → diffuse tenderness of testis, ? immunizations status- mumps
Herpes (both simplex and zoster) → prodrome, pins & needles pain, vesicles later
What diagnostic tests would be warranted in a male with groin pain?
Ultrasound/CT
Urinalysis/Urine culture
STI testing
GC/Chlamydia- urethral swab vs. urine
Trichomoniasis- urethral swab vs. urine (need culture)
Herpes- viral culture vs. PCR testing of lesion (test fluid from vesicle)
HIV, Hepatitis, Syphilis- serology testing (blood tests)
HPV (genital warts), Pubic Lice- visualize
Type and Cross (if patient may need surgery)
What are the important aspects of patient history in groin pain in a male?
OPQRSTa: onset, provoking sx, quality, radiation, severity, timing/duration, any associated sx
Trauma, bruising
Fever, rash, N/V
Sexual Hx: partners, condoms, previous STI’s, anal sex, pain with sex
Urinary Sx: burning, frequency, urgency, nocturia, stream, previous kidney stones
Family Hx of prostate/testicular cancer
Insect bites
What are the the underlying causes and risk factors of testicular torsion?
Some men may be predisposed to testicular torsion as a result of inadequate connective tissue within the scrotum.
However, the condition can result from trauma to the scrotum, particularly if significant swelling occurs.
It may also occur after strenuous exercise or may not have an obvious cause.
**Most common in males 10 to 25 years old, but it can occur at any age.
What are the typical symptoms of testicular torsion?
Sudden onset of severe pain in one testicle, with or without a previous predisposing event
Scrotal swelling
Nausea or vomiting
Light-headedness
Additional symptoms that may be associated with this disease: Testicular lump, Blood in the semen
What is the treatment for testicular torsion?
Surgery: Make a cut in the scrotum => Untwist the spermatic cord, if necessary => Stitch one or usually both testicles to the inside of the scrotum to prevent rotation
What are the potential complications of testicular torsion?
If the blood supply is cut off to the testicle for a prolonged period of time, it may atrophy and need to be surgically removed.
Atrophy of the testicle may occur days-to-months after the torsion has been corrected.
Severe infection of the testicle and scrotum is also possible if the blood flow is restricted for a prolonged period.
How is testicular torsion diagnosed?
Physical exam: Extremely tender and enlarged testicular region – more common on the right.
The testicle on the affected side is higher
Cremasteric reflex is likely absent
Diagnosis made by Doppler imaging showing decreased or absent blood flow to affected testicle.
What is the time frame for successful treatment of testicular torsion?
The sooner the testicle is untwisted, the greater the chance of successful treatment:
Within six hours, the testicle can be saved about 90% of the time
After 12 hours, chances of saving the testicle fall to about 50%
After 24 hours, the testicle can be saved only about 10% of the time
