Scrotal Pain

Question 1

Clinical features

Answer 1

Establish onset, course and duration of pain

Any associated urinary symptoms

Ask about sexual history and history of previous surgery

Examination of the scrotum should be done as well.

Focus on inspection for testicular lie and any signs of inflammation + palpation to find lumps or localised tenderness.

Question 2

Explain cremasteric reflex

Answer 2

Stroke the proximal and medial aspect of the thigh

Normal response is contraction of the cremaster muscle leading to retraction of tests upwards on the ipsilateral side.

Absence = potential sign of testicular torsion with 88% and 86% in sens and spec respectively.

Question 3

Explain Prehn’s sign

Answer 3

Alleviation of scrotal pain by lifting of the testicle

This is suggestive of the diagnosis of acute epididymitis

It has a sensitivity of 91% and spec of 78%

Question 4

Investigations

Answer 4

Urine dipstick + cultures

Urethral swab if STI is suspected

Blood tests mainly FBC, CRP and U&Es

USS of scrotum might be done if uncertainty arise to identify any structural or inflammatory pathology and the patency of blood vessels.

Do not delay scrotal exploration by doing ultrasound if torsion is suspected

Question 5

Dx

Answer 5

Testicular torsion

Torsion of testicular and epididymal appendages

Epididymitis

Testicular cancer

Referred pain

Henoc-Schönlein Purpura

Viral Orchitis

Question 6

Explain testicular torsion

Answer 6

Twisting of spermati cord with occlusion of testicualr and cremasteric arteries

This leads to ischaemia and subsequent testicular infarction

Question 7

Explain torsion of testicular and epididymal appendages

Answer 7

Testicular appendix aka hydatid of Morgagni and epididymal appendix are remnant of embryoligical development.

They can twist leading to unilateral scrotal pain and tenderness

There is often a normal testicular lie and present cremasteric reflex

Question 8

Examination findigns of Torsion of Testicular and Epididymal Appendages

Answer 8

Blue dot sign (i.e., tender nodule with blue discoloration on the upper pole of the testis) found in the upper half of the hemi-scrotum sign due to infarction of the appendices.

Question 9

Treatment of Torsion of Testicular and Epididymal Appendages

Answer 9

Analgesia

Surgical exploration is usually required to rule out testicular torsion

Question 10

Explain referred pain

Answer 10

Anteriolateral aspect of the scrotum is supplied by branches of the genitofemoral and the ilioinguinal nerve

Posterior scrotum is supplied by the perineal branches of the pudendal nerve and posterior femoral cutaneous

Irritation of these nerve can result in referred pain.

E.g. luminal ureteric stones or strangulated inguinal hernia.

Question 11

What is Henoch-Schönlein purpura

Answer 11

IgA-mediated small vessel vasculitis affecting skin, mucous membranes and kidneys.

Question 12

Clinical features of HSP

Answer 12

In children with classic triad of purpuric rash on limbs, arthritis and abdo pain.

There might also be scrotal symptoms including pain, erythema and swelling.

Question 13

Blood tests of HSP

Answer 13

Raised CRP or ESR

Raised serum IgA

Diagnosis is made through biopsy of kidney or skin to identify IgA deposition

Question 14

Causes of viral orchitis

Answer 14

Most commonly mumps leading to inflammation of the testes.

It casues bilateral acute scrotal pain + swelling

Develop around 4 to 8 days after initial parotitis

Question 15

Management of viral orchitis

Answer 15

Analgesia

It is self-limiting

Swelling acn persist up to 6 weeks post-infection