Testicular Issues (Acute Scrotal Pain/Swelling + Undescended Testis)

Question 1

What are the 6 main questions you need to ask if a patient presents with acute scrotal pain or swelling?

Answer 1

Age of child: neonatal, prepubertal, adolescent
Onset and severity
Trauma
Fever
Sexual Activity
Prior genitourinary surgeries/urological abnormalities

Question 2

What are the 6 features to be covered in the examination of this child?

Answer 2

Observation of the patients gait and resting position
Natural position of the testis in the scrotum while standing
Presence or absence of cremasteric reflex (think torsion)
Palpation of lower abdomen, inguinal canal and cord and then palpation of scrotum and contents while making sure to compare affected hemiscrotum with unaffected hemiscrotum
Transillumination (think hydrocele)
Is the swelling reducible? (think hernia)

Question 3

What are the investigations which need to be conducted (and which don’t)?

Answer 3

Check urinalysis and send sample for M&C

No need for blood tests or for Doppler U/S as it is not useful in the acute setting. While Doppler U/S can be useful in the visualisation of anatomy and blood flow. This investigation can be carried out if torsion and incarcerated hernia are ruled out by a surgical consult.

Question 4

Scenario 1: Acute Scrotal Swelling + Pain + Trauma =? (5 DDx)

Answer 4

Haematocoele
Haematoma
Testicular Rupture
Epidydimitis
Torsion

Question 5

Scenario 2: Acute Scrotal Swelling + Pain + No Trauma + Tender Testis =? (5 DDx)

Answer 5

Testicular Torsion
Epididymitis
Orchitis
Torsion of Appendix testis
Tumour

Question 6

Scenario 3: Acute Scrotal Swelling + Pain + No Trauma + NOT Tender Testis =? (4)

Answer 6

Torsion of Appendix testis
Incarcerated Hernia
HSP
Kawasaki’s Disease

Question 7

Scenario 4: Acute Scrotal Swelling + NO Pain + Enlarged Testis =? (3)

Answer 7

Tumour
Leukaemia
Antenatal Torsion (newborn)

Question 8

Scenario 5: Acute Scrotal Swelling + NO Pain + NO enlarged testis + Reducible Swelling =? (1)

Answer 8

Hernia

Question 9

Scenario 6: Acute Scrotal Swelling + NO Pain + NO enlarged testis + NOT reducible swelling + Scrotal wall swelling =? (3)

Answer 9

Idiopathic Oedema
HSP
Kawasaki’s Disease

Question 10

Scenario 7: Acute Scrotal Swelling + NO Pain + NO enlarged testis + NOT reducible swelling + NO scrotal swelling + Transillumination =? (3)

Answer 10

Hydrocoele
Speramatocoele
Hernia with hydrocele

Question 11

Scenario 8: Acute Scrotal Swelling + NO Pain + NO enlarged testis + NOT reducible swelling + NO scrotal swelling + NO Transillumination =? (2)

Answer 11

Varicocoele

Hernia

Question 12

What are 3 conditions which usually present with predominant pain?
What are 4 conditions which usually present with predominant swelling?

Answer 12

Pain: Testicular torsion, appendage torsion, epididymitis.
Swelling: hydrocoele, varicoele, tumour, spermatocoele (epididymal cyst)

Question 13

What predisposes an individual to getting testicular torsion and describe the anatomy of this?

Answer 13

Bell-clapper deformity.
High attachment of posterior part tunica vaginalis so both attachments are superior to the testis. (Instead of one superior and one posterior - covering anterior 2/3)

Question 14

What are the suggestive factors on Hx of testicular torsion?

Answer 14

Peaks in neonatal and adolescent age groups.

Less than 12 hour history, sudden onset, can occur during sleep (50-60%) or following minor trauma or spontaneous. May have previous episodes (intermittent torsion).

No fever, yes nausea/vomiting, no discharge/dysuria.

Question 15

What are the suggestive features O/E of testicular torsion?

Answer 15

Discolouration of the scrotum, exquisitely tender and swollen testis, riding high
Cremasteric reflex is absent

Question 16

What is the acute management of testicular torsion?

Answer 16

Early surgical consultation is vital, as delay in scrotal exploration and detorsion of a torted testis will result in testicular infarction within 8-12 hours.

Question 17

What features on Hx and O/E are seen in the torsion of the testicular appendix (hyatid of Morgani)?

Answer 17

On Hx: Peaks at 11 years old, there is a more gradual onset of testicular pain.

On O/E: Focal tenderness on the upper pole of the testis, blue dot sign is when the necrotic appendage is seen through scrotal skin.

Note: it is difficult to distinguish torsion of the testis and torsion of the appendage clinically.

Question 18

What is the acute management of torsion of the hyatid of Morgani/testicular appendage?

Answer 18

Analgesia and rest. The pain usually resolves in 2 to 12 days, pain should have lessened within 48 hours.

Question 19

What are the features on Hx and O/E suggestive of epididymoorchitis?

Answer 19

Hx: Usually in a young child, over days (acute is possible), usually gradual buildup, no trauma history, previous pain if previous episodes. Fever yes, rarely N/V, discharge/dysuria common.

O/E: Red, tender, swollen hemiscrotum; tenderness most marked posteriolateral to testis. Pyuria may be present.

Question 20

What is the management of epididymoorchitis?

Answer 20

Should be managed with antibiotics once a suitable urine sample has been sent.

Young infants or systemically unwell children should be admitted for i.v. antibiotics (eg. amoxycillin and gentamicin). Most patients can be successfully managed as out-patients, with co-trimoxazole.

Adolescents should have a first-pass urine sample for chlamydia and gonococcus PCR. The process is slow to resolve and the patient may have several weeks of gradually subsiding discomfort and scrotal swelling.

Question 21

How does an inguinal hernia form?

Answer 21

The processus vaginalis is the hole through which the testes descend into the scrotum during pregnancy. If this hole does not close behind the testes descent then an inguinal hernia may result (or a hydrocele or an encysted hydrocele of the cord). This means that bowel to enter the inguinal canal.

Question 22

What is the usual presentation of an inguinal hernia that is not strangulated or incarcerated? Who is more likely to get an inguinal hernia?

Answer 22

The younger you are the more likely to twist and as a result, the more urgent the treatment needs to take place.

Pre-term babies are more likely to have larger hernias because their tissue is more distensible.

The presentation of a simple inguinal hernia is intermittent swelling, overlying the external inguinal ring, that has been noticed by a parent. At times it may appear to cause discomfort. It is most likely to be obvious during an episode of crying or straining, and in infants may be seen during nappy changes.

Question 23

What is the presentation of a strangulated/incarcerated hernia?

Answer 23

Hx of intermittent inguinoscrotal bulge with associated irritability.

O/E: Firm, tender, irreducible, inguinoscrotal swelling

Question 24

What is the management of a strangulated/incarcerated inguinial hernia?

Answer 24

Important to reduce the hernia as soon as possible so that it doesn’t become incarcerated. If it is already incarcerated, then important to reduce to prevent the contents becoming gangrenous.

Question 25

What is a varicocele?

Answer 25

A varicocoele is a collection of abnormally large spermatic cord beings which is found mostly in teenage boys on the left hand side. O/E can see a mass of varicose veins (bag of worms) above the testicle, non tender and it is more prominent when standing.

Question 26

What is a hydrocele?

Answer 26

Hydrocele presents as a painless cystic swelling around the testes in the scrotum. It contains peritoneal fluid that has tracked down the narrow but patent processus vaginalis. It illuminates brilliantly.

Question 27

How do you manage a hydrocele?

Answer 27

Will often resorb and the tunica vaginalis close spontaneously in the first year. If still present at 2 years, surgical referral should be made for consideration of repair.

Question 28

How do you differentiate between a hydrocele and an inguinal hernia?

Answer 28

The upper limit of the hydrocele can be demonstrated distal to the external inguinal ring. This is different to an inguinal hernia when you cannot palpate the upper limit as the swelling extends into the external inguinal ring.

Can transilluminate a hydrocele

Can’t reduce a hydrocele

Question 29

Why is it important in terms of management to distinguish between a hydrocele and an inguinal hernia?

Answer 29

The management of hydroceole is not as urgent as that of inguinal hernia. Usually you wait till 2 years old for a hydrocele and then consider surgery. For an inguinal hernia, urgent management is crucial to not lead to more serious consequences. Furthermore, the younger you are, the less stressed you are about a hydrocele and the more stressed you are about an inguinal hernia.

Question 30

What is an undescended testis/cryptorchidism?

Answer 30

Undescended testis (or cryptorchidism) is a term used to describe the testis that does not reside spontaneously in the scrotum. Cryptorchidism occurs in about 2% of boys, being more common in premature infants. Spontaneous descent of the testis is unlikely beyond 3 months post-term.

Question 31

What are the 4 reasons that undescended testes are bad for a child?

Answer 31

Temperature of the testes has to be lower than body temperature for spermatogenesis to take place. Hence if undescended and inside the abdomen then decrease in fertility.

Increased risk of torsion

Can increase the risk of cancer of the testes as if it is undescended it will be undetected till late.

Self image

Question 32

How do you diagnose a child who has an undescended testis?

Answer 32

Diagnosis is made by examining the inguinoscrotal region. The testes should be found in the scrotal sac but the scrotum will be empty. The testis can then be milked down the line of the inguinal sac towards the scrotum. If the testis cannot be brought down into the scrotum, or will not remain there spontaneously then it is diagnosed as an undescended testis.

Question 33

How do you manage a child with undescended testis?

Answer 33

Undescended testes should be brought down into the scrotum surgically between 9 and 12 months of age. The later the testis is brought down, the more likely it is that there will be damage to spermatogenesis. Orchidopexy is performed as a day case procedure.