Evaluating Testicular Pain

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Evaluating Testicular Pain

• Kaveh Mansuripur
• Ambulatory Medicine Clerkship
• 4/9/09

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Learning Objectives

• By the end of the session, be able to
• List the differential dx for testicular pain
• Label or draw the relevant anatomy
• Describe the physical examination appropriate for
  a patient with testicular pain
• Select appropriate testing for patients with
  testicular pain in context of specific sxs and
  signs
• Select the most appropriate treatment for
  patients with specific causes of testicular pain

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Anatomy
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Case 1 Patient T.R.What is the Differential
Diagnosis?

• HPI
• 21 yo man presents with 3 hours of intense,
  constant testicular pain
• Began several hours after college track meet
• Associated nausea and vomiting
• PMH None
• Meds Glucosamine, condroitin, creatine
  supplements
• Alls PCN
• FH Non-contributory
• SH Sexually active, multiple partners

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Differential Diagnosis

• Testicular Torsion
• Appendiceal Torsion
• Epididymitis
• Trauma
• Inguinal Hernia
• Henoch-Schonlein Purpura
• Mumps
• Fourniers Gangrene
• Referred Pain

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Case 1 Patient T.R.

• Exam

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Case 1 Patient T.R.What is the Next Step?

• Exam
• Right testicle higher than left
• Long axis oriented horizontally
• Significant swelling
• No cremasteric reflex on either side
• No relief of pain on elevation

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Case 1 Patient T.R.Next Step

• If Diagnosis Certain (Torsion)
• To the OR.
• Outcomes directly related to length of time from
  onset
• Irreversible ischemia at mean of 12 hours
• If Diagnosis Less Obvious
• Doppler Ultrasound
• Test 82 sensitive, 99 specific for torsion
  (loss of flow)

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Case 1 Patient T.R.

• Operation
• testicular detorsion and fixation
• Unilateral or bilateral? Why?

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Case 1 Patient T.R.

• Operation
• testicular detorsion and fixation
• Unilateral or bilateral? Why?
• ANSWER Bilateral-- Torsion associated with
  absence/insufficeincy of gubernaculum. Often
  bilateral.
• What if surgery not an option?

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Case 1 Patient T.R.

• Non-operative Manual detorsion
• 2/3 of cases are torsed medially, 1/3 laterally
• Success marked by decreased pain, return to
  normal position.
• If unsuccessful, apply ice (successful in animal
  models)

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Testicular Torsion

• 40 over 21
• Associated with physical activity/sleep
• Exam
• Absent cremasteric
• Doppler
• Surgical Emergency

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Case 2 Patient F.J.

• HPI
• 11 year old boy presents with 3 days of
  increasing scrotal pain
• Localizes tenderness to anterior superior pole of
  right testicle
• dDx?

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Case 2 Patient F.J.

• Exam

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Case 2 Patient F.J.

• Exam
• Tender as reported
• Transillumination hydrocele at AS pole
• Cremasteric reflexes intact bilaterally
• Discoloration visible externally as
  sub-centimeter dot at site

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Case 2 Patient F.J.
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Case 2 Patient F.J.

• Further tests?

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Case 2 Patient F.J.

• Further tests?
• Ultrasound will show focus of decreased
  echogenicity at site
• Treatment?

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Case 2 Patient F.J.

• Further tests?
• Ultrasound will show focus of decreased
  echogenicity at site
• Treatment?
• Conservative
• Ice, anti-inflammatory medications
• Pain resolves in weeks-months
• Residual nodule
• Operative
• Low risk
• Recovery in days

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Appendiceal Torsion

• 80 between 7-14 years
• Leading pediatric scrotal pathology
• Gradual onset
• Tenderness localized to AS aspect
• Intact cremasteric reflex
• Blue Dot sign in 21

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Case 3 Patient J.D.

• CC 31 yo man with Testicular Pain
• HPI
• 5 days, waxing/waning. Began several hours after
  exercise. No previous episodes.
• Left testicle, some radiation to L. inguinal
  fold, L. gluteal region
• Achy in quality 4-8/10
• No N/V/F/C or other associated symptoms
• ED visit 3 days ago. Clean U/A at time. Told to
  FU outpatient if pain unresolved.

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Case 3 Patient J.D.

• PMH
• Noncontributory
• Meds
• None
• Allergies
• NKDA
• FH/SH
• HTN, MI in father
• 1ppd, social EtOH, bisexual.

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Case 3 Patient J.D.

• Exam
• Mild swelling around left testicle
• Normal lie
• Tenderness localizes to PS pole
• WHAT IS DIFFERENTIAL DIAGNOSIS?

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Case 3 Patient J.D.

• Exam
• Mild swelling around left testicle
• Normal lie
• Tenderness localizes to PS pole
• Diagnosis
• Epididymitis

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Case 3 Patient J.D.

• Bacterial Epididymitis
• What to give and why?

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Case 3 Patient J.D.

• Bacterial Epididymitis
• What to give and why?
• C. trachomatis and N. Gonorrhea most common in
  men under 35

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Case 3 Patient J.D.

• Bacterial Epididymitis
• What to give and why?
• C. Trachomatis and N. Gonorrhea most common in
  men under 35
• Doxycycline 100mg PO BID x10 days
• Ceftriaxone 250mg IM x1

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Case 3 Patient J.D.

• Bacterial Epididymitis
• What to give and why?
• C. Trachomatis and N. Gonorrhea most common in
  men under 35
• Doxycycline 100mg PO BID x10 days
• Ceftriaxone 250mg IM x1
• Coliforms?

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Case 3 Patient J.D.

• Bacterial Epididymitis
• What to give and why?
• C. Trachomatis and N. Gonorrhea most common in
  men under 35
• Doxycycline 100mg PO BID x10 days
• Ceftriaxone 250mg IM x1
• Coliforms?
• Quinolones (ofloxacin 300mg PO BID x10 days)

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Epididymitis

• Mostly subacute
• ABX
• Evaluate recurrent cases for GU malformation
• Acute more common in older men, prostatitis
• Fever, chills, GU symptoms

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References

• Edelsberg, JS, Surh, YS. The acute scrotum. Emerg
  Med Clin North Am 1988 6521.
• Eyre, RC. Evaluation of the acute scrotum in
  adult men. In UpToDate, Basow, DS (Ed),
  UpToDate, ?Waltham, MA, 2008.
• Fisher, R, Walker, J. The acute paediatric
  scrotum. Br J Hosp Med 1994 51290.