Scrotal pain case file
Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD, Adam J. Rosh, MD, MS
Case 48
A 17-year-old adolescent boy arrives at the emergency department (ED) after he developed the acute onset of severe right testicular pain about 4 hours ago while at soccer practice. The patient does not recall any recent trauma to the area and denies any fever, dysuria, or penile discharge. Although he is nauseous, he does not have any abdominal pain or vomiting.
On examination, his temperature is 99.5°F, blood pressure 138/84 mm Hg, heart rate 104 beats per minute, and respiratory rate of 22 breaths per minute. He is in acute distress due to pain. His abdomen is benign. On visual inspection, he has right scrotal erythema and swelling although no penile lesions or discharge. Because his scrotum is so diffusely tender, it is difficult to examine it more closely. However, there is no testicular rise when his inner thigh is stroked. His urinalysis shows 3 to 5 white blood cells (WBCs)/high power field (hpf).
⯈ What is the most likely diagnosis?
⯈ What is the next diagnostic step?
ANSWER TO CASE 48:
Scrotal Pain
Summary: This is a 17-year-old adolescent boy who presents with acute onset right testicular pain without any preceding trauma.
- Most likely diagnosis: Testicular torsion
- Next diagnostic step: Urological consultation. Manual detorsion can be attempted while awaiting the consultant.
ANALYSIS
Objectives
- Learn the differential diagnosis for acute scrotal pain.
- Recognize the clinical signs and symptoms associated with testicular torsion.
- Understand the diagnostic and therapeutic approach to suspected testicular torsion.
Considerations
The differential diagnosis of acute testicular pain includes testicular torsion, epididymitis, orchitis, torsion of the testicular appendages, hernia, hydrocele, and testicular tumor (Table 48–1). Because of the risk of ischemia and infarction of the testes, testicular torsion is the priority condition that must be promptly recognized and treated. This patient is 17 years old without a history of trauma. Adolescents during puberty are especially at risk of testicular torsion because of high hormonal stimulation. This patient’s history of acute onset, especially associated with vigorous physical activity, is classic. The involved testis is firm, tender, and located higher in the scrotum on examination, and the cremasteric reflex is absent, again consistent with testicular torsion. When the clinical presentation is unclear, Doppler flow studies of the intratesticular blood flow may be helpful. This patient, however, has a clear-cut diagnosis, and time is of the essence.
Approach To:
Scrotal Pain
CLINICAL APPROACH
When any male presents with scrotal pain, testicular torsion must be considered. Prompt diagnosis and therapy are vital because delays can lead to ischemia, loss of the testicle, and impaired fertility. In general, the best salvage time of the testis is attained within 4 to 6 hours after the onset of pain, but clinical parameters are often unreliable. Patients with testicular torsion often have a congenital “bell clapper” deformity, which allows the epididymis and testicle to hang freely and rotate in the scrotum. When torsion occurs, the spermatic cord becomes twisted, cutting off the blood supply to the testicle. Although torsion can occur at any age, it is most common in children less than 1 year old and around puberty.
When obtaining the history, the clinician should focus on the onset and duration of pain, alleviating and aggravating factors, and any associated symptoms, such as nausea and vomiting, fever, urethral discharge, and dysuria. He/she should also remember that some patients may complain of abdominal rather than scrotal pain. In addition, it is important to inquire about any previous episodes and any recent trauma. A typical patient with testicular torsion presents with the sudden onset of severe pain in the lower abdomen, inguinal area, or scrotum. Associated nausea and vomiting are common. The pain is often preceded by strenuous physical activity or trauma although episodes can occur during sleep. Pain that persists for more than one hour after scrotal trauma is not normal and merits further investigation. Past episodes that resolved spontaneously are not uncommon.
On examination, the clinician should pay close attention to any abdominal findings, scrotal swelling or skin changes, penile discharge or rash, inguinal lymphadenopathy or hernia, and testicular tenderness or masses. Classically, a torsed testicle is diffusely tender and swollen with an abnormal (horizontal) lie. There is usually a loss of the cremasteric reflex on the affected side. However, no historical or examination findings can definitively distinguish testicular torsion from other disease processes. In addition, infants and children may lack the typical examination findings.
Testicular torsion is largely a clinical diagnosis, and no diagnostic tests should delay urological evaluation and surgical exploration. If the diagnosis is uncertain, color-flow Doppler ultrasound (US) or radionuclide scintigraphy may be helpful. With testicular torsion, Doppler US will reveal decreased or absent testicular blood flow. The utility of these studies may be limited by their availability and timeliness. In addition, scintigraphy does not provide any anatomical information, and therefore cannot differentiate epididymitis from torsion of the appendix testis. Many times, leukocytes are found in the urine of men with testicular torsion. This finding should not distract the clinician from the diagnosis.
TREATMENT
When the diagnosis of testicular torsion is considered, prompt urological consultation is mandatory. Definitive treatment involves emergent surgical exploration, detorsion, and orchiopexy. While awaiting urological consultation, the clinician may attempt manual detorsion. Because most torsions occur in a lateral to medial manner, the testis should initially be turned in a medial to lateral direction like
“opening a book.” Successful detorsion results in significant pain relief. If the pain worsens, however, the maneuver should be tried in the opposite direction. Intravenous access and analgesics are also necessary. The differential diagnosis for acute scrotal pain includes several benign and emergent conditions (Table 48–1).
COMPREHENSION QUESTIONS
48.1 A 22-year-old baseball player comes to the ED complaining of 10 hours of severe right testicular pain. He denies a history of trauma. On examination, his right testis is diffusely tender and indurated, and the pain does not change with patient position. He has a cremasteric reflex on the right side. Which of the following is the best next step?
A. Continued observation
B. Oral antibiotics
C. Bed rest, ice to scrotum, and elevation of the scrotum
D. Surgical exploration of the scrotum
48.2 A 32-year-old jogger is brought into the emergency room with the acute onset of severe left testicular pain. A diagnosis of testicular torsion is made, and manual detorsion is successfully accomplished. Which of the following is the most appropriate advice to this patient?
A. Likely no further therapy is needed.
B. Surgical exploration may be needed if another episode of torsion occurs.
C. Surgical correction will be needed but does not necessarily need to be done urgently.
D. Surgical exploration still needed to be performed and should occur within 24 hours.
Match the probable diagnoses (A-F) to the clinical scenario in questions 48.3 to 48.6:
A. Torsion of the appendix testis
B. Testicular torsion
C. Epididymitis
D. Orchitis
E. Testicular tumor
F. Acute prostatitis
48.3 A 24-year-old man complains of severe left scrotal pain increasing over 24 hours. Urinalysis shows 25 WBC/hpf, and Doppler flow shows increased intratesticular flow.
48.4 A 58-year-old man complains of urgency, dysuria, lower back pain, and pain with ejaculation.
48.5 A 14-year-old adolescent complains of 2 days of testicular pain. On examination, there appears to be a tender nodule of the testis. Transillumination reveals a small blue spot at the affected area.
48.6 A 28-year-old man complains of heaviness in his scrotum. On examination, there is a firm, nontender mass involving his right testis.
ANSWERS
48.1 D. The clinical history is consistent with testicular torsion. The presence of a cremasteric reflex does not rule out the disease. Emergency scrotal exploration is the procedure of choice when the history, physical examination, and imaging tests do not rule out testicular torsion.
48.2 C. Detorsion of the torsed testis converts an emergent condition into one that is amenable to elective correction. Manual detorsion is not definitive therapy.
48.3 C. The Doppler ultrasound finding consistent with epididymitis is increased or preserved blood flow. Also epididymitis usually has a more gradual onset of pain. Fifty percent of patients with epididymitis have pyuria or bacteriuria.
48.4 F. Acute prostatitis usually occurs in older patients. Urinary urgency, hesitancy, frequency, and perineal pain with ejaculation are common symptoms. The most common causative organism is Escherichia coli. Appropriate antibiotic choices include fluoroquinolones (ciprofloxacin, ofloxacin, norfloxacin) as well as trimethoprim-sulfamethoxazole.
48.5 A. Torsion of a testicular appendage classically presents as a tender testicular nodule, and upon transillumination, a “blue dot” may be seen. Color Doppler blood flow is increased or normal.
48.6 E. Testicular carcinoma classically presents as a painless scrotal mass.
CLINICAL PEARLS
⯈ Testicular torsion should always be considered in the differential diagnoses of acute scrotal or abdominal pain.
⯈ No single historical or examination finding can definitively distinguish testicular torsion from other processes.
⯈ Time is testicle. If testicular torsion is suspected, prompt urological consultation is mandatory.
⯈ Definitive treatment of testicular torsion is surgery. Manual detorsion may be attempted as a temporizing measure.
References
Lewis AG, Bukowski TP, Jarvis PD, et al. Evaluation of acute scrotum in the emergency department. J Pediatr Surg. 1995;30:277-282.
Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, PA: Mosby Elsevier; 2009.
Mufti RA, Ogedegbe AK, Lafferty K. The use of Doppler ultrasound in the clinical management of acute testicular pain. Br J Urol. 1995;76:625-627.
Rabinowitz R. The importance of the cremasteric reflex in acute scrotal swelling in children. J Urol. 1984;132:89-90.
Ringdahl E. Testicular torsion. Am Fam Physician. 2006;74(10):1739-1743.
Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: McGraw-Hill; 2011.
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