Allison Eliscu, MD, FAAPRev. Aug 2012
True Urologic EmergencyOccurs in 1/4000 males Typically <25 years old (mostly 12-18yo)92-96% with no prior trauma or recent
intense activity50% with prior transient torsion/detorsionUsually caused by bell-clapper deformity
Anomaly whereby testicle is not fixed to scrotum
Twisting of testicle around spermatic cord↓
Venous drainage hindered↓
Venous pressure rises↓
Venous pressure equalizes arterial pressure
↓Compromised arterial flow
↓Testicular ischemia
Note the horizontal lie, elevation, and edema of the affected testicle
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Acute onset of testicular painPain is severe and constantMay be associated with recent trauma or
vigorous activityAssociated Sxs:
Nausea/vomiting (20-30%) Abdominal pain (20-30%) Fever (16%) Urinary frequency (4%)
Unilateral swellingErythema or darkening of testicleLoss of rugae on affected sideElevated testicleHorizontal lie (compared to normal vertical lie)Pain and tenderness of testicleUnilateral loss of cremasteric reflexNo relief of pain with elevation of testicle
Negative Prehn Sign
Clinical suspicion based on history and physical
Clinically evident cases require emergent urology consult
CBC and UA may help narrow differential diagnosis but SHOULD NOT DELAY MANAGEMENT
Consider if diagnosis uncertain AND WILL NOT DELAY MANAGEMENT
Doppler Ultrasound – Test of Choice Check doppler flow to testes 88-100% sensitivity, 90-100% specificity
Nuclear Medicine Scintography 100% sensitivity, specificity 89-97% **Takes much longer, more expensive, harder
to read
Manual detorsion (26-80% success) Should be done by urologist Patient should be sedated Most effective before significant edema present Rotate testicle up and away from midline (twds thigh)
Surgical detorsion with bilateral orchiopexy Bilaterally correction required since deformity usually
bilaterally Surgical correction required even if manually detorsed
Testicular viability related to time since onset of pain Within 6 hours – 90-100% viable At 12 hours – 20-50% viable At 24 hours – 0-10% viable
Do not delay surgery b/c of assumed nonviability based on duration of symptoms
Incidence 1/1000 men/year
Most common 15-30 yo males
Risk Factors: STDs, UTIs
Twisting of testicle around spermatic cord↓
Venous drainage hindered↓
Venous pressure rises↓
Venous pressure equalizes arterial pressure
↓Compromised arterial flow
↓Testicular ischemia
Note the horizontal lie, elevation, and edema of the affected testicle
This slide best viewed in slide show format
Bed Rest with scrotal elevation
NSAIDS for pain control
Empiric treatment with antibiotics Prepubertal – target UTI organisms Postpubertal/sexually active – GC/CT
Excellent prognosis with pain relief in 3 days
Twisting of small vestigial structure on anterosuperior aspect of testis
Most common in 7-13 year old males
History: Acute unilateral pain, erythema, and swelling Pain is less severe than torsion
Physical Exam: Tender focal mass at superior pole of testicle Blue Dot Sign in 21% of cases (necrotic
appendix) Normal cremasteric reflex May have reactive hydrocele
Diagnosis: Clinical diagnosis Can get ultrasound to rule-out torsion of testis Ultrasound may be normal or have increased blood flow to
the affected area
Management: Supportive care Treat with bed rest, scrotal support, and NSAIDS Pain resolves in 5-10 days
Onset
Of
Symptoms
Most Commonly
Affected
Age
Pain
LocationUA
Cremasteric Reflex
Torsion AcuteEarly
Puberty
Diffuse testicular
painNegative Negative
Torsion
Of
Appendix
Testis
Subacute PrepubertyLocalized to upper pole of testicle
NegativePositive
(Intact)
Epididymitis Gradual Adolescent
Epididymal (posterior + superior to
testis)
Positive
or
Negative
Positive(Intact)
Summary of Testicular Pain
A 13 year old male presents to the emergency room complaining of left testicular pain which woke him from sleep 2 hours ago and has been getting worse. He denies fever, recent trauma, or dysuria and he is not sexually active. On exam, you note significant swelling and bluish discoloration of the left testicle. He won’t let you touch the testicle since it is so tender and you are unable to elicit a cremasteric reflex on that side. The most appropriate next step is to:
A. Obtain a urinalysisB. Obtain a CBCC. Immediately call a urology consultD. Start antibiotics for a possible infectionE. Discharge him with NSAIDs for pain and
an athletic supporter for sports
A 13 year old male presents to the emergency room complaining of left testicular pain which woke him from sleep 2 hours ago and has been getting worse. He denies fever, recent trauma, or dysuria and he is not sexually active. On exam, you note significant swelling and bluish discoloration of the left testicle. He won’t let you touch the testicle since it is so tender and you are unable to elicit a cremasteric reflex on that side. The most appropriate next step is to:
Obtain a urinalysis Obtain a CBC Immediately call a urology consult Start antibiotics for a possible infection Discharge him with NSAIDs for pain and an
athletic supporter for sports
Answer: C. This patient has testicular torsion until proven otherwise. Acute onset of pain with significant swelling, discoloration, and tenderness along with loss of cremasteric reflex is most consistent with torsion. Urology should be contacted immediately. Since this is an obvious case of torsion, the urologist may defer an ultrasound and take him immediately to the operating room to detorse the testicle. Remember, with torsion, time is of the essence.
A 15 year old male presents to the emergency room complaining of acute onset testicular pain. You immediately think of testicular torsion as a possible etiology. Which of the following examination signs is most consistent with testicular torsion?
A. Minimal swelling of affected testicleB. Loss of cremasteric reflex on affected
sideC. Mass resembling a bag of worms above
the affected testicleD. Some relief of pain with elevation of the
affected testicleE. Vertical lying testicleF. Both B & D
A 15 year old male presents to the emergency room complaining of acute onset testicular pain. You immediately think of testicular torsion as a possible etiology. Which of the following examination signs is most consistent with testicular torsion?
A. Minimal swelling of affected testicleB. Loss of cremasteric reflex on affected
sideC. Mass resembling a bag of worms above
the affected testicleD. Some relief of pain with elevation of the
affected testicleE. Vertical lying testicleF. Both B & D
Answer: B. Testicular torsion is a urological emergency and must be recognized and managed surgically immediately. Any delay in diagnosis or management increases the risk of testicular necrosis. Signs of torsion include unilateral testicular swelling, bluish discoloration, and elevation of the affected testicle. Affected testicles may also lie in a horizontal position (compared to a normal vertical position). Elevating the testicle does not relieve any of the pain (Prehn’s Sign negative); this is compared to patients with epididymitis in whom there is some pain relief with elevation of the affected testicle (positive Prehn’s sign). Loss of cremasteric reflex is one of the most sensitive indicators of torsion. A cremasteric reflex is elicited by stroking the upper thigh and watching the ipsilateral testis. The reflex is intact if the ipsilateral testis elevates. The mass resembling a bag of worms in the spermatic cord (superior to the testicle) is consistent with a varicocele, caused by dilation of the pampiniform plexus. It is a fairly common finding in adolescent males and tends to be asymptomatic.
An 18 year old male presents to the office with testicular pain for the past 2 days which has been getting worse. He has no past medical history and reports mild dysuria but no fever, discharge, nausea, vomiting, or abdominal pain. He also denies recent trauma. He is sexually active with multiple female partners and uses condoms most of the time. On exam, you note mild swelling of the left testicle, with no discoloration. Pain is localized to the posterior aspect of the left testicle but is relieved with elevation of the testicle and cremasteric reflex is intact. Which of the following is the most likely etiology for his pain?
A. Chlamydia B. Testicular torsion C. Testicular tumor D. Urinary tract infection E. Torsion of the appendix testis
An 18 year old male presents to the office with testicular pain for the past 2 days which has been getting worse. He has no past medical history and reports mild dysuria but no fever, discharge, nausea, vomiting, or abdominal pain. He also denies recent trauma. He is sexually active with multiple female partners and uses condoms most of the time. On exam, you note mild swelling of the left testicle, with no discoloration. Pain is localized to the posterior aspect of the left testicle but is relieved with elevation of the testicle and cremasteric reflex is intact. Which of the following is the most likely etiology for his pain?
A. Chlamydia B. Testicular torsion C. Testicular tumor D. Urinary tract infection E. Torsion of the appendix testis
Answer: A. This patient has epididymitis which, in sexually active males, is most often caused by Chlamydia. Torsion presents with more acute and more diffuse pain which is not relieved by elevation (Prehn’s sign negative). Patients with torsion usually have unilateral swelling, may have unilateral loss of cremasteric reflex, and may have a bluish discoloration, be elevated above the contralateral testis, and lie horizontally (compared to the normal vertical lie). Dysuria is also not very common in patients with torsion. Torsion is a urological emergency and must be diagnosed and managed immediately. Testicular cancer is usually nontender and asymptomatic. UTIs tend to present with dysuria without testicular pain and it is not common for a male with no past medical history to present with an initial UTI as a teenager. Torsion of the appendix testis usually presents with more acute pain which is localized to the superior pole of the testicle and is not relieved with elevation. On exam, a small blue dot may be present.
A 20 year old male presents to the emergency room complaining of testicular pain for the past day. He rates it about 5/10 now. He also reports tactile fevers and dysuria but denies discharge. His exam is remarkable for mild swelling of the left testicle and pain localized to the posterior aspect of the testicle. You suspect epididymitis and send him for an ultrasound which supports the diagnosis of epididymitis. Which of the following is the most appropriate next step in management?
A. Discharge him home on bedreset with NSAIDS for pain control
B. Give him an ice pack to help with swellingC. Send a urine specimen for gonorrhea and
chlamydia testing and treat him if the results are positive
D. Empirically treat him for gonorrhea and chlamydia with doxycycline and ceftriaxone
A 20 year old male presents to the emergency room complaining of testicular pain for the past day. He rates it about 5/10 now. He also reports tactile fevers and dysuria but denies discharge. His exam is remarkable for mild swelling of the left testicle and pain localized to the posterior aspect of the testicle. You suspect epididymitis and send him for an ultrasound which supports the diagnosis of epididymitis. Which of the following is the most appropriate next step in management?
A. Discharge him home on bedreset with NSAIDS for pain control
B. Give him an ice pack to help with swellingC. Send a urine specimen for gonorrhea and
chlamydia testing and treat him if the results are positive
D. Empirically treat him for gonorrhea and chlamydia with doxycycline and ceftriaxone
Answer: D. Sexually active males with epididymitis should be empirically treated for gonorrhea and chlamydia with ceftriaxone 250mg IM once (coverage for gonorrhea) and doxycycline 100mg PO BID for 10 days (coverage for chlamydia). Bedrest and NSAIDs may be helpful for pain control but the infection must be treated before discharge.
Brenner JS, Ojo A. Causes of Scrotal Pain in Children and Adolescents. UpToDate Online. Updated April 2009.
Gatti JM, Murphy JP. Current Management of the acute scrotum. Semin Pediatr Surg. 2007;16:58-63.
Gatti JM, Murphy JP. Acute Testicular Disorders. Pediatr Rev. 2008 Jul;29(7):235-41.
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