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Testicular Pain

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Testicular Pain: Excerpt from In a Page: Signs and Symptoms

Testicular pain must be considered a testicle-threatening emergency because of the possibility of testicular torsion or Fournier's gangrene, although the most common etiologies are neither serious nor emergent. Testicular pain often is accompanied by significant concern on the part of the patient who worries that this might be cancer.

Differential Diagnosis

  • Epididymitis
    –Insidious onset of symptoms seen in adolescent (postpuberty) boys
    –Bacterial (e.g., Chlamydia, Enterobacter) versus viral (mumps, mononucleosis, adenovirus)
  • Testicular torsion
    –Twisting of the spermatic cord results in testicular ischemia
    –Acute onset of severe pain, diffuse tenderness
    –Negative urinalysis; absent cremasteric reflex
    –Testes on affected side are tender, shortened, and lie transversely
    –Duration of ischemia (time until detorsion is completed) determines the viability of the affected testicle
  • Hydrocele
    –A collection of fluid between the layers of the tunica vaginalis; usually nontender
  • Varicocele
    –Palpated as a “bag of worms” above testes
    –Dull ache exacerbated by strenuous exercise; left >right
  • Epididymal or testicular appendage torsion
    –Subacute onset seen in prepubertal boys
    –Localized to the upper pole of testicle
    –Negative U/A; normal cremasteric reflex
  • Ruptured abdominal aortic aneurysm
  • Peritonitis
  • Referred pain due to an incarcerated hernia, constipation, or kidney stone
    • Scrotal trauma
      –Results from a direct blow or saddle injury
      –May result in traumatic epididymitis, hematocele, or laceration of the tunica albuginae (testicular rupture)
    • Fournier's gangrene
      –Necrotizing fasciitis of the perineum
      –Seen primarily in older men
    • Henoch-Schönlein purpura
      –Systemic vasculitis resulting in scrotal pain, abdominal pain, arthralgias, nonthrombocytopenic purpura, and renal disease
      –Occurs in prepubertal boys
    • Tumor
      –Painless scrotal mass is a testicular neoplasm until proven otherwise

    Workup and Diagnosis

    • History and physical examination including abdomen, back, genitalia, and digital rectal examination
      –Note character of onset (sudden or subacute), duration (minutes, hours, or days), location (generalized or localized), quality (sharp or dull, moderate or severe, constant or intermittent), and previous episodes
      –Palpate testicle and spermatic cord to assess for tenderness, effusion, subcutaneous emphysema, size, and lie of testicle, and assess for hernias
      –Transilluminate for presence of fluid
      –“Blue dot sign”: Bluish discoloration along upper pole seen in about 20% of cases of torsion of the testicular appendix and due to infarction and necrosis
      –“Prehn's sign”: Relief of pain with elevation of the testis in testicular torsion
    • If testicular torsion is suspected, emergent detorsion is necessary, generally by a urologic specialist
    • Culture for Neisseria gonorrhoeae and Chlamydia trachomatis in sexually active males before urinalysis
    • Urinalysis in all patients: Elevated WBC or RBC levels suggest infection (e.g., epididymitis)
    • Ultrasound of the testicles using color Doppler measures blood flow and evaluates for masses
    • Radionucleotide scintigraphy may also be used to assess blood flow
    • Recent studies have advocated the use of MRI

      • Treatment

      • Testicular torsion is a surgical emergency
        –Immediate detorsion is necessary to salvage the testicle
        –If surgery unavailable, attempt manual detorsion
        –Detorsion maneuver: Infiltrate spermatic cord with 10–20 mL of 1% lidocaine, then twist testes counterclockwise on left or clockwise on right; successful detorsion is indicated by immediate relief
        –Urologic referral is indicated emergently if detorsion is unsuccessful; also refer for orchiopexy
      • Incarcerated inguinal hernias and testicular rupture require surgical repair
      • Epididymitis
        –Appropriate antibiotic therapy (empiric treatment)
        –NSAIDs and scrotal elevation for pain control
        –Viral causes require only supportive care
      • Varicocele requires urology referral to optimize fertility
      • Henoch-Schönlein purpura: Medical management
      • Tumor: Resection
      • UTI/pyelonephritis: Appropriate antibiotic therapy

Book Source Details

  • Book Title: In a Page: Signs and Symptoms
  • Author(s): Scott Kahan, Ellen G. Smith
  • Year of Publication: 2004
  • Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.



More About This Book:
Title: In a Page: Signs and Symptoms
Authors: Scott Kahan, Ellen G. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2004
ISBN: 1-4051-0368-X

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