Diagnosis of Testicular torsion
Testicular torsion Diagnosis: Book Excerpts
Diagnostic Tests for Testicular torsion: Online Medical Books
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SCROTAL SWELLING:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is it diffuse or focal? Diffuse scrotal swelling would suggest congestive heart failure, nephrosis, uremia, and cirrhosis, as well as focal disease such as filariasis or bilateral hydrocele. Focal scrotal swelling would suggest a hernia, hydrocele, torsion of the testicle, abscesses, epididymitis, orchitis, varicoceles, and testicular tumors.
- If it is diffuse, is there ascites or generalized edema? The presence of diffuse edema of the scrotum with ascites or generalized edema would suggest congestive heart failure, nephrosis, uremia, or cirrhosis.
- If it is focal, is it painful? The presence of painful scrotal swelling would suggest an incarcerated or strangulated inguinal hernia, torsion of the testicle, a hematoma, orchitis, epididymitis, furuncle, or periurethral abscess.
- Does it transilluminate? If the mass transilluminates, it is very likely a hydrocele of the testicle or a spermatocele.
- Is it reducible? If the mass is reducible, it is most likely an inguinal hernia or a varicocele.
DIAGNOSTIC WORKUP
Routine laboratory tests include a CBC, sedimentation rate, urinalysis, urine culture, and urethral smear. If prostatic disease is suspected, a PSA should be ordered. If intestinal obstruction is suspected, a flat plate of the abdomen and lateral decubiti should be ordered. A radionuclide testicular scan with technetium-99m is useful in differentiating between testicular torsion and epididymitis. Scrotal ultrasound may be done to evaluate any kind of testicular or scrotal mass. However, it is much less costly to refer the patient to a urologist.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
TESTICULAR SWELLING:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there pain or tenderness of the testicle? The presence of pain or tenderness should suggest torsion of the testicle, orchitis, epididymitis, and a strangulated inguinal hernia.
- Is the testicle retracted or does elevation of the testicle aggravate the pain? These findings would suggest torsion of the testicle.
- Does the swelling transilluminate? If the swelling transilluminates, the mass or swelling is most likely a hydrocele or spermatocele.
- Is the swelling reducible? If the swelling is reducible, the mass is probably an inguinal hernia or varicocele. A mass that does not reduce could still be an incarcerated inguinal hernia.
DIAGNOSTIC WORKUP
A CBC, sedimentation rate, urinalysis, chemistry panel, and VDRL test should be done routinely. If a tumor of the testicle is suspected, 24-hr urine gonadotrophins and alpha-fetoprotein levels may be ordered. If there is a urethral discharge, a smear and culture should be done. If a hernia is strongly suspected, a general surgeon should be consulted. Testicular scans with technetium-99m will help distinguish torsion of the testicle from orchitis or epididymitis. Scrotal ultrasound may be useful in differentiating a hematoma, abscess, or rupture from orchitis. It may also be helpful in evaluating testicular tumors. CT scan of the abdomen and pelvis may be necessary to rule out metastasis.
The expense of some or all of these tests may be avoided by consulting a urologist early in the diagnostic workup.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Scrotal Swelling:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
- Hydrocele
–Fluid surrounding the testicle
–Typically seen in infancy
–Results from remnant of testicular descent from the abdomen through the inguinal canal into the scrotum
–May be communicating or noncommunicating; communicating hydroceles have retained patency of the tract of descent, and noncommunicating hydroceles do not
–Communicating hydroceles may be reducible and are likely to fluctuate in size depending on the amount of fluid within the scrotal sac; crying or any increase in intra-abdominal pressure results in an increase in size
–Usually is noncommunicating; i.e., not reducible, and does not change in size with crying
–Testes may be difficult to palpate because surrounded by the hydrocele
- Hernia
–Protrusion of a loop of bowel into the scrotum
–Direct hernias represent a channel directly through the musculature of the pelvic floor; indirect hernias have proceeded through the inguinal canal
–Usually painless unless incarcerated
–Usually reducible and changes in size with changes in intra-abdominal pressure
–Testes usually palpable below the hernia
-
Varicocele
–A collection of dilated veins in the scrotum
–Usually painless, but patients may complain
of heaviness
-
Edema
–Generalized edema often is accompanied by scrotal edema
-
Tumor
–Presents as painless nodule on testes
–May be accompanied by sexual precocity or
gynecomastia secondary to hormone production by the tumor
-
Leukemia
–Patients may present with unilateral scrotal swelling (common site for relapse)
Workup and Diagnosis
-
History
–Onset, duration of symptoms
–Unilateral or bilateral
–Associated systemic symptoms
-
Physical exam
–General state of health, including growth parameters
and weight loss
–Unilateral or bilateral lesions
–Reducibility of scrotal mass or enlargement
–Palpation of testes: Tenseness, nodules
–Hydroceles can sometimes be transilluminated
–Patent defects can usually be palpated when there is a
hernia, particularly if the patient performs a Valsalva maneuver (“turn your head and cough”)
–Varicocele is usually left sided and feels like “a bag of worms”
-
Labs
–CBC and differential, LDH, ESR if malignancy is suspected
-
Radiology
–Ultrasound may be helpful confirming hernia, hydrocele, or varicocele
–PET scans are used to detect malignant metastasis or relapse
-
Studies
–A testicular nodule usually must be biopsied to rule out malignancy
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
TESTICULAR MASS:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Testicular masses may be differentiated by transillumination (hydroceles and spermatoceles transilluminates, whereas hernias and tumors do not). Hernias may also be differentiated by reducing them (some will not reduce, however, if they are incarcerated) and auscultation may reveal bowel sounds. In noncommunicating hydroceles and testicular tumors, one may get above the swelling, whereas in torsion and hernias one cannot. In torsion, the tenderness is increased by elevation of the testicle, whereas in orchitis the tenderness is relieved if elevation is done for an hour or more. Surgery may be the only way to differentiate the cause of the mass.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Scrotal swelling:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient isn’t in distress, proceed with the history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is the patient sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does he have a history of prostate surgery or prolonged catheterization? Does changing his body position or level of activity affect the swelling?
Take the patient’s vital signs, especially noting a fever, and palpate his abdomen for tenderness. Then examine the entire genital area. Assess the scrotum with the patient supine and standing. Note its size and color. Is the swelling unilateral or bilateral? Do you see signs of trauma or bruising? Are there rashes or lesions present? Gently palpate the scrotum for a cyst or lump. Note especially tenderness or increased firmness. Check the testicles’position in the scrotum. Finally, transilluminate the scrotum to distinguish a fluid-filled cyst from a solid mass. (A solid mass can’t be transilluminated.)
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Hypogonadism:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Accurate diagnosis necessitates a detailed patient history, physical examination, and hormonal studies. Serum and urinary gonadotropin levels increase in primary (hypergonadotropic) hypogonadism but decrease in secondary (hypogonadotropic) hypogonadism. Other relevant hormonal studies include assessment of neuroendocrine functions, such as thyrotropin, corticotropin, growth hormone, and vasopressin levels. Chromosomal analysis may determine the specific causative syndrome. Testicular biopsy and semen analysis determine sperm production, identify impaired spermatogenesis, and assess low levels of testosterone.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Testicular torsion:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Physical examination reveals tense, tender swelling in the scrotum or inguinal canal and hyperemia of the overlying skin. Doppler ultrasonography helps distinguish testicular torsion from strangulated hernia, undescended testes, or epididymitis.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Scrotal swelling:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient isn’t in distress, proceed with the history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is the patient sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does he have a history of prostate surgery or prolonged catheterization? Does changing his body position or level of activity affect the swelling?
Take the patient’s vital signs, especially noting fever, and palpate his abdomen for tenderness. Then examine the entire genital area. Assess the scrotum with the patient in supine and standing positions. Note its size and color. Is the swelling unilateral or bilateral? Do you see signs of trauma or bruising? Are there rashes or lesions present? Gently palpate the scrotum for a cyst or a lump. Note especially tenderness or increased firmness. Check the testicles’position in the scrotum. Finally, transilluminate the scrotum to distinguish a fluid-filled cyst from a solid mass. (A solid mass can’t be transilluminated.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Scrotal Pain/Swelling:
Differential Overview
(Field Guide to Bedside Diagnosis)
Pain Predominant
❑ Epididymitis
❑ Testicular torsion
❑ Prostatitis
❑ Referred pain
❑ Trauma
❑ Orchitis
❑ Torsion of the appendix testis
❑ Inguinal hernia/incarcerated
Swelling Predominant
❑ Varicocele
❑ Inguinal hernia
❑ Hydrocele
❑ Spermatocele
❑ Sebaceous cyst
❑ Testicular cancer
Diagnostic Approach
Testicular torsion, a medical emergency, should be the primary consideration in a patient with an acutely painful scrotum; however, epididymitis is a more common cause than torsion by 10:1. Reduction in pain by manual elevation of the testicle (Phren sign) helps to distinguish epididymitis from testicular torsion. A cremasteric reflex is absent in testicular torsion but present in torsion of the appendix testis.
Testicular cancer must be definitively ruled out whenever a firm induration or mass is found to be contiguous with the testicle.
Referred pain can be differentiated from scrotal pathology by a normal testicular examination.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Scrotal swelling:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
If the patient isn’t in distress, obtain his medical history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is he sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does the patient have a history of prostate surgery or prolonged catheterization? Is the swelling affected by changing his body position or level of activity?
Physical examination
Take the patient’s vital signs, especially noting fever, and palpate his abdomen for tenderness. Then examine the entire genital area. Assess the scrotum with the patient in supine and standing positions. Note its size and color. Is the swelling unilateral or bilateral? Do you see signs of trauma or bruising? Are there rashes or lesions present? Gently palpate the scrotum for a cyst or lump. Note especially tenderness or increased firmness. Check the testicles’position in the scrotum. Finally, transilluminate the scrotum to distinguish a fluid-filled cyst from a solid mass. (A solid mass can’t be transilluminated.)
» READ BOOK EXCERPT ONLINE »
Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Scrotal swelling:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the patient isn’t in distress, proceed with the medical history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is the patient sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does he have a history of prostate surgery or prolonged catheterization? Does changing his body position or level of activity affect the swelling?
CULTURAL CUE:Patients of certain cultural backgrounds, such as Mexican-Americans, may need to establish a trusting relationship before discussing matters of a personal nature.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Scrotal swelling:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient isn't in distress, proceed with the history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is the patient sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does he have a history of prostate surgery or prolonged catheterization? Does changing his body position or level of activity affect the swelling?
Take the patient's vital signs, especially noting fever, and palpate his abdomen for tenderness. Then examine the entire genital area. Assess the scrotum with the patient in a supine position and standing. Note its size and color. Is the swelling unilateral or bilateral? Do you see signs of trauma or bruising? Are there rashes or lesions present? Gently palpate the scrotum for a cyst or lump. Note especially tenderness or increased firmness. Check the testicles'position in the scrotum. Finally, transilluminate the scrotum to distinguish a fluid-filled cyst from a solid mass. (A solid mass can't be transilluminated.)
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
TESTICULAR MASS:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Testicular masses may be differentiated by transillumination
(hydroceles and spermatoceles transilluminate, whereas hernias and tumors do
not). Hernias may also be differentiated by reducing them (some will not
reduce, however, if they are incarcerated), and auscultation may reveal
bowel sounds. In noncommunicating hydroceles and testicular tumors, one may
get above the swelling, whereas in torsion and hernias one cannot. In
torsion, the tenderness is increased by elevation of the testicle, whereas
in orchitis the tenderness is relieved if elevation is done for an hour or
more. Serum alpha-fetoprotein beta-human chorionic gonadotropin (HCG) or
lactic dehydrogenase (LDH) will be elevated in testicular
tumors. Surgery may be the only way to differentiate the cause of the mass.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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