Evaluating Testicular PainEvaluating Testicular Pain

Kaveh Mansuripur

Ambulatory Medicine Clerkship

4/9/09

Kaveh Mansuripur

Ambulatory Medicine Clerkship

4/9/09

Learning ObjectivesLearning 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

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

AnatomyAnatomy

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

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

HPI: 21 yo man presents with 3 hours of intense, constant

testicular painBegan several hours after college track meetAssociated nausea and vomiting

PMH: NoneMeds: Glucosamine, condroitin, creatine supplementsAlls: PCNFH: Non-contributorySH: Sexually active, multiple partners

HPI: 21 yo man presents with 3 hours of intense, constant

testicular painBegan several hours after college track meetAssociated nausea and vomiting

PMH: NoneMeds: Glucosamine, condroitin, creatine supplementsAlls: PCNFH: Non-contributorySH: Sexually active, multiple partners

Differential DiagnosisDifferential Diagnosis

Testicular Torsion Appendiceal Torsion Epididymitis Trauma Inguinal Hernia Henoch-Schonlein Purpura Mumps Fournier’s Gangrene Referred Pain

Testicular Torsion Appendiceal Torsion Epididymitis Trauma Inguinal Hernia Henoch-Schonlein Purpura Mumps Fournier’s Gangrene Referred Pain

Case 1: Patient T.R.Case 1: Patient T.R.

Exam: Exam:

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

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

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

Case 1: Patient T.R.Next Step

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)

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)

Case 1: Patient T.R.Case 1: Patient T.R.

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

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

Case 1: Patient T.R.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?

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?

Case 1: Patient T.R.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)

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)

Testicular TorsionTesticular Torsion

40% over 21 Associated with

physical activity/sleep Exam Absent cremasteric Doppler Surgical Emergency

40% over 21 Associated with

physical activity/sleep Exam Absent cremasteric Doppler Surgical Emergency

Case 2: Patient F.J.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?

HPI: 11 year old boy presents with 3 days of

increasing scrotal pain Localizes tenderness to anterior

superior pole of right testicle dDx?

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

ExamExam

Case 2: Patient F.J.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

Exam: Tender as reported Transillumination: hydrocele at AS pole Cremasteric reflexes intact bilaterally Discoloration visible externally as sub-

centimeter dot at site

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

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

Further tests?Further tests?

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

Further tests? Ultrasound will show focus of decreased

echogenicity at site

Treatment?

Further tests? Ultrasound will show focus of decreased

echogenicity at site

Treatment?

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

Further tests? Ultrasound will show focus of decreased

echogenicity at siteTreatment?

Conservative Ice, anti-inflammatory medications Pain resolves in weeks-months Residual nodule

Operative Low risk Recovery in days

Further tests? Ultrasound will show focus of decreased

echogenicity at siteTreatment?

Conservative Ice, anti-inflammatory medications Pain resolves in weeks-months Residual nodule

Operative Low risk Recovery in days

Appendiceal TorsionAppendiceal 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%

80% between 7-14 years Leading pediatric scrotal

pathology Gradual onset Tenderness localized to AS

aspect Intact cremasteric reflex “Blue Dot” sign in 21%

Case 3: Patient J.D.Case 3: Patient J.D.

CC: 31 yo man with Testicular PainHPI

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.

CC: 31 yo man with Testicular PainHPI

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.

Case 3: Patient J.D.Case 3: Patient J.D.

PMH

Noncontributory

Meds

None

Allergies

NKDA

FH/SH

HTN, MI in father

1ppd, social EtOH, bisexual.

PMH

Noncontributory

Meds

None

Allergies

NKDA

FH/SH

HTN, MI in father

1ppd, social EtOH, bisexual.

Case 3: Patient J.D.Case 3: Patient J.D.

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

WHAT IS DIFFERENTIAL DIAGNOSIS?

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

WHAT IS DIFFERENTIAL DIAGNOSIS?

Case 3: Patient J.D.Case 3: Patient J.D.

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

Diagnosis: Epididymitis

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

Diagnosis: Epididymitis

Case 3: Patient J.D.Case 3: Patient J.D.

Bacterial Epididymitis What to give and why?

Bacterial Epididymitis What to give and why?

Case 3: Patient J.D.Case 3: Patient J.D.

Bacterial Epididymitis What to give and why? C. trachomatis and N. Gonorrhea most common

in men under 35

Bacterial Epididymitis What to give and why? C. trachomatis and N. Gonorrhea most common

in men under 35

Case 3: Patient J.D.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

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

Case 3: Patient J.D.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?

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?

Case 3: Patient J.D.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)

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)

EpididymitisEpididymitis

Mostly subacute ABX Evaluate recurrent cases for GU malformation

Acute more common in older men, prostatitis Fever, chills, GU symptoms

Mostly subacute ABX Evaluate recurrent cases for GU malformation

Acute more common in older men, prostatitis Fever, chills, GU symptoms

ReferencesReferences

Edelsberg, JS, Surh, YS. The acute scrotum. Emerg Med Clin North Am 1988; 6:521.

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; 51:290.

Edelsberg, JS, Surh, YS. The acute scrotum. Emerg Med Clin North Am 1988; 6:521.

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; 51:290.