Testicular pain/testicular torision
Case Scenario:
John is a 17 year old male who presents to the ER (at 8am) with a complaint of sudden onset left testicular pain
History Elements:
- Onset: 4 hours ago at 4am
- Location: left testicle and left scrotum; nonradiating
- Duration: The pain is constant and severe
- Character: severe sharp stabbing pain in the testicle and surrounding swelling. Patient says the pain was so severe that it woke him up this morning and caused him to have nausea and vomiting.
- Pain is worse with movement and palpation of the area; there are no alleviating factors
- He says the pain is a 10/10, and is the worst pain he has ever felt in his life.
- No history of trauma to the area
- No pain in his penis or penile head
- Patient denies any discharge from the penile head
- Normal quantity and frequency of urine; no pain with urination
- Patient is circumcised
- Patient has never been sexually active, as has never had an STI
- ROS Pertinent positives: sharp left sided testicular and scrotal pain, pain with palpation and movement. Nausea, 2 episodes of vomiting, abdominal pain and dizziness secondary to the pain.
- ROS Pertinent negatives: pain with urination, increased urinary frequency or urgency, urinary retention, fever, chills, penile pain or discharge, diarrhea, back pain, radiating pain, lesions, changes in stool.
- Patient denies any recent travel or sick contacts
- He denies any allergies, medical history or surgical history.
Past medical history: denies any medical problems. Patient has all of his immunizations.
Past surgical history: circumcision when he was born, denies any other surgeries
Family history: both parents are alive and well
Physical Exam:
Vitals:
BP: 110/70, right arm, sitting
HR: 116 beats/minute, regular
RR: 20 breaths/minute, unlabored
Temperature: 36.5℃, oral
SpO2 Sat: 100%, Room air
Height: 172 cm
Weight 79kg
BMI: 26.7 kg/m2
General appearance: John is a 17 year old male who appears his stated age. He is alert and oriented x 3 to person, place and time and is well-groomed with good hygiene. He is well developed and dressed appropriately. Patient is in Severe distress in the ED.
Skin: Warm and moist with good hydration and turgor. The skin has no lesions, rashes or scars. Skin is nonicteric and capillary refill is less then 2 seconds in both fingers and toes.
HEENT: Normocephalic, atraumatic. No signs of rashes or lesions, no alopecia or lice. Nontender to palpation. Ears: no lesions or foreign bodies, auditory acuity is intact AU. Eyes: EOM and PEARLA, conjunctiva is clear and cornea is white and non-icteric. Nose: no foreign bodies or epistaxis. Pharynx: well hydrated with no lesions or ulcerations, no erythema or exudates. Neck: trachea midline, thyroid unremarkable, and no signs of lymphadenopathy.
Chest: No scars o lesions. Chest rise is symmetric. Non-tender to palpation.
Lungs: Breath sounds are equal, no accessory muscle use, no wheezes or rales.
Heart: Regular rate and rhythm. S1 and S2 are present with no murmurs heard. S3 and S4 are not heard. No S2 splitting. JVP is less then 30 degrees. No friction rubs or gallops present.
Abdomen: Soft and nondistended. No lesions or masses, symmetrical. Abdomen is nontender to palpation or all quadrants, and bowel sounds are normoactive. Soft, symmetrical, non-distended abdomen. Non-tender to palpation throughout (no guarding or rebound tenderness) and normoactive bowel sounds present in all four quadrants. No CVA tenderness. No pain at McBurney point. No signs of any hernias.
Genitourinary: John is a circumcised male who is a tanner stage 4. There is significant left scrotal swelling. Left scrotum is very tender to palpation; difficult to palpate due to severe pain, and appears descended. Left tests has a horizontal lie and has a absent cremasteric reflex on the left. Left sided scrotal skin is warm, erythematous, and indurated. Right scrotum and testicle are unremarkable, with a positive cremasteric reflex.
Differential Diagnosis:
- Testicular torsion
- Patient is a young adolescent male who has severe sudden onset unilateral testicular pain. The pain is severe enough to cause nausea and vomiting and is very tender to touch. This physical exam also shows tender testicle, along with absent cremasteric reflex which is sensitive for this disease.
- Torsion of ependymal appendage:
- This needs to be considered when the patient has one sided testicular and scrotal pain. The scrotum will be tender to touch. On exam however this would have a lump at the top of the testicle, with a blue dot sign at the superior aspect of the testicle.
- Epididymitis:
- Inflammation of the epididymitis. Can lead to swollen, red and warm scrotum. Can also lead to one sided testicular pain that comes on gradually.
- Hydrocele:
- Collection of fluid around a unilateral scrotum. However, these are often less likely to be painful, hence it is not a high probable differential for our patient since his pain is sudden and sharp.
- Testicular cancer:
- Less likely considering the age and presentation of our patient. Hoever due to the unilateral pain and swelling this should be considered. It can cause one sided or bilateral painful testicular lump formation, and swelling and pain of the scrotum.
Tests:
- Urinalysis
| color | Clear, yellow |
| Specific gravity | 1.03 |
| pH | 7.0 |
| nitrates | negative |
| ketones | negative |
| urobilirubin | negative |
| leukocytes | negative |
| protein | negative |
| glucose | negative |
| blood | Negative |
- CBC and CRP
- RBCs will be normal, WBCs can be increased. Normal complete blood count. Elevated CRP due to the inflammation.
Imaging:
Scrotal ultrasound with doppler:
• Left testis: enlarged; measures 4.7 × 2.8 × 3.4 cm with a calculated volume of 31.2 mL.
• Right testis: normal in size and echotexture with no focal abnormality; measures 4.3 × 2.3 × 2.4 cm with a calculated volume of 16.5 mL.
Treatment:
- Since there is a 4-8 hour window until significant ischemic damage occurs, this is considered a surgical emergency.
- Urology referral needs to be put in STAT.
- Emergent scrotal surgical exploration is indicated
- Manual detorsion can be performed (open book technique) but should not be used to delay surgery; and must be done carefully since the cord can get further twisted. For this a spinal block, IV sedation or analgesic is given to relax the cremasteric fibers and allow for manipulation.
- Surgical detorsion is the definitive treatment. Return of blood flow can be confirmed with doppler ultrasound
- Orchiopexy of the damaged testicle and the contralateral testicle is indicated to anchor the testis to the scrotal wall and prevent repeat torsion.
- Pain control and anti-inflammatory medication can also be given
Pt Counseling/Education:
- Testicular torsion is when the spermatic cord rotates and gets twisted. This decreased the blood supply to the testicle and it gets swollen and causes sharp sudden pain.
- Boys need to be informed that if they ever feel sudden sharp pain, that they need to inform someone immediately since this is a surgical emergency.
- After getting the testicle detorsed it is important to continue following up with your doctor in order to ensure proper functioning and blood flow.
https://onlinelibrary-wiley-com.york.ezproxy.cuny.edu/doi/pdf/10.1002/9781119568193.ch56
