VOL 46: JUNE • JUIN 2000❖Canadian Family Physician•Le Médecin de famille canadien 1289
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Emergency Case
Acute testicular pain
Harold Schubert, MD, MSC, CCFP(EM)
QUESTIONS
A 24-year-old man presented to an emergency department (ED) with a pain in his abdomen. He began vomiting immediately after onset of pain in his right testicle. What historical and clinical features suggest testicular torsion? What is the time frame for sur vival of the testis? How is torsion best diagnosed?
T
esticular torsion is an ischemic emergency with a repor ted inci-dence of approximately one case in 4000 men younger than 25 (statistics fr om the United Kingdom). Incidence peaks at two ages: the perina- tal period and adolescence. The highest peak occurs at age 16 to 17. In prepubertal boys, epididymitis is rare, and torsion is the most likely cause of acute testicular pain. After puber ty, the reverse is true.
Testicular torsion is a high triage priority for EDs.
For survival of the testis, definitive treatment must be given within 6 hours of onset of symptoms.1Most delays occur before patients reach hospital, but delays also occur in ED waiting rooms because patients pre- sent complaining of abdominal pain. Hence, men pre- senting to EDs with abdominal pain should be questioned by triage personnel about testicular pain.
Two types of testicular torsion
Testicular torsion occurs when a testis rotates 360ο or more on its axis. There are two types of torsion.
The common type (intravaginal) is associated with a congenital anomaly: the tunica vaginalis extends high on the spermatic cord (bell-and-clapper defor- mity) (Figure 1). Strong contraction of the cremas- ter muscles, which wrap in a spiral fashion around
the spermatic cord, might also be involved in pro- ducing torsion because most cases of testicular tor- sion reportedly occur in cold weather.1
The less common type (extravaginal) occurs in the perinatal period. There is no congenital anomaly of tunica vaginalis insertion; the defect is believed to be inadequate adherence of the tunica vaginalis to the scrotal wall. This allows the spermatic cord and entire tunica vaginalis, with its contents, to twist.
Diagnosis
The most consistent historical feature of testicular torsion is short duration of symptoms.2Torsion most often occurs during exercise, but can occur at rest or during sleep. The pain becomes severe within min- utes or hours and could be identified as abdominal, flank, or groin pain with vomiting. Torsion can be intermittent or recurrent.
Physical examination might be dif ficult due to swelling and exquisite tenderness. The single most consistent clinical indicator for testicular torsion is uni- lateral loss of the cremasteric reflex2; the scrotum does not elevate when the inner thigh is stroked. The affect- ed testicle and epididymis are riding high and are very
Spermatic cord
Epididymis
Testis Tunica vaginalis
Normal
Figure 1. Suspension of the testis: Normal and bell-and-clapper formation.
Bell-and-clapper formation
Dr Schubert practises emergency medicine at the University of British Columbia Hospital in Vancouver.
1290 Canadian Family Physician•Le Médecin de famille canadien❖VOL 46: JUNE • JUIN 2000
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tender. Often both testes have a horizontal lie. Inflammation of the scrotal skin increases with dura- tion of torsion.
Urgent consultation with a urol- ogist is indicated if testicular tor- sion is suspected. Consultation should not wait for results of any laboratory or imaging tests. Testis sur vival depends on the testicle being de-torted in the operating room within 6 hours of onset of symptoms. Even with successful treatment, substantial testicular atrophy occurs in more than 60%
of cases, leading to reduced sperm counts and endocrine function.1 Colour Doppler sonography (CDS) has become the imaging method of choice for equivocal cases. Diagnosis of testicular torsion is made when intratesticular blood flow is visualized on the normal side but is absent or greatly reduced on the affected side. Imaging with CDS must be done on an urgent basis with the 6-hour time frame in mind.
Sensitivity and specificity rates approach 100% for testicular torsion;
CDS imaging of spiral twisting of the spermatic cord further confirms the reliability of this test.3
Differential diagnosis
Epididymitis.Epididymitis, with or without orchitis, is the most common cause of testicular pain.1It is most often associated with sexu- ally transmitted diseases (STDs);
peak incidence is at age 25. In preadolescents or men older than 50, it is associated with urinar y tract infections (UTIs) or prostati- tis. The pain of epididymitis usually is of less acute onset than that of testicular torsion (days rather than minutes or hours), and there might be dysuria and urethral discharge.
Physical examination reveals a swollen and tender epididymis and possibly a warm and erythematous scrotum. Testis and prostate might
also be tender. The cremasteric reflex will likely be intact but might be absent in severe cases.2Fever and leukocytosis might be present.
In sexually active men, first-void urine chlamydia testing and ure- thral cultures should be done.
Urinanalysis and culture are essen- tial for preadolescents or men who are not sexually active. Imaging with CDS is invaluable to differenti- ate epididymitis from testicular tor- sion but, if torsion is considered, a urologist should be consulted first.
Treatment for epididymitis is empiric antibiotic therapy based on association with STDs, UTIs, or prostatitis. Follow up should be arranged when cultures and sensi- tivities are completed. If STDs are involved, consorts must be treated.
Torsion of appendix testis . The scrotum might contain vari- ous small embr yonic remnants, the appendix testis being the most common (present in more than 80% of men). These remnants are all pedunculated and at risk of spontaneous torsion. Loss of such appendices by ischemia is not functionally important.1
Torsion of an appendix testis might be as acute and painful as testicular torsion. Tenderness is usually localized to a pea-sized mass at the superior pole of the testis that might be visible through the scrotal skin as the “blue dot sign.”2The cremasteric reflex will be intact.2The critical point is clini- cal differentiation from testicular torsion; any uncertainty should be addressed by urgent consultation with a urologist.
Testicular malignancy. Malig- nancy is most often painless in its early stages. About 10% of patients with testicular malignancy, howev- er, present with acute pain due to hemor rhage into the tumour.
Again, there is urgent need for dis- crimination from testicular torsion and, torsion or tumour, urgent need for consultation with a urologist.
Testicular trauma. Penetrating scrotal trauma, where testis viability is in question, requires urgent investigation by a urologist. Simple scrotal skin wounds can be treated as other skin wounds.
Blunt trauma to the scrotum can burst or rupture a testis, which might then require surgical repair.
Imaging with CDS on an urgent basis is valuable in this setting to determine extent of trauma and blood flow status. If CDS shows an intact and viable testicle, treatment includes rest, ice, and analgesics.
ANSWERS
Testicular torsion is suggested by testicular pain with rapid onset and short duration; absence of the cre- masteric reflex is the most reliable clinical indicator. Testis survival is nearly 100% if the testis is de-torted in the operating room within 6 hours of onset of symptoms.
Suspected testicular torsion is best diagnosed by surgical investigation of the scrotum by a urologist. In equivocal cases, CDS is a highly reliable aid to diagnosis.
References
1.Hill GS, editor. Uropathology. London, Engl: Churchill Livingstone; 1989.
2. Kadish HA, Bolte RG. A retrospective review of pediatric patients with epi- didymitis, testicular torsion and torsion of testicular appendages. Pediatrics 1998;102(1):73-6.
3. Baud C, Veyrac C, Couture A, Ferran JL. Spiral twist of the spermatic cord: a reliable sign of testicular tor- sion. Pediatr Radiol 1998;28:950-4.
