Testicle Pain
The acute
scrotum presents as testicular pain or swelling. Testicular
torsion represents a surgical emergency because the likelihood of
testicular salvage diminishes with the duration of torsion. Testicular
torsion must be quickly excluded in any patient.
The history and physical examination can significantly narrow the
differential diagnosis of an acute scrotum, if not establish the exact cause.
None of the conditions responsible for acute scrotal pain or swelling has a
single pathognomonic finding, but the combined background information and
physical findings frequently suggest the correct diagnosis of testicle pain.
The age of the patient is important. Testicular
torsion is most common in neonates and postpubertal boys, although it
can occur in males of any age. Schönlein-Henoch purpura and torsion of a
testicular appendage typically occur in prepubertal boys, whereas
epididymitis most often develops.
The onset and duration of pain must be carefully determined.
Testicular torsion usually begins abruptly, as if a switch has been flipped.
The pain is severe, and the patient often appears uncomfortable. Moderate pain
developing gradually over a few days is more suggestive of epididymitis or
appendiceal torsion. With either of these conditions, the patient may appear
relatively comfortable.
The physician needs to be aware that an embarrassed child may state
that he has lower abdominal or inguinal pain rather than scrotal
Diagnosis of Selected Conditions Responsible for
Testicle Pain
|
Condition
|
Onset of symptoms
|
Age
|
Tenderness
|
Urinalysis
|
Cremasteric reflex
|
Treatment
|
| Testicular torsion |
Acute |
Early puberty |
Diffuse |
Negative |
Negative |
Surgical exploration |
| Appendiceal torsion |
Subacute |
Prepubertal |
Localized to upper pole |
Negative |
Positive |
Bed rest and scrotal elevation |
| Epididymitis |
Insidious |
Adolescence |
Epididymal |
Positive or negative |
Positive |
Antibiotics |
|
A history of trauma does not exclude the diagnosis of
testicular torsion. Scrotal trauma incurred during sports activities or
rough, boisterous play often causes severe pain of short duration. Pain
that persists for more than one hour after scrotal trauma.
Information should always be obtained about prior
occurrence of pain. When asked, many patients with torsion.
Physical Examination
The physician can often assess the severity of pain
by observing the patient before beginning the physical examination.
Diagnostic Studies
Urinalysis should be performed to rule out urinary
tract infection in any patient with an acute scrotum. Pyuria with or
without bacteria suggests infection and is consistent with epididymitis.
Based on our experience, a white blood cell count is not helpful.
Treatment of Testicle Pain
Spermatic Cord Torsion
The "bell clapper" deformity is one underlying cause of testicular
torsion in older children. In this deformity, the testicle lacks a
normal attachment to the tunica vaginalis and therefore hangs freely. As
a result, the spermatic cord can twist.
Torsion of Testicular Appendages
The appendix testis, a müllerian duct remnant located at the
superior pole of the testicle, is the most common appendage to undergo torsion.
The epididymal appendix, located on the head of the epididymis, is a wolffian
duct remnant and may also become twisted.
Epididymitis or Orchitis
Epididymitis in adolescents and young adults is often related to
sexual activity and does not present with a urinary tract infection.
Scrotal Trauma
Severe testicular injury is uncommon and usually results from either a
direct blow to the scrotum or a straddle injury. Damage occurs when the testis
is forcefully compressed against the pubic bones. A spectrum of injuries may
occur.
Other Causes
Acute idiopathic scrotal edema is another possible cause of an acute
scrotum. This condition is characterized by the rapid onset of significant
edema without tenderness. Erythema may be present. The patient is usually
afebrile, and all diagnostic tests are negative.
Schönlein-Henoch purpura, a systemic vasculitic syndrome of
uncertain etiology, is characterized by nonthrombocytopenic purpura,
arthralgia, renal disease, abdominal pain,
A hydrocele occurs because of a patent processus
vaginalis. The hydrocele can seal off, trapping peritoneal fluid around
the testis, or it can persist and dilate, possibly causing bowel
herniation. Most hydroceles resolve spontaneously.