Evaluation of Testicular Pain Marcos Machado, M.D. Michael Macksood, D.O. February 28, 2007

Embryology 2mo 3mo 7mo 9mo Descent of the testes Gubernaculum shortening Vaginal process becomes serous bilaminar structure ant to testis Upper part of vaginal process obliterated in 1 st year of life->tunica vaginalis

2mo 3mo

7mo 9mo

Descent of the testes

Gubernaculum shortening

Vaginal process becomes serous bilaminar structure ant to testis

Upper part of vaginal process obliterated in 1 st year of life->tunica vaginalis

Anatomy Spermatic cord (Begins at internal ring and ends at testis) testicular artery pampiniform plexus vas deferens artery of vas deferens lymphatic vessels genitofemoral nerve branches sympathetic hypogastric plexus remnant of processus vaginalis.

Spermatic cord (Begins at internal ring and ends at testis)

testicular artery

pampiniform plexus

vas deferens

artery of vas deferens

lymphatic vessels

genitofemoral nerve branches

sympathetic hypogastric plexus

remnant of processus vaginalis.

Anatomy – blood supply Aorta->Testicular artery Pampiniform plexus of the spermatic cord

Aorta->Testicular artery

Pampiniform plexus of the spermatic cord

Acute vs. Chronic Pain Acute Pain onset seconds to hours Chronic Pain lasting more than 3 months Insidious onset

Acute

Pain onset seconds to hours

Chronic

Pain lasting more than 3 months

Insidious onset

Acute Pain Onset seconds to minutes. Testicular Torsion Traumatic injury to scrotum Torsion of testicular appendage Onset in hours Strangulated Inguinal Hernia Torsion of Testicular Appendage Epididymitis / Orchitis

Onset seconds to minutes.

Testicular Torsion

Traumatic injury to scrotum

Torsion of testicular appendage

Onset in hours

Strangulated Inguinal Hernia

Torsion of Testicular Appendage

Epididymitis / Orchitis

Acute Pain – Rare causes Testicular Cancer (5% of testicular pain cases) Familial mediterranean fever Pancreatitis Tick bite or venomous bite Henoch Schonlein Purpura Diverticulitis Cysticercosis Inguinal Hernia Torsion of Spermatocele Torsion of Cavernous Lymphangioma Acute Appendicitis Lumbar Radiculopathy Local hemorrhage Associated with Testicular Cancer Associated with testicular appendage

Testicular Cancer (5% of testicular pain cases)

Familial mediterranean fever

Pancreatitis

Tick bite or venomous bite

Henoch Schonlein Purpura

Diverticulitis

Cysticercosis

Inguinal Hernia

Torsion of Spermatocele

Torsion of Cavernous Lymphangioma

Acute Appendicitis

Lumbar Radiculopathy

Local hemorrhage

Associated with Testicular Cancer

Associated with testicular appendage

Chronic Testicular Pain Idiopathic in 25% of cases Intermittent Testicular Torsion Post-genitourinary surgery Sperm granuloma (post-Vasectomy) Varicocele Testicular Cancer (painless in 60% of cases) Genitourinary infection (e.g. STD) Referred pain Nephrolithiasis in the mid-ureter (most common) Radiculopathy Genitofemoral and ilioinguinal nerves (T10-L1)

Idiopathic in 25% of cases

Intermittent Testicular Torsion

Post-genitourinary surgery

Sperm granuloma (post-Vasectomy)

Varicocele

Testicular Cancer (painless in 60% of cases)

Genitourinary infection (e.g. STD)

Referred pain

Nephrolithiasis in the mid-ureter (most common)

Radiculopathy

Genitofemoral and ilioinguinal nerves (T10-L1)

Topics for today Acute problems Torsion Trauma Strangulated Inguinal Hernia Epididymitis / Orchitis Chronic problems Testicular CA STD Varicocele

Acute problems

Torsion

Trauma

Strangulated Inguinal Hernia

Epididymitis / Orchitis

Chronic problems

Testicular CA

STD

Varicocele

Testicular Torsion Actually torsion of spermatic cord Surgical emergency due to strangulation of blood supply Peak incidence at 13 yrs old but occurs at any age

Actually torsion of spermatic cord

Surgical emergency due to strangulation of blood supply

Peak incidence at 13 yrs old but occurs at any age

Testicular Torsion History and symptoms Acute onset, pain and swelling, N/V Lower abdominal pain Sometimes preceded by straining Hx of self-resolving intermittent torsion Absence of dysuria, fever, STD

History and symptoms

Acute onset, pain and swelling, N/V

Lower abdominal pain

Sometimes preceded by straining

Hx of self-resolving intermittent torsion

Absence of dysuria, fever, STD

Testicular Torsion PE Tender, swollen, high in scrotum Absent cremasteric reflex on affected side -Prehn’s sign (+ in epididymitis) Labs Normal UA No leukocytosis

PE

Tender, swollen, high in scrotum

Absent cremasteric reflex on affected side

-Prehn’s sign (+ in epididymitis)

Labs

Normal UA

No leukocytosis

Testicular Torsion Doppler If clinical signs equivocal 80-90% Sn, 75-90% Sp

Doppler

If clinical signs equivocal

80-90% Sn, 75-90% Sp

Testicular Torsion Treatment Manual detorsion (open like a book) Surgical Both with orchipexy Bilateral ochipexy b/c other side is likely to torse Rate of salvage <6hrs – 85-97% 6-12hrs – 55-85% 12-24hrs – 20-80% >24hrs - <10%

Treatment

Manual detorsion (open like a book)

Surgical

Both with orchipexy

Bilateral ochipexy b/c other side is likely to torse

Rate of salvage

<6hrs – 85-97%

6-12hrs – 55-85%

12-24hrs – 20-80%

>24hrs - <10%

Torsion of Testicular Appendage Appendix testes is a Mullerian duct remnant Torses easily Must be differentiated from torsed testicle. MCC of peds scrotal pain Usually pre-pubertal Onset 12-24 hours.

Appendix testes is a Mullerian duct remnant

Torses easily

Must be differentiated from torsed testicle.

MCC of peds scrotal pain

Usually pre-pubertal

Onset 12-24 hours.

Torsion of Testicular Appendage PE Tiny, tender, palpable mass at upper pole &quot;Blue dot&quot; sign (21%) Ischemic appendage visible through the scrotum Testes and epididymis not diffusely tender or swollen. Cremasteric reflex usually intact. If +Blue-dot sign & normal, nontender testes Can exclude testicular torsion Image if uncertain Typical course: 7-14 days Management NSAIDs Necrotic tissue reabsorbed w/o sequelae

PE

Tiny, tender, palpable mass at upper pole

&quot;Blue dot&quot; sign (21%)

Ischemic appendage visible through the scrotum

Testes and epididymis not diffusely tender or swollen.

Cremasteric reflex usually intact.

If +Blue-dot sign & normal, nontender testes

Can exclude testicular torsion

Image if uncertain

Typical course: 7-14 days

Management

NSAIDs

Necrotic tissue reabsorbed w/o sequelae

Testicular Trauma Color doppler to dx extent of injury Range of injury Hematocele (hematoma within tunica vaginalis) Intratesticular hematoma Rupture (disruption of tunical albuginea)

Color doppler to dx extent of injury

Range of injury

Hematocele (hematoma within tunica vaginalis)

Intratesticular hematoma

Rupture (disruption of tunical albuginea)

Testicular Trauma Rupture Usually from crushing between external object and pubic symphysis. Signs & Sx Acute, severe pain +/- N/V Hematoma or ecchymosis of overlying skin Imaging U/S 75% specific, 64% sensitive

Rupture

Usually from crushing between external object and pubic symphysis.

Signs & Sx

Acute, severe pain +/- N/V

Hematoma or ecchymosis of overlying skin

Imaging

U/S 75% specific, 64% sensitive

Testicular Trauma Surgery Scrotal exploration indicated if high degree of suspicion Orchiectomy rate <10% if evacuation/debridement begun within 72 hours

Surgery

Scrotal exploration indicated if high degree of suspicion

Orchiectomy rate <10% if evacuation/debridement begun within 72 hours

Strangulated Inguinal Hernia Indirect Inguinal Hernia (persistent processus vaginalis) Not really testicular pain, but must differentiate from it. Pain can refer to testes secondary to encroachment on testicular blood supply and egress

Indirect Inguinal Hernia (persistent processus vaginalis)

Not really testicular pain, but must differentiate from it.

Pain can refer to testes secondary to encroachment on testicular blood supply and egress

Strangulated Inguinal Hernia Incarcerated hernia Painful enlargement of a previous hernia or defect Cannot be manipulated through the fascial defect N/V, sx of bowel obstruction (possible) Strangulated hernia Incarcerated hernia with toxic appearance Systemic toxicity secondary to ischemic bowel poss. Strangulation probable if pain and tenderness of incarcerated hernia persist after reduction.

Incarcerated hernia

Painful enlargement of a previous hernia or defect

Cannot be manipulated through the fascial defect

N/V, sx of bowel obstruction (possible)

Strangulated hernia

Incarcerated hernia with toxic appearance

Systemic toxicity secondary to ischemic bowel poss.

Strangulation probable if pain and tenderness of incarcerated hernia persist after reduction.

Strangulated Inguinal Hernia PE Inguinal canal exam Inguinal U/S Mass vs. hernia Tx Broad-spectrum antibiotics Herniorrhaphy Resection of necrotic bowel if necessary.

PE

Inguinal canal exam

Inguinal U/S

Mass vs. hernia

Tx

Broad-spectrum antibiotics

Herniorrhaphy

Resection of necrotic bowel if necessary.

Epididymitis Hx 1-2day onset, unilateral pain & swelling Dysuria, urethral d/c PE Resembles torsion Painful indurated epididymis Pyuria +Prehn’s sign (pain better with elevation) Labs UA & C/S, CBC, GC/Chlam cx

Hx

1-2day onset, unilateral pain & swelling

Dysuria, urethral d/c

PE

Resembles torsion

Painful indurated epididymis

Pyuria

+Prehn’s sign (pain better with elevation)

Labs

UA & C/S, CBC, GC/Chlam cx

Epididymitis Most Common Causes Young boys – congenital anomalies <40 yr old - GC/Clamydia >40 yr old – enterobacteria more common Homosexual – STD & fungal UTI

Most Common Causes

Young boys – congenital anomalies

<40 yr old - GC/Clamydia

>40 yr old – enterobacteria more common

Homosexual – STD & fungal UTI

Epididymitis Treatment Mild - outpatient GC/Clamydia – ceftriaxone 250mg IM x1 then doxycycline 100mg PO BID x 10d Enterobacteria – cipro 500mg BID until C/S Mod to severe – inpatient Intractable pain, failed outpatient tx Broad spectrum Abx, urology consult, U/S to r/o abscess formation and assess blood flow

Treatment

Mild - outpatient

GC/Clamydia – ceftriaxone 250mg IM x1 then doxycycline 100mg PO BID x 10d

Enterobacteria – cipro 500mg BID until C/S

Mod to severe – inpatient

Intractable pain, failed outpatient tx

Broad spectrum Abx, urology consult, U/S to r/o abscess formation and assess blood flow

Epididymitis Complications Sepsis Infertility Scrotal abscess Epididymo-orchitis (involving testis) Fournier gangrene

Complications

Sepsis

Infertility

Scrotal abscess

Epididymo-orchitis (involving testis)

Fournier gangrene

Testicular Cancer MC tumor in men 15-34yo Rarely painful Painless testicular masses are CA until proven otherwise “ heaviness” in scrotum Solid or indurated mass Generally intratesticular

MC tumor in men 15-34yo

Rarely painful

Painless testicular masses are CA until proven otherwise

“ heaviness” in scrotum

Solid or indurated mass

Generally intratesticular

Testicular Cancer PE Palpation for tissue texture anomalies and extratesticular extensions Transillumination for cystic qualities Lab Monitor endocrine markers like AFP, hCG Imaging Scrotal U/S

PE

Palpation for tissue texture anomalies and extratesticular extensions

Transillumination for cystic qualities

Lab

Monitor endocrine markers like AFP, hCG

Imaging

Scrotal U/S

Testicular Cancer Tx No biopsy – straight to radical orchiectomy Prognosis Limited disease – usually complete cure Advanced disease – 70-80% cure

Tx

No biopsy – straight to radical orchiectomy

Prognosis

Limited disease – usually complete cure

Advanced disease – 70-80% cure

Varicocele Dilation of pampiniform plexus Often regress 40% Sx Pain, ipsilateral testicular atrophy, infertility L>R. R rare w/o L PE Small ->fullness; Larger ->”bag of worms” Tx Supportive unless <20yo or infertility Surgical repair

Dilation of pampiniform plexus

Often regress 40%

Sx

Pain, ipsilateral testicular atrophy, infertility

L>R. R rare w/o L

PE

Small ->fullness; Larger ->”bag of worms”

Tx

Supportive unless <20yo or infertility

Surgical repair

References www.uptodate.com www.emedicine.com www.aafp.org American Urological Association. Torsion of the testis: changing concepts. AUA update series IX. 1990.) World J. Urol. 17:101. 1999

www.uptodate.com

www.emedicine.com

www.aafp.org

American Urological Association. Torsion of the testis: changing concepts. AUA update series IX. 1990.)

World J. Urol. 17:101. 1999

Thanks.