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Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
Evaluation of Testicular Pain
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Evaluation of Testicular Pain

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Evaluation of Testicular Pain

Evaluation of Testicular Pain

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  • hi marcos.. can i pls download ur slides .. for study purposes ... my email: newmaracer_46@yahoo.com
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  • FOR MEDICAL / NURSING SLIDES AND ANIMATION, TRY TO VISIT http://NurseReview.org I highly recommend that site. Very informative!
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  • Fantastic slides show.







    Can I please Download your slides. I would like to use them for teaching purpose, in our departmental teaching programm.







    Thank you







    S.Memon



    My email address: smemon11@aol.com
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  • 1. Evaluation of Testicular Pain Marcos Machado, M.D. Michael Macksood, D.O. February 28, 2007
  • 2. Embryology <ul><li>2mo 3mo </li></ul><ul><li>7mo 9mo </li></ul><ul><li>Descent of the testes </li></ul><ul><li>Gubernaculum shortening </li></ul><ul><li>Vaginal process becomes serous bilaminar structure ant to testis </li></ul><ul><li>Upper part of vaginal process obliterated in 1 st year of life->tunica vaginalis </li></ul>
  • 3. Anatomy <ul><li>Spermatic cord (Begins at internal ring and ends at testis) </li></ul><ul><ul><li>testicular artery </li></ul></ul><ul><ul><li>pampiniform plexus </li></ul></ul><ul><ul><li>vas deferens </li></ul></ul><ul><ul><li>artery of vas deferens </li></ul></ul><ul><ul><li>lymphatic vessels </li></ul></ul><ul><ul><li>genitofemoral nerve branches </li></ul></ul><ul><ul><li>sympathetic hypogastric plexus </li></ul></ul><ul><ul><li>remnant of processus vaginalis. </li></ul></ul>
  • 4. Anatomy – blood supply <ul><li>Aorta->Testicular artery </li></ul><ul><li>Pampiniform plexus of the spermatic cord </li></ul>
  • 5. Acute vs. Chronic Pain <ul><li>Acute </li></ul><ul><ul><li>Pain onset seconds to hours </li></ul></ul><ul><li>Chronic </li></ul><ul><ul><li>Pain lasting more than 3 months </li></ul></ul><ul><ul><li>Insidious onset </li></ul></ul>
  • 6. Acute Pain <ul><li>Onset seconds to minutes. </li></ul><ul><ul><li>Testicular Torsion </li></ul></ul><ul><ul><li>Traumatic injury to scrotum </li></ul></ul><ul><ul><li>Torsion of testicular appendage </li></ul></ul><ul><li>Onset in hours </li></ul><ul><ul><li>Strangulated Inguinal Hernia </li></ul></ul><ul><ul><li>Torsion of Testicular Appendage </li></ul></ul><ul><ul><li>Epididymitis / Orchitis </li></ul></ul>
  • 7. Acute Pain – Rare causes <ul><li>Testicular Cancer (5% of testicular pain cases) </li></ul><ul><li>Familial mediterranean fever </li></ul><ul><li>Pancreatitis </li></ul><ul><li>Tick bite or venomous bite </li></ul><ul><li>Henoch Schonlein Purpura </li></ul><ul><li>Diverticulitis </li></ul><ul><li>Cysticercosis </li></ul><ul><li>Inguinal Hernia </li></ul><ul><li>Torsion of Spermatocele </li></ul><ul><li>Torsion of Cavernous Lymphangioma </li></ul><ul><li>Acute Appendicitis </li></ul><ul><li>Lumbar Radiculopathy </li></ul><ul><li>Local hemorrhage </li></ul><ul><ul><li>Associated with Testicular Cancer </li></ul></ul><ul><ul><li>Associated with testicular appendage </li></ul></ul>
  • 8. Chronic Testicular Pain <ul><li>Idiopathic in 25% of cases </li></ul><ul><li>Intermittent Testicular Torsion </li></ul><ul><li>Post-genitourinary surgery </li></ul><ul><li>Sperm granuloma (post-Vasectomy) </li></ul><ul><li>Varicocele </li></ul><ul><li>Testicular Cancer (painless in 60% of cases) </li></ul><ul><li>Genitourinary infection (e.g. STD) </li></ul><ul><li>Referred pain </li></ul><ul><ul><li>Nephrolithiasis in the mid-ureter (most common) </li></ul></ul><ul><ul><li>Radiculopathy </li></ul></ul><ul><ul><li>Genitofemoral and ilioinguinal nerves (T10-L1) </li></ul></ul>
  • 9. Topics for today <ul><li>Acute problems </li></ul><ul><ul><li>Torsion </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Strangulated Inguinal Hernia </li></ul></ul><ul><ul><li>Epididymitis / Orchitis </li></ul></ul><ul><li>Chronic problems </li></ul><ul><ul><li>Testicular CA </li></ul></ul><ul><ul><li>STD </li></ul></ul><ul><ul><li>Varicocele </li></ul></ul>
  • 10. Testicular Torsion <ul><li>Actually torsion of spermatic cord </li></ul><ul><ul><li>Surgical emergency due to strangulation of blood supply </li></ul></ul><ul><li>Peak incidence at 13 yrs old but occurs at any age </li></ul>
  • 11. Testicular Torsion <ul><li>History and symptoms </li></ul><ul><ul><li>Acute onset, pain and swelling, N/V </li></ul></ul><ul><ul><li>Lower abdominal pain </li></ul></ul><ul><ul><li>Sometimes preceded by straining </li></ul></ul><ul><ul><li>Hx of self-resolving intermittent torsion </li></ul></ul><ul><ul><li>Absence of dysuria, fever, STD </li></ul></ul>
  • 12. Testicular Torsion <ul><li>PE </li></ul><ul><ul><li>Tender, swollen, high in scrotum </li></ul></ul><ul><ul><li>Absent cremasteric reflex on affected side </li></ul></ul><ul><ul><li>-Prehn’s sign (+ in epididymitis) </li></ul></ul><ul><li>Labs </li></ul><ul><ul><li>Normal UA </li></ul></ul><ul><ul><li>No leukocytosis </li></ul></ul>
  • 13. Testicular Torsion <ul><li>Doppler </li></ul><ul><ul><li>If clinical signs equivocal </li></ul></ul><ul><ul><li>80-90% Sn, 75-90% Sp </li></ul></ul>
  • 14. Testicular Torsion <ul><li>Treatment </li></ul><ul><ul><li>Manual detorsion (open like a book) </li></ul></ul><ul><ul><li>Surgical </li></ul></ul><ul><ul><li>Both with orchipexy </li></ul></ul><ul><ul><ul><li>Bilateral ochipexy b/c other side is likely to torse </li></ul></ul></ul><ul><li>Rate of salvage </li></ul><ul><ul><li><6hrs – 85-97% </li></ul></ul><ul><ul><li>6-12hrs – 55-85% </li></ul></ul><ul><ul><li>12-24hrs – 20-80% </li></ul></ul><ul><ul><li>>24hrs - <10% </li></ul></ul>
  • 15. Torsion of Testicular Appendage <ul><li>Appendix testes is a Mullerian duct remnant </li></ul><ul><ul><li>Torses easily </li></ul></ul><ul><li>Must be differentiated from torsed testicle. </li></ul><ul><li>MCC of peds scrotal pain </li></ul><ul><ul><li>Usually pre-pubertal </li></ul></ul><ul><li>Onset 12-24 hours. </li></ul>
  • 16. Torsion of Testicular Appendage <ul><li>PE </li></ul><ul><ul><li>Tiny, tender, palpable mass at upper pole </li></ul></ul><ul><ul><li>&quot;Blue dot&quot; sign (21%) </li></ul></ul><ul><ul><ul><li>Ischemic appendage visible through the scrotum </li></ul></ul></ul><ul><ul><li>Testes and epididymis not diffusely tender or swollen. </li></ul></ul><ul><ul><li>Cremasteric reflex usually intact. </li></ul></ul><ul><ul><li>If +Blue-dot sign & normal, nontender testes </li></ul></ul><ul><ul><ul><li>Can exclude testicular torsion </li></ul></ul></ul><ul><ul><li>Image if uncertain </li></ul></ul><ul><li>Typical course: 7-14 days </li></ul><ul><li>Management </li></ul><ul><ul><li>NSAIDs </li></ul></ul><ul><ul><li>Necrotic tissue reabsorbed w/o sequelae </li></ul></ul>
  • 17. Testicular Trauma <ul><li>Color doppler to dx extent of injury </li></ul><ul><li>Range of injury </li></ul><ul><ul><li>Hematocele (hematoma within tunica vaginalis) </li></ul></ul><ul><ul><li>Intratesticular hematoma </li></ul></ul><ul><ul><li>Rupture (disruption of tunical albuginea) </li></ul></ul>
  • 18. Testicular Trauma <ul><li>Rupture </li></ul><ul><ul><li>Usually from crushing between external object and pubic symphysis. </li></ul></ul><ul><ul><li>Signs & Sx </li></ul></ul><ul><ul><ul><li>Acute, severe pain +/- N/V </li></ul></ul></ul><ul><ul><ul><li>Hematoma or ecchymosis of overlying skin </li></ul></ul></ul><ul><ul><li>Imaging </li></ul></ul><ul><ul><ul><li>U/S 75% specific, 64% sensitive </li></ul></ul></ul>
  • 19. Testicular Trauma <ul><li>Surgery </li></ul><ul><ul><li>Scrotal exploration indicated if high degree of suspicion </li></ul></ul><ul><ul><li>Orchiectomy rate <10% if evacuation/debridement begun within 72 hours </li></ul></ul>
  • 20. Strangulated Inguinal Hernia <ul><li>Indirect Inguinal Hernia (persistent processus vaginalis) </li></ul><ul><li>Not really testicular pain, but must differentiate from it. </li></ul><ul><ul><li>Pain can refer to testes secondary to encroachment on testicular blood supply and egress </li></ul></ul>
  • 21. Strangulated Inguinal Hernia <ul><li>Incarcerated hernia </li></ul><ul><ul><li>Painful enlargement of a previous hernia or defect </li></ul></ul><ul><ul><li>Cannot be manipulated through the fascial defect </li></ul></ul><ul><ul><li>N/V, sx of bowel obstruction (possible) </li></ul></ul><ul><li>Strangulated hernia </li></ul><ul><ul><li>Incarcerated hernia with toxic appearance </li></ul></ul><ul><ul><li>Systemic toxicity secondary to ischemic bowel poss. </li></ul></ul><ul><ul><li>Strangulation probable if pain and tenderness of incarcerated hernia persist after reduction. </li></ul></ul>
  • 22. Strangulated Inguinal Hernia <ul><li>PE </li></ul><ul><ul><li>Inguinal canal exam </li></ul></ul><ul><li>Inguinal U/S </li></ul><ul><ul><li>Mass vs. hernia </li></ul></ul><ul><li>Tx </li></ul><ul><ul><li>Broad-spectrum antibiotics </li></ul></ul><ul><ul><li>Herniorrhaphy </li></ul></ul><ul><ul><li>Resection of necrotic bowel if necessary. </li></ul></ul>
  • 23. Epididymitis <ul><li>Hx </li></ul><ul><ul><li>1-2day onset, unilateral pain & swelling </li></ul></ul><ul><ul><li>Dysuria, urethral d/c </li></ul></ul><ul><li>PE </li></ul><ul><ul><li>Resembles torsion </li></ul></ul><ul><ul><li>Painful indurated epididymis </li></ul></ul><ul><ul><li>Pyuria </li></ul></ul><ul><ul><li>+Prehn’s sign (pain better with elevation) </li></ul></ul><ul><li>Labs </li></ul><ul><ul><li>UA & C/S, CBC, GC/Chlam cx </li></ul></ul>
  • 24. Epididymitis <ul><li>Most Common Causes </li></ul><ul><ul><li>Young boys – congenital anomalies </li></ul></ul><ul><ul><li><40 yr old - GC/Clamydia </li></ul></ul><ul><ul><li>>40 yr old – enterobacteria more common </li></ul></ul><ul><ul><li>Homosexual – STD & fungal UTI </li></ul></ul>
  • 25. Epididymitis <ul><li>Treatment </li></ul><ul><ul><li>Mild - outpatient </li></ul></ul><ul><ul><ul><li>GC/Clamydia – ceftriaxone 250mg IM x1 then doxycycline 100mg PO BID x 10d </li></ul></ul></ul><ul><ul><ul><li>Enterobacteria – cipro 500mg BID until C/S </li></ul></ul></ul><ul><ul><li>Mod to severe – inpatient </li></ul></ul><ul><ul><ul><li>Intractable pain, failed outpatient tx </li></ul></ul></ul><ul><ul><ul><li>Broad spectrum Abx, urology consult, U/S to r/o abscess formation and assess blood flow </li></ul></ul></ul>
  • 26. Epididymitis <ul><li>Complications </li></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>Infertility </li></ul></ul><ul><ul><li>Scrotal abscess </li></ul></ul><ul><ul><li>Epididymo-orchitis (involving testis) </li></ul></ul><ul><ul><li>Fournier gangrene </li></ul></ul>
  • 27. Testicular Cancer <ul><li>MC tumor in men 15-34yo </li></ul><ul><li>Rarely painful </li></ul><ul><ul><li>Painless testicular masses are CA until proven otherwise </li></ul></ul><ul><li>“ heaviness” in scrotum </li></ul><ul><li>Solid or indurated mass </li></ul><ul><li>Generally intratesticular </li></ul>
  • 28. Testicular Cancer <ul><li>PE </li></ul><ul><ul><li>Palpation for tissue texture anomalies and extratesticular extensions </li></ul></ul><ul><ul><li>Transillumination for cystic qualities </li></ul></ul><ul><li>Lab </li></ul><ul><ul><li>Monitor endocrine markers like AFP, hCG </li></ul></ul><ul><li>Imaging </li></ul><ul><ul><li>Scrotal U/S </li></ul></ul>
  • 29. Testicular Cancer <ul><li>Tx </li></ul><ul><ul><li>No biopsy – straight to radical orchiectomy </li></ul></ul><ul><li>Prognosis </li></ul><ul><ul><li>Limited disease – usually complete cure </li></ul></ul><ul><ul><li>Advanced disease – 70-80% cure </li></ul></ul>
  • 30. Varicocele <ul><li>Dilation of pampiniform plexus </li></ul><ul><li>Often regress 40% </li></ul><ul><li>Sx </li></ul><ul><ul><li>Pain, ipsilateral testicular atrophy, infertility </li></ul></ul><ul><ul><li>L>R. R rare w/o L </li></ul></ul><ul><li>PE </li></ul><ul><ul><li>Small ->fullness; Larger ->”bag of worms” </li></ul></ul><ul><li>Tx </li></ul><ul><ul><li>Supportive unless <20yo or infertility </li></ul></ul><ul><ul><li>Surgical repair </li></ul></ul>
  • 31. References <ul><li>www.uptodate.com </li></ul><ul><li>www.emedicine.com </li></ul><ul><li>www.aafp.org </li></ul><ul><li>American Urological Association. Torsion of the testis: changing concepts. AUA update series IX. 1990.) </li></ul><ul><li>World J. Urol. 17:101. 1999 </li></ul>
  • 32. Thanks.

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