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Evaluation of Testicular Pain

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Evaluation of Testicular Pain

Evaluation of Testicular Pain

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  • 1. Evaluation of Testicular Pain Marcos Machado, M.D. Michael Macksood, D.O. February 28, 2007
  • 2. 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
  • 3. 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.
  • 4. Anatomy – blood supply
    • Aorta->Testicular artery
    • Pampiniform plexus of the spermatic cord
  • 5. Acute vs. Chronic Pain
    • Acute
      • Pain onset seconds to hours
    • Chronic
      • Pain lasting more than 3 months
      • Insidious onset
  • 6. 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
  • 7. 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
  • 8. 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)
  • 9. Topics for today
    • Acute problems
      • Torsion
      • Trauma
      • Strangulated Inguinal Hernia
      • Epididymitis / Orchitis
    • Chronic problems
      • Testicular CA
      • STD
      • Varicocele
  • 10. 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
  • 11. 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
  • 12. Testicular Torsion
    • PE
      • Tender, swollen, high in scrotum
      • Absent cremasteric reflex on affected side
      • -Prehn’s sign (+ in epididymitis)
    • Labs
      • Normal UA
      • No leukocytosis
  • 13. Testicular Torsion
    • Doppler
      • If clinical signs equivocal
      • 80-90% Sn, 75-90% Sp
  • 14. 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%
  • 15. 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.
  • 16. 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
  • 17. Testicular Trauma
    • Color doppler to dx extent of injury
    • Range of injury
      • Hematocele (hematoma within tunica vaginalis)
      • Intratesticular hematoma
      • Rupture (disruption of tunical albuginea)
  • 18. 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
  • 19. Testicular Trauma
    • Surgery
      • Scrotal exploration indicated if high degree of suspicion
      • Orchiectomy rate <10% if evacuation/debridement begun within 72 hours
  • 20. 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
  • 21. 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.
  • 22. Strangulated Inguinal Hernia
    • PE
      • Inguinal canal exam
    • Inguinal U/S
      • Mass vs. hernia
    • Tx
      • Broad-spectrum antibiotics
      • Herniorrhaphy
      • Resection of necrotic bowel if necessary.
  • 23. 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
  • 24. Epididymitis
    • Most Common Causes
      • Young boys – congenital anomalies
      • <40 yr old - GC/Clamydia
      • >40 yr old – enterobacteria more common
      • Homosexual – STD & fungal UTI
  • 25. 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
  • 26. Epididymitis
    • Complications
      • Sepsis
      • Infertility
      • Scrotal abscess
      • Epididymo-orchitis (involving testis)
      • Fournier gangrene
  • 27. 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
  • 28. 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
  • 29. Testicular Cancer
    • Tx
      • No biopsy – straight to radical orchiectomy
    • Prognosis
      • Limited disease – usually complete cure
      • Advanced disease – 70-80% cure
  • 30. 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
  • 31. 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
  • 32. Thanks.