Evaluation of Testicular Pain

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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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Evaluation of Testicular Pain

  1. 1. Evaluation of Testicular Pain Marcos Machado, M.D. Michael Macksood, D.O. February 28, 2007
  2. 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. 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. 4. Anatomy – blood supply <ul><li>Aorta->Testicular artery </li></ul><ul><li>Pampiniform plexus of the spermatic cord </li></ul>
  5. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 32. Thanks.

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