1. Testicular pain has several potential causes including epididymitis, orchitis, testicular torsion, and other less common conditions. 2. Physical exam findings alone cannot rule out testicular torsion, and imaging studies like ultrasound have false negative rates. 3. In cases of high clinical suspicion for testicular torsion based on factors like severe pain, uncertain lie of the testicle, and diminished cremasteric reflex, immediate surgical exploration is preferable to delaying diagnosis or treatment.

1. 12182014
EVALUATION OF
TESTICULAR PAIN
Jeffrey J. Steinberg

2. Educational
Objectives:
1. Recognize the differential diagnosis of
testicular pain in adults
2. Consider the appropriate evaluation
for testicular pain, including when to
refer for urgent evaluation
3. Consider appropriate treatment
modalities in patients presenting with
testicular pain

3. Anatomy
❖The testes develop from condensations of tissue within
the urogenital ridge at approximately six weeks of
gestation.
❖With longitudinal growth of the embryo, the testes
ultimately descend into the scrotum by the third trimester.
❖ As the testes leave the abdomen, the peritoneal lining
covers them, creating the processus vaginalis.
❖The spermatic arteries and pampiniform venous plexus
enter the inguinal canal proximal to the testes, and with
the vas deferens, form the spermatic cord.
❖ The testicle is tethered to the scrotum distally by the
gubernaculum.

4. Case One
❖ Mr. Prehn, a 55-year-old gentleman,
presents with four days of an aching,
throbbing pain in his left testicle. He has
a sedentary job but notes that the
symptoms began after he went hiking
five days ago. He notes that “it feels
funny when I pee,” but denies pain with
urination. He also denies fever, flank
pain, penile discharge or GI symptoms.
He reports that he is monogamous with
his wife and last had intercourse two
weeks ago.
❖ He has a history of mild benign
prostatic hypertrophy and
hypertension. He is otherwise well.

5. Differential
Diagnosis
•Acute scrotum is defined as a sudden
painful swelling of the scrotum or its
contents, accompanied by local signs
or systemic symptoms.
•Epididymitis is the most common
cause of intrascrotal inflammation,
and retrograde ascent of pathogens is
the usual route of infection.
comprehensive differential which includes: epididymitis/orchitis (infectious and non-infectious), hematologic disorders, idiopathic scrotal edema, genitourinary infection, hernia, hydrocele, varicocele, torsion of the spermatic cord, trauma, tumor, and torsion of the appendix testicle or appendix epididymis.The top
three diagnoses in this gentleman are epididymitis, orchitis (least likely), and the consideration of testicular torsion. Other diagnoses to consider are varicocele and hernia (these diagnoses would be higher on the list in this age-group but they do not usually present with urinary symptoms).
Risk factors for epididymitis include sexual activity, strenuous physical activity, especially with repeated trauma such as motorcycle riding, bicycling, or prolonged sitting. Also, recent urinary tract surgery, instrumentation, and anatomic abnormalities such as urologic obstruction can induce epididymitis. Our
patient has several risk factors: prolonged sitting, the repeated trauma from hiking, and possibly his benign prostatic hypertrophy (causing obstruction).
Studies show that the type of bacteria in epididymitis varies with age. For those younger than 14 and older than 35, common urinary tract pathogens such as E. coli are most common. For those ages 14-35, gonococcal and chlamydia infections are most likely. Epididymitis from coliform bacteria are found in
patients who engage in insertive anal intercourse.
More rare causes include post-infectious inflammation in response to viral infections, vasculitis, and drug reaction (e.g., amiodarone).
Orchitis alone is almost always caused by a viral infection such as the mumps.
Lurking in the back of the provider’s mind should be the question: Does this patient have testicular torsion, a surgical emergency? It is important to recognize that the data strongly suggest that it is impossible to rule out testicular torsion by history and physical exam alone.

6. CASE ONE
CONTINUED:
On exam, he is afebrile and his vitals are
stable. You note that both testicles have a
normal lie, with a normal cremasteric
reflex. There are shotty, mobile, slightly
tender inguinal lymph nodes. The upper
pole of the left testicle is very tender and
swollen. Your patient is visibly
uncomfortable. The Prehn sign is
positive.

7. What is the Prehn Sign?
❖ The Prehn sign is the relief of testicular pain with
the elevation of the testis.
❖ With epididymitis, pain is usually relieved with
elevation of the testis.
❖ With testicular torsion, pain is usually exacerbated.
❖ It is important to be mindful that this single
finding neither rules in or out testicular torsion.

8. You’ve been lied to…
Cremaster Myth and
the Lie
• A number of series document the equivocal findings
associated with testicular torsion and epididymitis.
• Contrary to traditional teaching, several series have
demonstrated that 100% of patients with testicular torsion
had a cremasteric reflex.
• Also, several series note the absence of cremasteric reflex
with epididymitis.
• Similarly, elevated lie was found in only 36% of patients
with testicular torsion.
• Tenderness at the upper pole of the testes, suggestive of
epididymitis, was also associated with testicular torsion
a number of series document the equivocal findings associated with testicular torsion and epididymitis. Contrary to traditional teaching, several series have demonstrated
that 100% of patients with testicular torsion had a cremasteric reflex. Also, several series note the absence of cremasteric reflex with epididymitis
Similarly, elevated lie was found in only 36% of patients with testicular torsion. Tenderness at the upper pole of the testes, suggestive of epididymitis, was also
associated with testicular torsion (Mellick, 2012).

9. Work Up
❖ Urinalysis and urine culture
❖ Consider swabs for C. trachomatis and N.
gonorrhea, while being sensitive to the issue of the
patient’s reported monogamy.
❖ A same-day ultrasound, but need not have
emergent surgical evaluation.
❖ C-reactive protein measurements have been helpful
in differentiating epididymitis and testicular
torsion. One study showed that C- reactive protein
had a sensitivity and specificity of 96.2% and 94.2%
for epididymitis (Trojian, 2009). However, C-
reactive protein measurements are presently not in
the algorithm; one should not delay ordering the
ultrasound.
❖ The take-home point: even in low-risk patients, the
momentum of data has swung the pendulum in
favor of ultrasound to rule out the high-risk
situation of testicular torsion.
It is reasonable to check a urinalysis and urine culture to evaluate for urinary tract infection.
Also, one might consider swabs for C. trachomatis and N. gonorrhea, while being sensitive to the issue of the patient’s reported monogamy
Given his history and exam, the patient’s presentation is strongly suggestive of epididymitis. Thus, according to the algorithm cited in Sharp’s paper, he should have a same-day ultrasound, but need not have emergent surgical evaluation
Interestingly, C-reactive protein measurements have been helpful in differentiating epididymitis and testicular torsion. One study showed that C- reactive protein had a sensitivity and specificity of 96.2% and 94.2% for epididymitis (Trojian, 2009).
However, C-reactive protein measurements are presently not in the algorithm; one should not delay ordering the ultrasound.
The take-home point: even in low-risk patients, the momentum of data has swung the pendulum in favor of ultrasound to rule out the high-risk situation of testicular torsion.

10. The failure of both history and physical examination and color Doppler ul- trasound to def initively make the diagnosis in signif icant per- centages of patients is
demonstrated in the 2007 multicenter study by Kalfa et al.60 In that study, 208 patients had spermatic cord torsion proven at surgery. However, the clinical diagnosis of
TT before any ultrasonographic examination was judged as highly probable in 78.5% of the cases, possible in 10.2%, and unlikely in 11.3% of these torsed patients.
Moreover, CDS failed to establish the diagnosis of spermatic cord torsion in 50 cases (24%) because the testicular vascularization was judged as normal or increased
compared with the other testis.60 In a study published in 2005, Lam et al63 expressed high confidence in color Doppler ultrasound for the diagnosis of TT. Yet, in that
large series, 323 patients had an initial negative ultrasound finding, but 29 were explored eventually on clinical indications. Four of these patients (1.2% of 323) were
diagnosed intraoperatively as TT.

11. Treatment for Epididymitis
❖ Given his age, risk factors, and exam, this patient likely has epididymitis from
common bacteria found in urinary tract infectious such as e coli. Treatment with
levofloxacin 500mg each day for 10 days or ofloxacin 300mg bid x 10 days is
indicated.
❖ Other supportive therapies include non-steroidal anti-inflammatory
medications, scrotal elevation, cold packs, and limitation of activity.
❖ Patients should be counseled that there is a small risk for sepsis, abscess, and
infertility even when acute epididymitis is treated promptly and appropriately.
Given his age, risk factors, and exam, this patient likely has epididymitis from common bacteria found in urinary tract infectious such as e coli. Treatment with levofloxacin 500mg each day for 10 days or ofloxacin 300mg bid x 10 days is indicated.
If there were a concern for gonococcal or chlamydial infection (age between 14 - 35 years old), treatment with ceftriaxone 250mg IM x 1 and doxycycline 100mg pO bid x 10 days is indicated. Azithromycin 1000mg pO x 1 can be given instead of doxycycline if patient
compliance is uncertain.
Ciprofloxacin was, at one time, commonly used. However, given the widespread resistance by gonococcal and non-gonococcal bacteria, ciprofloxacin is no longer recommended.
Other supportive therapies include non-steroidal anti-inflammatory medications, scrotal elevation, cold packs, and limitation of activity.
Patients should be counseled that there is a small risk for sepsis, abscess, and infertility even when acute epididymitis is treated promptly and appropriately.

12. Case Two
❖ A 19 year old gentleman presents
to your office first thing in the
morning. He notes that he awoke
with a terrible pain in his right
testicle. On exam, the epididymis
seems tender. When you elevate
the testicle, the pain seems to
increase. The cremasteric reflex is
present, but seems diminished
relative to the left testicle. You are
uncertain if the lie is normal or not.
You note a curious “blue dot” near
the superior pole of the testicle.

13. Time is Testicle
❖ Given the patient’s extreme pain, diminished cremasteric reflex (poor sensitivity but fair
specificity) and uncertain “lie,” there is enough clinical concern to warrant immediate referral for
surgical exploration.
❖ Physical findings alone cannot rule out testicular torsion, which is a surgical emergency.
❖ A negative surgical exploration is preferable to a delay in diagnosis in the setting of high clinical
suspicion.
❖ Further, the false negative rate of Doppler ultrasound is not insignificant, and was as high as 24%.
❖ Ordering an ultrasound first would result in a delay of care when the clinical suspicion is high.
Medicolegal risks are also significant. Mellick’s article states that testicular torsion was the third most common cause of a malpractice lawsuit in males 12 - 17 years old.
In this setting, the most common misdiagnosis was epididymitis (72%). Among these malpractice cases, atypical presentations of testicular torsion were common. Since
testicular torsion is quite rare, with an incidence of 4.5 per 100,000 among males ages 1 - 25, and presentations can vary, this creates a “perfect storm” of medicolegal
legal risk.

14. Testicle Salvage
❖ Successful salvage of a torsed
testicle is as high as 90-100%
if surgical exploration is
performed within six hours
of symptom onset.
❖ Successful salvage decreased
to 50% if symptoms are
present for more than 12
hours and is less than 10% if
symptoms are present for 24
hours or more.

15. Torsion Types
❖ The age distribution of testicular torsion is bimodal, with one peak in the neonatal period and the second
peak around puberty. In neonates, extravaginal torsion predominates, with the entire cord, including the
processus vaginalis, twisting, which presents as painless scrotal swelling. Testicular viability in neonatal
torsion is universally poor; one literature review of 18 case series with 284 patients found a salvage rate
of about 9%.
❖ In older children and adults, testicular torsion is usually intravaginal (twisting of the cord within the
tunica vaginalis). The bell-clapper deformity, in which there is abnormal fixation of the tunica vaginalis to
the testicle, results in increased mobility of the testicle within the tunica vaginalis. The “bell clapper”
deformity is bilateral 80% of the time.
❖ Whether testicular torsion is intravaginal or extravaginal, twisting of the spermatic cord initially
increases venous pressure and congestion, with subsequent decrease in arterial blood flow and ischemia.
Although symptoms are typically unilateral, the anatomic conditions that predispose a person to torsion
must be presumed to be bilateral.

16. Desert Island Scenario
❖You are on a desert island
with right testicular
torsion. You read
somewhere that you can
manually detorse a
testicle. Which direction
do you turn the testicle?

17. Desert Island Scenario Answer:
❖Most testicular torsion
occurs by the testicle turning
“inwards” – from the lateral
side to the medial.
❖Thus, the convention is that
you turn the testicle as if
“opening the pages of a
book;” in other words, from
the medial side to the lateral
side.

18. Imitation Testicle Torsion
❖ The “blue dot” sign suggests torsion of the
appendage testis, which is an embryological
remnant of the Mullerian system.
❖ The “blue dot” sign is when the infarcted
appendage is visualized through the scrotum.
Torsion of the appendix epididymis, a Wolffian
remnant, is also possible.
❖ Diagnosis is usually made by Doppler
ultrasound.
❖ While pain may be significant in both these
conditions, treatment is supportive and
symptoms usually resolve in one to three days.
❖ While the “blue dot” raises the diagnosis of a
torsed appendix testes, the clinical concern in
this case is still high enough for testicular torsion
so urgent referral to a urologist is warranted.

19. Torsion Take Away
• Scrotal Doppler ultrasonography is the imaging study of choice to aid in the
diagnosis of testicular torsion; however, prompt referral should not be
delayed to perform this study.
• Immediate surgery should be performed if testicular torsion is suspected,
and should not be delayed by imaging studies if physical examination
findings are strongly suggestive.
• Manual detorsion should be attempted if surgery is not an immediate option;
however, prompt referral should not be delayed to perform this maneuver.

20. Primary References
❖ 1. Trojian TH, Lishnak TS, Heiman D. Epididymitis and
orchitis: an overview. Am Fam Physician. 2009;79(7):
583-7. http://www.aafp.org/afp/2009/0401/p583.pdf
❖ 2. Sharp VJ, Kiean K. Testicular torsion: diagnosis,
evaluation, and management. Am Fam Physician.
2013;88(12):835-40. http://www.aafp.org/afp/
2013/1215/p835.pdf

21. Thanks and keep ‘em hanging…