Liam felt a sharp pain in his right testicle after a football game. In the locker room, his right testis was higher than the left and extremely tender. His coach noticed Liam walking slowly with a protective gait and sent him to the hospital for possible emergency surgery. Liam is exhibiting signs and symptoms of testicular torsion including sudden severe scrotal pain, elevated and tender testis, nausea, and inability to walk normally. Testicular torsion requires urgent surgical intervention to detorse the testis within 6-24 hours to save viability. The coach recognized the potential medical emergency and ensured Liam received prompt evaluation and treatment.

1. ACUTE SCROTAL PAIN
JAMES MWANGI K.

2. Embryology
 Descent of testes at 32-40 wks gestation
 Descends within processes vaginalis
 Outpouching of peritoneal cavity
 Tunica vaginalis is potential space that remains after
closure of process vaginalis

3. Anatomy
 Spermatic cord –testicular vessels, lymph, vas deferens
 Epididymis - sperm formed in testicle and undergo maturation, stored in
lower portion
 Vas Deferens – muscular action propels sperm up and out during
ejaculation
 Gubernaculum –
 fixation point for testicle to tunica vaginalis
 Tunica Vaginalis – potential space
 Encompasses anterior 2/3’s of testicle
 Tunica albuginea is inner layer opposing testis

4. Anatomy
Anterior
Posterior

5. Male External genitalia
 Scrotum
 Penis
Male internal genitalia
o Testes
o Epididymis
o Ductus deferens (Vas
deference)
o Ejaculatory duct
o Urethra.
o Spermatic cord
o Accessory organs are:-
seminal, prostate & bulbo-
urethral glands
Anatomy

6. Causes of Pain and Swelling
 Pain
 Testicular torsion
 Torsion of appendix testis
 Epididymitis
 Trauma
 Orchitis and Others
 Swelling
 Hydrocele
 Varicocele
 Spermatocele
 Tumor

8. Torsion
 Inadequate fixation of testes to tunica vaginalis at
gubernaculum
 Torsion around spermatic cord
 Venous compression to edema to ischemia

9. Epidemiology
 Accounts for 30% of all acute scrotal swelling
 Bimodal ages – neonatal (in utero) and pubertal ages
 65% occur in ages 12-18yo
 Incidence 1 in 4000 in males <25yo
 Increased incidence in puberty due to inc weight of testes

10. Predisposing Anatomy
 Bell-clapper deformity
 Testicle lacks normal
attachment at vaginalis
 Increased mobility
 Tranverse lie of testes
 Typically bilateral
 Prevalence 1/125

11. Torsion: Clinical Presentation
 Abrupt onset of pain – usually testicular, can be lower
abdominal, inguinal
 Often < 12 hrs duration
 May follow exercise or minor trauma
 May awaken from sleep
 Cremasteric contraction with nocturnal stimulation in REM
 Up to 8% report testicular pain in past

12. Torsion: Examination
 Edematous, tender, swollen
 Elevated from shortened spermatic cord
 Horizontal lie common (PPV 80%)
 Reactive hydrocele may be present
 Cremasteric reflex absent in nearly all (unreliable in <30mo
old) (PPV 95%)
 Prehn’s sign elevation relieves pain in epididymitis and not
torsion is unreliable

13. Diagnosis – “Time is Testicle”
 Ideally -- prompt clinical diagnosis
 Imaging
 Don’t waste time!
 Color doppler – decreased intratesticular flow
 False + in large hydrocele, hematoma
 Sens 69-100% and Spec 77-100%
 Lower sensitivity in low flow pre-pubertal testes
 Nuclear Technetium-99 radioisotope scan
 Show testicular perfusion
 30 min procedure time
 Sens and spec 97-100%

14. Management
 Detorsion within 6hr = 100% viability
 Within 12-24 hrs = 20% viability
 After 24 hrs = 0% viability
 Surgical detorsion and orchiopexy if viable
 Contralateral exploration and fixation if bell-clapper deformity
 Orchiectomy if non-viable testicle
 Never delay surgery on assumption of nonviability as
prolonged symptoms can represent periods of intermittent
torsion

15. Torsion: Special Considerations
 Adolescents may be embarrassed and not seek care until
late in course
 Torsion 10x more likely in undescended testicle
 Suspicious if empty scrotum, inguinal pain/swelling

16. Torsion of Appendix Testis
 Appendix testis
 Small vestigial structure,
remnant of Mullerium duct
 Pedunculated, 0.3cm long
 Other appendix structures
 Prepubertal estrogen may
enlarge appendix and cause
torsion

17. Torsion of Appendix Testis
 Peak age 3-13 yo (prepubertal)
 Sudden onset, pain less severe
 Classically, pain more often in abd or groin
 Non-tender testicle
 Tender mass at superior or inferior pole
 May be gangrenous, “blue-dot” (21% of cases)
 Normal cremasteric reflex, may have hydrocele
 Inc or normal flow by doppler U/S

18. Torsion of Appendix Testis
Blue dot of gangrenous
appendix testis

19. Torsion of Appendix Testis
 Management supportive
 analgesics, scrotal support to relieve swelling
 Surgery for persistent pain
 no need for contralateral exploration

20.  Liam a Kabarak University student, is finishing his last football game as team
gets ready for the 2nd half. Liam gets up from a sit, he feels a twinge of pain in
the right side of his scrotum. On his way back to the locker room, he can’t stand
up straight. In the shower, he examines his scrotum but doesn’t see any bruising
or swelling. However, his right testis is higher than his left, and it’s so tender he
can barely get dressed. He is walking hunched over and feels nauseated. The
coach notices Liam protective, slow gait and sees him stop to vomit in the trash
bin. “What’s going on, Liam? You played a great game tonight.” “Oh, sorry,
Coach. I am just a little sick to my stomach,” replies Liam. “And this is
embarrassing, but my right testicle is killing me. I don’t remember getting hit
there, but it is so painful I can’t touch it.” His coach says, “Liam, you are going
straight to the hospital for possible emergency surgery . Call your parents.” Why
does his coach send Liam to the hospital for a possible emergency surgery?
Clinical correlate:
A Serious Game of Twister

21. Epididymitis
 Inflammation of epididymis
 Subacute onset pain, swelling localized to epididymis,
duration of days
 With time swelling and pain less localized
 Testis has normal vertical lie
 Systemic signs of infection
 inc WBC and CRP, fever + in 95%
 Cremasteric reflex preserved
 Urinary complaints: discharge/dysuria PPV 80%

22. Epididymitis
 Scrotum has overlying erythema, edema in 60%
 Normal vertical
lie

23. Epididymitis
 Sexually active males
 Chlamydia > N. gonorrhea > E. coli
 Less commonly pseudomonas (elderly) and tuberculosis
(renal TB)
 Young boys, adolescents often post-infectious (adenovirus)
or anatomic
 Reflux of sterile urine through vas into epididymis
 50-75% of prepubertal boys have anatomic cause by imaging

24. Epididymitis Diagnosis
 Leukocytosis on UA in ~40% of patients
 PCR Chlamydia + in 50%, GC + in 20% of sexually active
 95% febrile at presentation
 Doppler scan show increased flow
 If hx consistent with STD, CDC recommends:
 Cx of urethral discharge, PCR for C and G
 Urine culture and UA
 Syphilis and HIV testing

25. Doppler Epididymitis
 Left Epididymitis
 Inc blood flow in
and around left testis

26. Epididymitis Treatment
 Sexually active treat with Ceftriaxone/Doxycycline or
Ofloxacin
 Pre-pubertal boys
 Treat for co-existing UTI if present
 Symptomatic tx with NASIDs, rest
 Referral all to GU for studies to rule out VUR, post urethral
valves, duplications
 Negative culture has 100% NPV for anomaly

27. Orchitis
 Inflammation/infection of testicle
 Swelling pain tenderness, erythema and shininess to overlying
skin
 Spread from epididymitis,
hematogenous, post-viral
 Viral: Mumps, coxsackie,
echovirus, parvovirus
 Bacterial: Brucellosis

28. Mumps Orchitis
 Extremely rare if vaccinated
 20-30% of pts with mumps, 70% unilateral, rare before
puberty
 Presents 4-6 days after mumps parotitis
 Impaired fertility in 15%, inc risk if bilateral

29. Trauma
 Result of testicular compression against the pubis bone,
from direct blow, or straddle injuries
 Extent depends on location of rupture
 Tunica albuginea ruptures (inner layer of tuncia vaginalis) allows
intratesticular hematoma to rupture into hematocele
 Rupture of tunica vaginalis allow blood to collect under scrotal
wall causing scrotal hematoma
 Doppler often sufficient to assess extent
 Surgery for uncertain dx, tunica albuginea rupture,
compromised doppler flow

30. Testicular Hematoma
 Blood as a filling
defect in testis

31. Other Causes of Pain
 Incarcerated inguinal hernia
 Henoch-Schonlein Purpura
 Vasculitis of testicular vessels
 Rarely presents with only scrotal pain
 Referred pain
 Retrocecal appendix, urolithiasis, lumbar/sacral nerve injury
 Non specific scrotal pain
 Minimal pain, nl exam – return immediately for inc
symptoms

32. Scrotal Swelling
 Hydrocele
 Varicocele
 Spermatocele
 Testicular Cancer

33. Approach to Scrotal Mass
Scrotal
Mass
Infectious Anatomic Malignancy
PAINFUL
• Epididymitis
• Orchitis
• Hydrocele
• Varicocele
• Spermatocele
• Torsion of Testis
• Torsion of Appendix Testis
• Testis Tumor

34. Hydrocele
 Fluid accumulation
in potential space of
tunica vaginalis
 May be primary from
patent PV or secondary
to torsion/epididymitis

35. Hydrocele
 Transilluminating
anterior cystic
mass

36. Hydrocele
 Mass increases in size during day or with crying and
decreases at night if communicating
 If non-communicating and <1 yo follow
 If communicating (enlarging), scrotum tense (may impair
blood flow) requires repair
 Unlikely to close spontaneously and predisposes to hernia

37. Varicocele
 Collection dilated veins in
pampiniform plexus
surrounding spermatic cord
 More common on left side
 R vein direct to IVC
 L vein acute angle to renal vein
 ~20% of all adolescent males

38. Varicocele
 Often asymptomatic or c/o dull ache/fullness upon standing
 Spermatic cord has ‘bag of worms’ appearance that
increased with standing/valsalva
 If prepubertal, rapidly enlarging, or persists in supine
position rule out IVC obstruction
 Most management conservatively
 Surgery if affected testis < unaffected testis volume

39. Spermatocele
 Painless sperm containing
cyst of testis, epipdidymis
 Distinct mass from testis
on exam
 Transilluminates
 Do not affect fertility
 Surgery for pain relief only

40. Acute Idiopathic Scrotal Edema
 Scrotal skin red and tender
 underlying testis normal
 no hydrocele
 Erythema extends off
scrotum onto perineum
 Empiric tx, cause unknown
 Antihistamine, steroids
 Resolves w/in 48-72hrs

41. Testicular Cancer
 Most common solid tumor in 15-30 yo males
 20% of all cancers in this group
 Painless mass
 Rapidly growing germ cell tumors may cause hemorrhage
and infarction
 Present as firm mass
 Typically do not transilluminate
 Diagnostic imaging with U/S initially

42. Testicular Cancer
 Typically occurs in young
healthy Men.
 Very good cure rates Even
for Metastatic Disease!

43. Testicular Cancer
Testis Cancer
Primary
Germ Cell
Tumors
Seminoma
Nonseminoma
Non-Germ Cell
Tumors
Secondary

44. Testicular Cancer
Testis Cancer
Primary
Germ Cell
Tumors
Seminoma
Nonseminoma
Non-Germ Cell
Tumors
Secondary

45. Germ Cell Testicular Cancer
 Seminoma
 Non-Seminoma
 Embryonal Carcinoma
 Teratoma
 Teratocarcinoma (Teratoma +Embryonal Carcinoma)
 Choriocarcinoma
 Yolk Sac Tumour (typically infants)

46. Testicular Cancer
Testis Cancer
Primary
Germ Cell
Tumors
Seminoma
Nonseminoma
Non-Germ Cell
Tumors
Secondary

47. Non-Germ Cell Testicular Cancer
 Leydig Cell Tumor
 Sertoli Cell Tumor

48. Testicular Cancer
Testis Cancer
Primary
Germ Cell
Tumors
Seminoma
Nonseminoma
Non-Germ Cell
Tumors
Secondary

49. Secondary Testicular Cancer
 Lymphoma
 Leukemia

50. Testicular Cancer
 Presentation
 Typically painless intratesticular mass discovered on self
examination
 Age 15-35
 Albeit some tumor subytpes cluster in infancy and some at later
age (60’s)

51. Testicular Cancer
 Investigations
 Labs
 B-HCG
 Produced by choriocarcinoma & in some Seminomas
 Alpha-fetoprotein
 Produced by Yolk Sac, Embryonal Carcinoma & Teratocarcinoma
 LDH
 Correlates with tumor volume
 Imaging
 Scrotal U/S
 CT Abdo and Pelvis: assess for retroperitoneal mets
 CXR
 +/- CT Head

52. Testicular Cancer
 Treatment:
 Radical Orchiectomy
 ALWAYS Inguinal approach
 NEVER scrotal approach
 PLUS…