This document provides information on evaluating and diagnosing causes of testicular pain. Key points covered include: - Taking a history to identify characteristics of the pain, trauma history, changes in testicle size, sexual history, urinary symptoms, and associated abdominal pain. - Performing a focused exam including inspection, palpation, checking the cremasteric reflex and Phren's sign. - Common differentials to consider include testicular torsion, torsion of the appendix testis, and epididymitis. Additional tests like ultrasound may help distinguish between causes. - Management depends on the diagnosis but may include pain medication, antibiotics, manual detorsion in the ER, or surgical correction for torsion

1. Testicular Pain
Saeed Al-Ghamdi

2. Anatomy of the Testis

3. Key Questions in the
History
Characteristic of the
pain
Recurrent pain suggests torsion
History of trauma
History of change in the
size of the testicle
Changes during Valsalva suggests
communicating hydrocoele or varicocele
Sexual history STD’s can cause epididymitis
Difficulty voiding urine Suggests intra-abdominal mass (hernia), UTI,
neurologic problems or spinal cord disease
Flank pain or Hematuria Suggests kidney stone with referred pain to
the scrotum
Abdominal pain with
diminished appetite,
nausea and vomiting
Suggests testicular torsion

4. Focused Exam
Inspection
Palpation
Cremasteric Reflex
Phren’s sign
Blue dot sign

5. Inspection
Inspect while the patient is standing – check the penis,
pubic hair and inguinal areas.
Inspect for ulcers, papules, pubic hair infestations or
lymphadenopathy

6. Inspection
The left testicle is
slighlty lower than the
right

7. Palpation
Roll the testicle between thumb and forefingers to look for
masses
Palpate for the epididymis and go up towards the
spermatic cord.
Transilluminate the scrotum if swelling is suspected.

8. Cremasteric Reflex
Stroking the upper thigh
results in elevation of
the ipsilateral testicle.
Usually present in boys
30 months to 12 years
Less reliable in
teenagers and infants

9. Phren’s Sign
Elevation of the scrotal contents relieves pain in patients
with epididymitis and not with testicular torsion.
POSITIVE SIGN – Relief of pain with elevation =
EPIDIDYMITIS

10. Blue Dot Sign
Almost always
suggestive of torsion of
the appendix testis.

11. Additional Tests
Test Purpose
Complete Blood Count Elevated WBC count in torsion
Test usually obtained for pre-
operative purposes
Urinalysis and Culture R/o UTI
Pyuria may be seen in Epididymitis
Gram stain, culture, rapid molecular
amplification testing of urethral
discharge
-or-
Nucleic amplification test of urine
R/o sexually transmitted diseases
Color Doppler Ultrasound of the
Scrotum
Check perfusion
R/o torsion if cannot be excluded on
clinical grounds

12. Differential Diagnosis
Testicular Torsion
Torsion of Appendix Testis
Epididymitis/Orchitis

13. Torsion of the Testicle
Inadequate fixation of
the testis to the tunica
vaginalis through the
gubernaculum
“Bell-clapper” deformity
Twisting of the spermatic
cord
Venous compression
and edema
Ischemia

14. Torsion of the Testicle
Peak incidence in the neonatal period and the pubertal
period
~65% occur during the 12-18 year old range due to
increasing weight of the testicles

15. Torsion of the Testicle
Abrupt onset of severe
testicular or scrotal pain
<12 hours of duration
90% have associated
nausea and vomiting
Pain can be constant
unless the testicle is
torsing and detorsing
Most boys report a
previous episode in the
past

16. Torsion of the Testicle
Diagnosis is made clinically. Impression is stronger if
there are previous episodes
Doppler ultrasound should be done if there are uncertainty
in diagnosis

17. Manual detorsion (26-80% success) ((( in ER )))
Should be done by urologist
Patient should be sedated
Most effective before significant edema present
Rotate testicle up and away from midline (towards thigh)
Surgical detorsion with bilateral orchidopexy ((( in OR )))
Bilaterally correction required since deformity usually
bilaterally
Surgical correction required even if manually detorsed

18. Torsion of the Appendix Testis
Pedunculated shapes of
these structures
predispose them to
torsion
Occurs most commonly
in 7-12 year old boys

19. Torsion of the Appendix Testis
Pain is of sudden onset, similar to testicular torsion
The testicle is non-tender, but there is a tender localized
mass usually at the superior or inferior pole
(+) Blue dot sign – gangrenous appendix
Doppler ultrasound may be necessary to rule out testicular
torsion – will show a lesion of low echogenicity. Blood
flow to the affected area may be increased

20. Torsion of the Appendix Testis
Management
Bed rest, Analgesia, Scrotal Support
5-10 days out patient
Resolution Surgery
No follow-up
necessary
Removal of the appendage;
exploration of contralateral testis not
necessary

21. Epididymitis
Inflammation of the epididymis
Occur more frequently in late adolescent boys and even in
younger males who deny sexual activity.
Risk factors
Sexual activity
Heavy physical exertion
Direct trauma
Bacterial epididymitis – think of anatomical abnormalities

22. Epididymitis
(+) Sexual activity
Chlamydia
N. gonorrhea
E. coli
Viruses
(-) Sexual Activity
Mycoplasma
Enteroviruses
Adenovirus

23. Epididymitis
Acute or subacute onset
of testicular pain
History of urinary
frequency, dysuria, and
fever
Normal cremasteric
reflex, with negative
Prehn’s sign

24. Epididymitis
Doppler ultrasound may be necessary to rule out testicular
torsion
All patients should get a urinalysis and urine culture

25. Epididymitis
ADMSSION CRITERIA CHILDREN SEXUALLY ACTIVE
Doubt diagnosis
(?Torsion)
(+) Leukocytes in urine
Empiric antibiotics –
Bactrim*/Keflex*
Ceftriaxone x 1 +
Doxycycline x 10
days
Severe pain Ofloxacin
Immunocompromised (-) Leukocytes in urine
Supportive treatment
[NON-BACTERIAL]
Levofloxacin
Unreliable patient
Non-compliance
• It is equally important to treat sexual partners if an STD is the likely
cause.
• Supportive therapy: Scrotal support, bed rest and NSAIDS

26. Scrotal Swelling
Scrotal Swelling History & PE
Hydrocele • (+) Transillumination
• Increase in size during the day or with Valsalva
• If non-communicating, no change in size.
Varicocele • The spermatic cord has a “bag of worms” feeling
secondary to vessel dilation
• The varicoceles may be more palpable with
standing or with Valsalva
• (-) Transilluminate
Spermatocele • Painless, fluid filled cyst on the head of the
epididymis
• (+) Transillumination localized to the head of the
testis
Testicular CA • Firm, painless mass that does not transilluminate
• (+) Reactive hydrocele

27. Thank you!