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Evaluating Testicular PainEvaluating Testicular Pain
Kaveh Mansuripur
Ambulatory Medicine Clerkship
4/9/09
Kaveh Mansuripur
Ambulatory Medicine Clerkship
4/9/09
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Learning ObjectivesLearning Objectives
By the end of the session, be able to: List the differential dx for testicular pain Label or draw the relevant anatomy Describe the physical examination appropriate for
a patient with testicular pain Select appropriate testing for patients with
testicular pain in context of specific sxs and signs Select the most appropriate treatment for patients
with specific causes of testicular pain
By the end of the session, be able to: List the differential dx for testicular pain Label or draw the relevant anatomy Describe the physical examination appropriate for
a patient with testicular pain Select appropriate testing for patients with
testicular pain in context of specific sxs and signs Select the most appropriate treatment for patients
with specific causes of testicular pain
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AnatomyAnatomy
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Case 1: Patient T.R.What is the Differential Diagnosis?
Case 1: Patient T.R.What is the Differential Diagnosis?
HPI: 21 yo man presents with 3 hours of intense, constant
testicular painBegan several hours after college track meetAssociated nausea and vomiting
PMH: NoneMeds: Glucosamine, condroitin, creatine supplementsAlls: PCNFH: Non-contributorySH: Sexually active, multiple partners
HPI: 21 yo man presents with 3 hours of intense, constant
testicular painBegan several hours after college track meetAssociated nausea and vomiting
PMH: NoneMeds: Glucosamine, condroitin, creatine supplementsAlls: PCNFH: Non-contributorySH: Sexually active, multiple partners
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Differential DiagnosisDifferential Diagnosis
Testicular Torsion Appendiceal Torsion Epididymitis Trauma Inguinal Hernia Henoch-Schonlein Purpura Mumps Fournier’s Gangrene Referred Pain
Testicular Torsion Appendiceal Torsion Epididymitis Trauma Inguinal Hernia Henoch-Schonlein Purpura Mumps Fournier’s Gangrene Referred Pain
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Case 1: Patient T.R.Case 1: Patient T.R.
Exam: Exam:
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Case 1: Patient T.R.What is the Next Step?
Case 1: Patient T.R.What is the Next Step?
Exam: Right testicle higher than left Long axis oriented horizontally Significant swelling No cremasteric reflex on either side No relief of pain on elevation
Exam: Right testicle higher than left Long axis oriented horizontally Significant swelling No cremasteric reflex on either side No relief of pain on elevation
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Case 1: Patient T.R.Next Step
Case 1: Patient T.R.Next Step
If Diagnosis Certain (Torsion): To the OR. Outcomes directly related to length of time
from onset Irreversible ischemia at mean of 12 hours
If Diagnosis Less Obvious Doppler Ultrasound Test 82% sensitive, 99% specific for torsion
(loss of flow)
If Diagnosis Certain (Torsion): To the OR. Outcomes directly related to length of time
from onset Irreversible ischemia at mean of 12 hours
If Diagnosis Less Obvious Doppler Ultrasound Test 82% sensitive, 99% specific for torsion
(loss of flow)
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Case 1: Patient T.R.Case 1: Patient T.R.
Operation: testicular detorsion and fixation Unilateral or bilateral? Why?
Operation: testicular detorsion and fixation Unilateral or bilateral? Why?
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Case 1: Patient T.R.Case 1: Patient T.R.
Operation testicular detorsion and fixation Unilateral or bilateral? Why?
ANSWER: Bilateral-- Torsion associated with absence/insufficeincy of gubernaculum. Often bilateral.
What if surgery not an option?
Operation testicular detorsion and fixation Unilateral or bilateral? Why?
ANSWER: Bilateral-- Torsion associated with absence/insufficeincy of gubernaculum. Often bilateral.
What if surgery not an option?
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Case 1: Patient T.R.Case 1: Patient T.R.
Non-operative: Manual detorsion 2/3 of cases are torsed medially, 1/3 laterally Success marked by decreased pain, return to
normal position. If unsuccessful, apply ice (successful in animal
models)
Non-operative: Manual detorsion 2/3 of cases are torsed medially, 1/3 laterally Success marked by decreased pain, return to
normal position. If unsuccessful, apply ice (successful in animal
models)
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Testicular TorsionTesticular Torsion
40% over 21 Associated with
physical activity/sleep Exam Absent cremasteric Doppler Surgical Emergency
40% over 21 Associated with
physical activity/sleep Exam Absent cremasteric Doppler Surgical Emergency
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Case 2: Patient F.J.Case 2: Patient F.J.
HPI: 11 year old boy presents with 3 days of
increasing scrotal pain Localizes tenderness to anterior
superior pole of right testicle dDx?
HPI: 11 year old boy presents with 3 days of
increasing scrotal pain Localizes tenderness to anterior
superior pole of right testicle dDx?
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Case 2: Patient F.J.Case 2: Patient F.J.
ExamExam
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Case 2: Patient F.J.Case 2: Patient F.J.
Exam: Tender as reported Transillumination: hydrocele at AS pole Cremasteric reflexes intact bilaterally Discoloration visible externally as sub-
centimeter dot at site
Exam: Tender as reported Transillumination: hydrocele at AS pole Cremasteric reflexes intact bilaterally Discoloration visible externally as sub-
centimeter dot at site
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Case 2: Patient F.J.Case 2: Patient F.J.
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Case 2: Patient F.J.Case 2: Patient F.J.
Further tests?Further tests?
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Case 2: Patient F.J.Case 2: Patient F.J.
Further tests? Ultrasound will show focus of decreased
echogenicity at site
Treatment?
Further tests? Ultrasound will show focus of decreased
echogenicity at site
Treatment?
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Case 2: Patient F.J.Case 2: Patient F.J.
Further tests? Ultrasound will show focus of decreased
echogenicity at siteTreatment?
Conservative Ice, anti-inflammatory medications Pain resolves in weeks-months Residual nodule
Operative Low risk Recovery in days
Further tests? Ultrasound will show focus of decreased
echogenicity at siteTreatment?
Conservative Ice, anti-inflammatory medications Pain resolves in weeks-months Residual nodule
Operative Low risk Recovery in days
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Appendiceal TorsionAppendiceal Torsion
80% between 7-14 years Leading pediatric scrotal
pathology Gradual onset Tenderness localized to AS
aspect Intact cremasteric reflex “Blue Dot” sign in 21%
80% between 7-14 years Leading pediatric scrotal
pathology Gradual onset Tenderness localized to AS
aspect Intact cremasteric reflex “Blue Dot” sign in 21%
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Case 3: Patient J.D.Case 3: Patient J.D.
CC: 31 yo man with Testicular PainHPI
5 days, waxing/waning. Began several hours after exercise. No previous episodes.
Left testicle, some radiation to L. inguinal fold, L. gluteal region
“Achy” in quality; 4-8/10 No N/V/F/C or other associated symptoms ED visit 3 days ago. Clean U/A at time. Told
to FU outpatient if pain unresolved.
CC: 31 yo man with Testicular PainHPI
5 days, waxing/waning. Began several hours after exercise. No previous episodes.
Left testicle, some radiation to L. inguinal fold, L. gluteal region
“Achy” in quality; 4-8/10 No N/V/F/C or other associated symptoms ED visit 3 days ago. Clean U/A at time. Told
to FU outpatient if pain unresolved.
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Case 3: Patient J.D.Case 3: Patient J.D.
PMH
Noncontributory
Meds
None
Allergies
NKDA
FH/SH
HTN, MI in father
1ppd, social EtOH, bisexual.
PMH
Noncontributory
Meds
None
Allergies
NKDA
FH/SH
HTN, MI in father
1ppd, social EtOH, bisexual.
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Case 3: Patient J.D.Case 3: Patient J.D.
Exam Mild swelling around left testicle Normal lie Tenderness localizes to PS pole
WHAT IS DIFFERENTIAL DIAGNOSIS?
Exam Mild swelling around left testicle Normal lie Tenderness localizes to PS pole
WHAT IS DIFFERENTIAL DIAGNOSIS?
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Case 3: Patient J.D.Case 3: Patient J.D.
Exam Mild swelling around left testicle Normal lie Tenderness localizes to PS pole
Diagnosis: Epididymitis
Exam Mild swelling around left testicle Normal lie Tenderness localizes to PS pole
Diagnosis: Epididymitis
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Case 3: Patient J.D.Case 3: Patient J.D.
Bacterial Epididymitis What to give and why?
Bacterial Epididymitis What to give and why?
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Case 3: Patient J.D.Case 3: Patient J.D.
Bacterial Epididymitis What to give and why? C. trachomatis and N. Gonorrhea most common
in men under 35
Bacterial Epididymitis What to give and why? C. trachomatis and N. Gonorrhea most common
in men under 35
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Case 3: Patient J.D.Case 3: Patient J.D.
Bacterial Epididymitis What to give and why? C. Trachomatis and N. Gonorrhea most
common in men under 35 Doxycycline 100mg PO BID x10 days Ceftriaxone 250mg IM x1
Bacterial Epididymitis What to give and why? C. Trachomatis and N. Gonorrhea most
common in men under 35 Doxycycline 100mg PO BID x10 days Ceftriaxone 250mg IM x1
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Case 3: Patient J.D.Case 3: Patient J.D.
Bacterial Epididymitis What to give and why? C. Trachomatis and N. Gonorrhea most
common in men under 35 Doxycycline 100mg PO BID x10 days Ceftriaxone 250mg IM x1
Coliforms?
Bacterial Epididymitis What to give and why? C. Trachomatis and N. Gonorrhea most
common in men under 35 Doxycycline 100mg PO BID x10 days Ceftriaxone 250mg IM x1
Coliforms?
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Case 3: Patient J.D.Case 3: Patient J.D.
Bacterial Epididymitis What to give and why? C. Trachomatis and N. Gonorrhea most
common in men under 35 Doxycycline 100mg PO BID x10 days Ceftriaxone 250mg IM x1
Coliforms? Quinolones (ofloxacin 300mg PO BID x10
days)
Bacterial Epididymitis What to give and why? C. Trachomatis and N. Gonorrhea most
common in men under 35 Doxycycline 100mg PO BID x10 days Ceftriaxone 250mg IM x1
Coliforms? Quinolones (ofloxacin 300mg PO BID x10
days)
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EpididymitisEpididymitis
Mostly subacute ABX Evaluate recurrent cases for GU malformation
Acute more common in older men, prostatitis Fever, chills, GU symptoms
Mostly subacute ABX Evaluate recurrent cases for GU malformation
Acute more common in older men, prostatitis Fever, chills, GU symptoms
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ReferencesReferences
Edelsberg, JS, Surh, YS. The acute scrotum. Emerg Med Clin North Am 1988; 6:521.
Eyre, RC. Evaluation of the acute scrotum in adult men. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2008.
Fisher, R, Walker, J. The acute paediatric scrotum. Br J Hosp Med 1994; 51:290.
Edelsberg, JS, Surh, YS. The acute scrotum. Emerg Med Clin North Am 1988; 6:521.
Eyre, RC. Evaluation of the acute scrotum in adult men. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2008.
Fisher, R, Walker, J. The acute paediatric scrotum. Br J Hosp Med 1994; 51:290.