Basic Science and Clinical Significance
Testicular torsion is rare above age 30; only 50 cases have been reported in the literature. Epididymo-orchitis is uncommon below age 14.
In testicular torsion (torsion of the spermatic cord), a sudden onset of pain, swelling, and retraction of the testis occurs with the testicle frequently, but not always, found high in the scrotal sac. There may have been recurrent attacks in the past. The Doppler scan may show absence of pulsatile blood flow, and the radionuclide scan will show lack of isotope uptake in the affected testis. Failure to operate within 2 to 4 hours after the onset of pain will result in testicular damage. Recently, immunologic mechanisms have been incriminated in loss of fertility in the contralateral testis following unilateral torsion and partial testicular infarction or ischemia. Therapy requires correction of the torsion and bilateral orchidopexy to prevent recurrence.
Figure 186.1
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Approach to treatment of acute pain (less than 2 hours" duration), tenderness, and swelling of one testicle in a patient under age 25.
Strategy 1: All patients with painful, tender testicular swelling are explored. Fifty percent will have torsion and 50% will have epididymo-orchitis, torsion of an appendix, or a rare testicular tumor.
Strategy 2: Do scan prior to exploration. Explore only those with a "cold" scan. (A) Such an approach will miss up to 4% of cases of torsion. False positives leading to exploration because of a "cold" scan are hydroceles and incarcerated hernias. The latter also require surgery. This strategy reduces the number of unnecessary explorations. Since the false negative rate is 0 to 4% for detection of torsion, failure to explore all cases as soon as possible may lead to misdiagnosis in as many as 4% of patients presenting within 2 to 4 hours with severe pain in one testis due to torsion. The chief cause of loss of testicular function is delay by the patient or physician beyond 4 hours before considering scans or surgery. This accounts for 20% of salvageable testes being lost.
shows the alternative approaches to management. Some surgeons refuse to rely on radionuclide scans and immediately explore the scrotal sac of all young men presenting with a painful, tender scrotal swelling. Such an approach may lead to nearly 80 to 90% testicular salvage but unnecessary surgery for 50% of those operated on. Use of scans and new computer-diagnostic programs may allow more selectivity for surgical exploration, but the selective approach to a painful, tender scrotal mass is still controversial, since up to 4% of salvageable testes may be missed.
In epididymo-orchitis, dysuria, frequency, suprapubic, perineal, and penile discomfort may precede testicular pain and swelling. The urine may be normal or show pyuria (48%). The epididymis alone or both the testis and epididymis may be swollen and tender. Localized focal epididymal tenderness may occur. Fever and chills (35%) can occur, and the onset may be acute (51%) or insidious. The causes are infection with sexually transmitted organisms such as the gonococcus or Chlamydia trachomatis, both usually responsive to doxycycline. Coliform bacteria may also be causative and are most common in men above age 35. Recurrent attacks can occur.
Testicular abscess can complicate epididymo-orchitis or torsion and requires surgical drainage. It can be suspected from the radionuclide scan and a prolonged course in a patient presenting with the symptoms and signs of epididymo-orchitis.
Torsion of a testicular or epididymal appendix is rare after age 18 and is most common before puberty. Intense pain occurs at the upper pole of the involved testis and a firm, tender 0.5 to 1.0 cm nodule can be felt. The ischemic appendix is purple and, when viewed through the scrotum, produces a "blue dot" sign. Once diagnosed, this disorder has been successfully managed by nonoperative means. In 15% of patients surgery has been required because of persistent pain. A reactive hydrocele, scrotal edema, redness, and testicular and epididymal swelling may develop and make accurate diagnosis impossible without surgery. The major risk is in missing a case of testicular torsion, since torsion of a testicular appendix will usually resolve spontaneously.
Testicular blunt trauma may cause hematoma and contusion, rupture of the testis, or secondary torsion and infarction. Acute scrotal swelling from blunt trauma should be studied by radionuclide angiography and explored for rupture or torsion.
Thirty percent of patients with testicular tumors present with testicular pain, tenderness, and swelling. This is most common with teratomas, but also occurs with seminomas and embryonal carcinomas. Radionuclide scans may be "hot" or show a halo effect similar to that seen with an abscess or a missed torsion. Surgical removal, radiotherapy, and chemotherapy are required.
Viral orchitis may occur with mumps, with salivary gland involvement, and with rubella and coxsackie viral infections. Orchids also occurs with chickenpox, some echovirus infections, dengue, and lymphocytic choriomeningitis. Analgesics and scrotal support are required for symptomatic relief until the testicular pain and tenderness resolve in 1 to 8 weeks.
A small number of patients develop testicular pain within months or years after vasectomy. In some patients, postvasectomy pain is associated with a tender sperm granuloma at the vasectomy site. In others, it is associated with epididymal swelling and tenderness. These pains are increased by ejaculation and can be relieved by vasovasostomy, which restores fertility and reduces the high back-pressure in the vas and epididymis. Excision of painful sperm granulomas at the vasectomy site brings relief without restoring fertility to patients with painful vasectomy site granulomas.
A number of patients explored for testicular pain and tenderness have apparently normal-appearing testes. The cause of their pain and tenderness remains undetermined, but such cases are found in most surgical series.
Ureterolithiasis may present with hematuria, flank and lower abdominal pain, testicular pain, and a positive intravenous pyelogram. Microscopic hematuria is more common than gross hematuria. Such stones usually pass down the ureter and out in the urine, since testicular pain occurs with stones in the lower ureter.
Prostatitis causes urinary frequency, urgency, penile discomfort, dysuria, and perineal and testicular aching as well as lower abdominal pain. The diagnosis can be made by examination of the first ounce of a voided early morning urine or by massage of the prostate to obtain prostatic fluid. The latter procedure should be avoided in acute prostatitis because of the possibility of producing bacteremia.
Sexual arousal orchialgia may occur after heavy petting in young males. It can be relieved by ejaculation.
A small incarcerated inguinal hernia can cause inguinal and testicular pain by compression of the genital branch of the genitofemoral nerve.
Lyme arthritis follows a tick bite that causes infection with Borrelia burgdorferi, a spirochetal organism. Fever, disabling arthritis, and a distinctive skin rash characterize this disorder, which now occurs in many geographic regions in the United States.
Polyarteritis nodosa very rarely may present with bilateral testicular pain and tenderness as well as testicular induration. Biopsy of a tender indurated area may reveal the diagnosis in 80 to 90% of cases. Only 2 to 18% of patients with this disorder have orchialgia, while biopsies in 36 to 86% of testes in patients with polyarteritis nodosa are abnormal.
Testicular involvement by leukemia causes bilateral enlargement and sometimes pain and tenderness. Six to 36% of leukemic patients have clinical evidence of testicular disease. Hepatic, splenic, and nodal involvement are frequent associated findings. In one series of acute lymphoblastic leukemia, the clinical incidence of testicular involvement was 9%.
The most frequent cause of drug-related testicular pain is mazindol, a drug used to promote weight reduction. In some individuals, it can cause sexual dysfunction and testicular pain which resolve on stopping the drug and recur when the patient is challenged again with the drug.
Cremasteric spasm is of unknown cause. It can be treated by excision of the cremasteric muscle and interruption of the genital branch of the genitofemoral nerve.
Genitofemoral neuralgia causes intermittent or constant inguinal, testicular, and upper medial thigh pain. The pain is increased by walking, stooping, or extension of the hips and is decreased by hip flexion and bed rest. The inguinal canal may be tender. Neuralgia results from nerve entrapment following appendectomy or a hernia repair. Neurectomy of the genitofemoral nerve within the abdomen brings relief. Bilateral involvement may occur. Some cases are idiopathic.
Ilioinguinal neuralgia causes inguinal, testicular, and low back pain. Tenderness occurs medial to the anterosuperior iliac spine. There is limitation of internal rotation of the hips and extension. Hypesthesia may occur in the inguinal area. Nerve blocks may relieve the pain.
Nodular fibrositis causes low back pain relieved by injection of the subcutaneous mobile nodule with lidocaine and methylprednisolone. Rarely, palpation of such a nodule can reproduce testicular pain.
Iliac artery aneurysm may be associated with inguinal and testicular pain and a pulsatile unilateral lower abdominal mass.
Acute appendicitis can cause left- or right-sided testicular and inguinal pain as purulent material spreads to the dependent portions of the inguinal canal. Abdominal pain is associated with the testicular pain. The testicle may be drawn up into the scrotum. This more commonly occurs with torsion or epididymo-orchitis.
Epididymitis and epididymo-orchitis
