Urology Surgery: Testicular Pain

00:01 Thank you for joining me on this discussion of testicular pain in the section of urology.

00:09 Let's go over the anatomy of a testicle briefly.

00:13 On the center of the screen is a typical schematic of a testicle.

00:17 Note, highlighted in a green box is a tunica vaginalis.

00:21 It’s particularly important when we discuss torsion of the testicle.

00:26 Squiggly line about the left upper quadrant of that picture is the vas deferens.

00:30 And, of course, dead center is the testicle itself.

00:34 Now, let's move on to a discussion of testicular torsion.

00:38 Testicular torsion involves torsion of the spermatic cord structures.

00:43 As the picture demonstrates, normal on the left, twisted or torsed testicle on the right.

00:50 As the torsion happens, the spermatic cord, which produces the blood supply to the testicle, is all also compromised.

00:58 As a result, there's a risk of ischemia to the testicle.

01:02 This can cause a lot of pain.

01:04 The pathophysiology behind testicular torsion is important.

01:08 We recognize that the tunica vaginalis is not securely attached to the posterior lateral aspect of the testicle.

01:14 Recall another disease process where the attach – anatomic attachments are important? That's right. Colonic volvulus.

01:22 If the attachment of the tunica vaginalis is too high or insufficient, the spermatic cord is to freely floating and, as a result, can twist.

01:32 What are some physical findings? As you can imagine, there can be severe unilateral testicular pain associated with scrotal swelling and a reflexive nausea or vomiting.

01:42 Additionally, during testicular torsion, patient may lose their cremasteric reflex.

01:48 As a reminder, the cremasteric muscles are extensions of the internal oblique muscle fibers.

01:54 The cremasteric reflex is normally elicited by touching the inner thigh and watching if the testicle rises.

02:01 With testicular torsion, this reflex is lost.

02:04 Additionally, as a major differentiating point between testicular torsion and epididymitis, there's usually no relief of pain with the elevation of the testicle in torsion.

02:16 Routine laboratory values are of little consequence and are not indicative of testicular torsion.

02:22 Frankly, not necessary.

02:26 But ultrasounds are useful, specifically duplexes.

02:31 Ultrasound duplex assesses your flow of the spermatic vessels.

02:35 And, of course, the lack of spermatic vessel flow is indicative of torsion and indicative of high risk for ischemia.

02:42 Remember, only obtain an ultrasound if low suspicion of torsion.

02:46 Otherwise, you should rush to the operating room for surgical exploration.

02:50 Every minute counts! Now, let’s discuss the surgery.

02:54 Remember, very importantly, a delay in the de-torsion may lead to testicular ischemia.

03:00 Therefore, don't proceed to a duplex unless you have some question or a suspicion that it's actually not a torsion.

03:06 Scrotal fixation is necessary after the de-torsion.

03:10 As you can remember, the tunica vaginalis is inappropriately seated.

03:14 And if the testicle is not viable, you may actually have to remove it.

03:19 Now, let's move on to epididymitis.

03:22 Epididymitis is also a common cause for testicular pain.

03:26 Remember that the epididymitis, as the name implies, is an inflammation of the epididymis.

03:32 Retrograde passage of urine can occur from the prostatic urethra to the epididymis via the ejaculatory ducts and vas deferens.

03:42 As a result, epididymitis can occur.

03:45 There is some association with chlamydia and urine organisms and you should just be aware of this association.

03:53 Physical findings are very similar to testicular torsion.

03:57 Unilateral testicular pain, scrotal swelling and a reflexive nausea/vomiting.

04:02 Therefore, it's important to have differentiating factors between torsion and epididymitis.

04:08 As you can imagine, when the testicular – when the testicle is involved, it’s pretty difficult to examine the patient.

04:15 With epididymitis, there can also be a loss of cremasteric reflex.

04:20 However, there's generally some modicum of relief of pain on elevation.

04:24 This is called the Prehn’s Sign.

04:26 Again, laboratories may not be helpful, although as a sign of increased inflammation, there may be elevated white blood cell count.

04:33 But don't count on that.

04:35 How do we treat epididymitis? Unlike torsion, which is a surgical emergency, epididymitis can be treated medically.

04:42 Especially if an STD or sexual transmitted disease is related, particularly in chlamydia or gonorrhea, you should offer the patient ceftriaxone and doxycycline.

04:51 Otherwise, it's largely supportive care with non-steroidals, analgesics and sometimes ice packs can help.

04:58 Now, it's time to remind you of some important clinical pearls and high-yield information.

05:03 Remember, elevation of the testicle relieves pain in epididymitis, whereas does not in torsion.

05:09 Although this is classic teaching, frankly, it’s impractical in clinical care.

05:13 When a patient has testicular pain, it generally hurts no matter what you do.

05:17 And remember, testicular torsion is a urologic emergency.

05:22 Don't wait for additional diagnostic studies unless you suspect, in fact, that it's not testicular torsion.

05:30 Thank you very much for joining me on this discussion of testicular pain.