Thank you for joining me
on this discussion of testicular pain
in the section of urology.
Let's go over the anatomy of a testicle briefly.
On the center of the screen
is a typical schematic of a testicle.
Note, highlighted in a green box is a tunica vaginalis.
It’s particularly important when we discuss
torsion of the testicle.
Squiggly line about the left upper quadrant of that picture
is the vas deferens.
And, of course, dead center is the testicle itself.
Now, let's move on to a discussion of testicular torsion.
Testicular torsion involves torsion
of the spermatic cord structures.
As the picture demonstrates,
normal on the left,
twisted or torsed testicle on the right.
As the torsion happens,
the spermatic cord, which produces
the blood supply to the testicle,
is all also compromised.
As a result, there's a risk
of ischemia to the testicle.
This can cause a lot of pain.
The pathophysiology behind
testicular torsion is important.
We recognize that the tunica
vaginalis is not securely attached
to the posterior lateral aspect of the testicle.
Recall another disease process where the attach –
anatomic attachments are important?
That's right. Colonic volvulus.
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.
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.
Additionally, during testicular torsion,
patient may lose their cremasteric reflex.
As a reminder, the cremasteric muscles
are extensions of the internal oblique muscle fibers.
The cremasteric reflex is normally elicited
by touching the inner thigh
and watching if the testicle rises.
With testicular torsion, this reflex is lost.
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.
Routine laboratory values are of little consequence
and are not indicative of testicular torsion.
Frankly, not necessary.
But ultrasounds are useful, specifically duplexes.
Ultrasound duplex assesses
your flow of the spermatic vessels.
And, of course, the lack of spermatic
vessel flow is indicative of torsion
and indicative of high risk for ischemia.
Remember, only obtain an ultrasound
if low suspicion of torsion.
Otherwise, you should rush to the
operating room for surgical exploration.
Every minute counts!
Now, let’s discuss the surgery.
Remember, very importantly,
a delay in the de-torsion
may lead to testicular ischemia.
Therefore, don't proceed to a duplex
unless you have some question or a
suspicion that it's actually not a torsion.
Scrotal fixation is necessary after the de-torsion.
As you can remember, the tunica vaginalis
is inappropriately seated.
And if the testicle is not viable,
you may actually have to remove it.
Now, let's move on to epididymitis.
Epididymitis is also a common cause for testicular pain.
Remember that the epididymitis, as the name implies,
is an inflammation of the epididymis.
Retrograde passage of urine
can occur from the prostatic urethra
to the epididymis
via the ejaculatory ducts and vas deferens.
As a result, epididymitis can occur.
There is some association with
chlamydia and urine organisms
and you should just be
aware of this association.
Physical findings are very similar to testicular torsion.
Unilateral testicular pain,
and a reflexive nausea/vomiting.
Therefore, it's important to have differentiating
factors between torsion and epididymitis.
As you can imagine,
when the testicular –
when the testicle is involved,
it’s pretty difficult to examine the patient.
there can also be a loss of cremasteric reflex.
However, there's generally some
modicum of relief of pain on elevation.
This is called the Prehn’s Sign.
Again, laboratories may not be helpful,
although as a sign of increased inflammation,
there may be elevated white blood cell count.
But don't count on that.
How do we treat epididymitis?
Unlike torsion, which is a surgical emergency,
epididymitis can be treated medically.
Especially if an STD or sexual transmitted disease is
related, particularly in chlamydia or gonorrhea,
you should offer the patient
ceftriaxone and doxycycline.
Otherwise, it's largely supportive care
analgesics and sometimes ice packs can help.
Now, it's time to remind you of some important
clinical pearls and high-yield information.
Remember, elevation of the testicle
relieves pain in epididymitis,
whereas does not in torsion.
Although this is classic teaching,
frankly, it’s impractical in clinical care.
When a patient has testicular pain,
it generally hurts no matter what you do.
And remember, testicular torsion
is a urologic emergency.
Don't wait for additional diagnostic studies
unless you suspect, in fact,
that it's not testicular torsion.
Thank you very much for joining me
on this discussion of testicular pain.