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scrotal pain/mass (testicular pain, testicular torsion)

Etiology: 1) trauma a) testicular laceration b) hematoma c) hematohydrocele 2) testicular torsion 3) torsion of testicular & epididymal appendages 4) epididymitis 5) viral orchitis (mumps) 6) hydrocele, hematocele, varicocele, epididymal cyst, spermatocele 7) testicular cancer 8) renal colic urolithiasis 9) inguinal hernia 10) acute appendicitis 11) distal abdominal aortic aneurysm 13) Henoch-Schonlein purpura 14) Fournier's gangrene Clinical manifestations: 1) torsion of the testicle or testicular appendage a) abrupt onset of pain b) nausea/vomiting, abdominal pain c) pain exacerbated by elevating the testicle onto the pubic symphysis (negative Prehn's sign) d) absence of cremasteric reflex 99& sensitive for testicular torsion [2] 2) epididymitis, incarcerated hernia & viral orchitis present with gradual onset of scrotal pain 3) pain relieved by elevating the testicle onto the pubic symphysis (Prehn's sign +) suggests epididymitis 4) hematuria suggests nephrolithiasis 5) hydrocele, testicular cancer, varicocele & epididymal cyst are generally painless 6) parotitis preceding testicular pain by 1-2 weeks suggest orchitis 7) bowel palpable in scrotum or bowel sounds audible in scrotum suggests inguinal hernia 8) painful swelling & erythema of the scrotum or perineum with signs of necrosis & sepsis suggest Fournier's gangrene Laboratory: 1) complete blood count (CBC) 2) urinalysis, culture & sensitivity 3) tumor markers a) chorionic gonadotropin b) alpha fetoprotein Radiology: 1) flat & upright X-ray of abdomen 2) testicular ultrasound or testicular scintigraphy to demonstrate diminished blood flow with testicular torsion - heterogeneous, hypoechoic testicular mass likely testicular cancer 3) intravenous pyelogram (IVP) 4) renal ultrasound 5) abdominal ultrasound 6) abdominal CT Management: 1) testicular torsion is a surgical emergency a) surgical detorsion must be achieved in 4-6 hours b) after 24 hours, the testicle will be infarcted c) bilateral orchiopexy is indicated to prevent recurrence 2) torsion of testicular appendage a) bed rest, analgesia, scrotal elevation b) surgical exploration is indicated when the diagnosis is uncertain or the pain persists 3) transillumination a) if mass transiluminates 1] it is either a hydrocele or spermatocele 2] generally asymptomatic 3] may cause discomfort is large 4] surgical excision 5] aspiration not useful because the recur 6] ultrasound not necessary b) if mass does not transilluminate 1] ultrasound of mass 2] referral to urology 4) see epididymitis 5) see urinary calculus 6) see varicocele 7) epididymal cyst or hydrocele: aspirate if painful 8) testicular neoplasm: surgery, radiation, chemotherapy 9) see orchitis 10) inguinal hernia: surgery 11) see appendicitis: surgery

Related

cremasteric reflex Prehn's sign scrotum testis

Specific

testicular swelling; testicular mass testicular torsion

General

pain [odyn-] abnormal morphologic structure (malformation) male genital disease

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 398-401
  2. Medical Knowledge Self Assessment Program (MKSAP) 15, 16 American College of Physicians, Philadelphia 2009, 2012 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - Wampler SM, Llanes M. Common scrotal and testicular problems. Prim Care. 2010 Sep;37(3):613-26 PMID: 20705202