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    Approaching Acute Testicular Pain

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    Among the conditions to impact males, disorders of the testicles represent a set of conditions, varying from benign in nature to true emergencies, that can be seen frequently in the outpatient setting, urgent care, and emergency department.

    An important understanding of clinical male anatomy, as well as how conditions manifest, is important to providing good care.

    Conditions impacting the testicles can range from incidental findings that do not cause symptoms to acutely pathologic disorders that require emergent surgical management.

    testicular pain
    By OpenStax College [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

    Testicular Anatomy

    Normal testicular anatomy should be understood to help narrow down the diagnosis. Testicles are usually approximately 3 to 5 cm in size, ovoid shaped, with a smooth surface. One testicle is usually larger than the other and may hang lower.

    The spermatic cord travels down into the testicle and becomes the vas deferens.

    The vascular structures are contained here as well. The testis is covered by the tunica vaginalis. The epididymis is a tightly coiled tubular structure that is palpable at the posterior aspect of the testicle.

    The function of the epididymis is the storage of sperm. The appendix testis is an appendage that is located at the anterosuperior aspect of the testicle.

    Getting a Good History

    Performing a thorough, focused history and physical exam is important to help verify the diagnosis and triage patients who need immediate care. The emergent concerns related to testicular conditions include the dreaded testicular torsion, acute epididymo-orchitis, and Fournier’s gangrene.

    A comprehensive history is an important place to start. The onset, nature, timing, and level of pain should be assessed. Patients with acute onset of severe testicular pain should raise suspicion for testicular torsion.

    Accompanying fever, lower urinary tract symptoms should raise concern for epididymo-orchitis.

    Chronic testicular pain should have varicocele, spermatocele, hydrocele, inguinal hernia and malignancy on the differential.

    Family, social, and past medical history should be assessed. A comprehensive sexual history should be assessed. Patients should be asked if they have risk factors for sexually transmitted diseases.

    The Physical Exam: Acute Testicular Pain

    The testicle exam is important, as it may give the diagnosis. It is important to perform a comprehensive, thorough abdominal and genitourinary exam despite awkwardness or patient discomfort.

    An abdominal exam should be performed to assess for tenderness. The inguinal region should be evaluated for any bulges that may indicate a hernia. This should also be performed during Valsalva.

    Each testicle should be evaluated for appearance, texture, tenderness, and mobility.

    Diffuse swelling, edema, or erythema may indicate Fournier’s gangrene. A unilaterally swollen, high riding testicle can be suggestive of testicular torsion.

    The cremasteric reflex should always be assessed. This can be accomplished by lightly stroking the superior and medial aspect of the bilateral thighs. In a normal healthy testicle, one should observe the testicle on the same side pull up toward the abdomen. An absent cremasteric reflex is testicular torsion until proven otherwise.

    Palpation in the region of pain, however uncomfortable, must be assessed. A diffusely, severely painful testicle should warrant a testicular torsion work up.

    Pain in the posterior aspect of the testicle can indicate epididymitis. Palpating a “bag of worms” may indicate a varicocele. Trans-illumination of the scrotum can help determine if there is fluid in the testicle such as a hydrocele or hematocele.

    Testicular Emergencies

    As discussed previously, when assessing a patient with a testicular complaint, one must always consider testicular torsion, Fournier’s gangrene, and acute epididymo-orchitis due to their high rate of morbidity if not assessed and treated early on.

    Testicular torsion is an acute surgical emergency. This is a condition where the testicle’s blood supply is cut off due to a rotation of the testicle on its’ axis. If not corrected within six to twelve hours, the testicle becomes necrotic and unsalvageable.

    This is usually a very acute onset of severe scrotal pain, diffuse tenderness and swelling. The classic presentation is in an athlete or an adolescent boy who rolled over in bed in the middle of the night.

    The impacted testicle is usually “high riding”. Buzzwords for exams include the “bell clapper deformity”, due to the testicle’s ability to sway.

    In extreme settings, an experienced clinician can try to “open the book” to “detorse” the testicle. This is accomplished by trying to rotate the testicle medial to lateral, much like opening a book.

    Ultrasound is the gold standard for diagnosis of testicular torsion, but ordering an ultrasound should not delay definitive management. The definitive treatment of testicular torsion is surgical. It is a surgical emergency and should be treated as such.

    Fournier’s gangrene, although fairly rare, is important to comment on because of its’ rapid progression and high rate of morbidity and mortality. This is a necrotizing fasciitis of the perineum and scrotum. 

    On exam, the entire genital area is edematous, erythematous. Skin may have bullae and palpable crepitus.

    The diagnosis is usually accompanied by systemic symptoms including fever, tachycardia, and signs of septicemia such as hypotension. The treatment for Fournier’s Gangrene is prompt surgical exploration and debridement in the operating room. It is another urologic surgical emergency.

    Acute Epididymitis

    Acute epididymitis is the number one cause of acute scrotal pain. Patients may describe an aching, dull sensation in the testicle. Pain may be in the inguinal region or in the posterior aspect where the epididymis resides.

    Patients should be questioned about sexual activity and STD testing should be performed when warranted. The most common cause of epididymitis in males under 35 is Gonorrhea and Chlamydia. In older males, the culprit is usually E. Coli or Pseudomonas.

    Symptoms include localized tenderness, fever, lower urinary tract symptoms. Supportive testing includes a urinalysis which may show white blood cells.

    The treatment in males less than 35 should presume gonorrhea or chlamydia as the cause. The first line treatment in this category is one dose of 250 mg intramuscular of ceftriaxone followed by doxycycline 100 mg twice a day for ten days.

    In older patients, treatment can be accomplished with levofloxacin 500 mg daily for ten days or ofloxacin 300 mg twice a day for ten days. Pain control can be accomplished by NSAIDs, scrotal support, and Tylenol.

    An important pearl to help narrow the differential is that epididymitis tends to be gradual in onset, while testicular torsion is much more acute and much more severe.

    Torsion Of The Testicular Appendage

    Another commonly tested etiology of testicle pain is that of torsion of the testicular appendage. This is where the appendix testis rotates.

    This is also more gradual in onset.

    The hallmark of this condition is the “blue dot” sign which is commonly tested. This is a blueish nodule at the upper testicle.

    Additionally, Prehn’s sign is also commonly tested. This is a physical exam test where the clinician elevates the testicles to see if pain is decreased. If pain is decreased, this is considered a positive Prehn’s sign which can be indicative of epididymitis or torsion of the testicular appendix. A negative Prehn’s sign indicates no relief or worsening pain and should point the clinician toward testicular torsion.

    Other Etiologies of Acute Testicular Pain

    Other considerations related to testicular complaints include varicocele, hydrocele, hematocele, and malignancy. These will be covered elsewhere.

    Testicular pain remains a commonly encountered condition among many areas of medicine. Due to their potential for increased morbidity and mortality, testicular torsion, Fournier’s gangrene, and acute epididymo-orchitis must always be considered in the differential.

    Sources:
    Vlasica, Katherine (2016). Epididymitis. 5 minute Clinical Consult.
    Jonathan Green and Michael Hirsh (2016). Testicular Torsion. 5 minute Clinical Consult.

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    Daniel Champigny, PA-C is a 2016 graduate of The Pennsylvania State University. Prior to attending PA school, Dan worked in pre-hospital medicine as an EMT. Currently, he's in primary care/family medicine in rural Pennsylvania and also works in urgent care. He is a certified impact consultant and is passionate about the management and treatment of concussions. Dan additionally has interests in preventive care, evidence based medicine, and teaching. In his spare time, Dan enjoys running and hiking.