Testicular Pain in Adolescent Males

1. Testicular Pain in Adolescent Males Allison Eliscu, MD, FAAP Rev. Aug 2012

2. Testicular Torsion

3. Testicular Torsion – The Basics • True Urologic Emergency • Occurs in 1/4000 males • Typically <25 years old (mostly 12-18yo) • 92-96% with no prior trauma or recent intense activity • 50% with prior transient torsion/detorsion • Usually caused by bell-clapper deformity • Anomaly whereby testicle is not fixed to scrotum

4. Pathogenesis of Testicular Torsion Twisting of testicle around spermatic cord ↓ Venous drainage hindered ↓ Venous pressure rises ↓ Venous pressure equalizes arterial pressure ↓ Compromised arterial flow ↓ Testicular ischemia Note the horizontal lie, elevation, and edema of the affected testicle This slide best viewed in slide show format

5. Symptoms of Torsion • Acute onset of testicular pain • Pain is severe and constant • May be associated with recent trauma or vigorous activity • Associated Sxs: • Nausea/vomiting (20-30%) • Abdominal pain (20-30%) • Fever (16%) • Urinary frequency (4%)

6. Testicular Torsion - Examination Unilateral swelling Erythema or darkening of testicle Loss of rugae on affected side Elevated testicle Horizontal lie (compared to normal vertical lie) Pain and tenderness of testicle Unilateral loss of cremasteric reflex No relief of pain with elevation of testicle Negative Prehn Sign

7. Diagnosis of Testicular Torsion Clinical suspicion based on history and physical Clinically evident cases require emergent urology consult CBC and UA may help narrow differential diagnosis but SHOULD NOT DELAY MANAGEMENT

8. Imaging in the Diagnosis of Torsion • Consider if diagnosis uncertain AND WILL NOT DELAY MANAGEMENT • Doppler Ultrasound – Test of Choice • Check doppler flow to testes • 88-100% sensitivity, 90-100% specificity • Nuclear Medicine Scintography • 100% sensitivity, specificity 89-97% • **Takes much longer, more expensive, harder to read

9. Management of Torsion Manual detorsion (26-80% success) Should be done by urologist Patient should be sedated Most effective before significant edema present Rotate testicle up and away from midline (twds thigh) Surgical detorsion with bilateral orchiopexy Bilaterally correction required since deformity usually bilaterally Surgical correction required even if manually detorsed

10. Prognosis of Torsion Testicular viability related to time since onset of pain Within 6 hours – 90-100% viable At 12 hours – 20-50% viable At 24 hours – 0-10% viable Do not delay surgery b/c of assumed nonviability based on duration of symptoms

11. Epididymitis

12. Epididymitis Epidemiology Incidence 1/1000 men/year Most common 15-30 yo males Risk Factors: STDs, UTIs

13. Pathogenesis of Testicular Torsion Twisting of testicle around spermatic cord ↓ Venous drainage hindered ↓ Venous pressure rises ↓ Venous pressure equalizes arterial pressure ↓ Compromised arterial flow ↓ Testicular ischemia Note the horizontal lie, elevation, and edema of the affected testicle This slide best viewed in slide show format

14. Management of Epididymitis Bed Rest with scrotal elevation NSAIDS for pain control Empiric treatment with antibiotics Prepubertal – target UTI organisms Postpubertal/sexually active – GC/CT Excellent prognosis with pain relief in 3 days

15. Torsion of Appendix Testis

16. Torsion of Appendix Testis Twisting of small vestigial structure on anterosuperior aspect of testis Most common in 7-13 year old males

17. Presentation of Torsed Appendix Testis • History: • Acute unilateral pain, erythema, and swelling • Pain is less severe than torsion • Physical Exam: • Tender focal mass at superior pole of testicle • Blue Dot Sign in 21% of cases (necrotic appendix) • Normal cremasteric reflex • May have reactive hydrocele

18. Diagnosis and Manaagement of Torsed Appendix Testis • Diagnosis: • Clinical diagnosis • Can get ultrasound to rule-out torsion of testis • Ultrasound may be normal or have increased blood flow to the affected area • Management: • Supportive care • Treat with bed rest, scrotal support, and NSAIDS • Pain resolves in 5-10 days

19. Summary of Testicular Pain

20. A 13 year old male presents to the emergency room complaining of left testicular pain which woke him from sleep 2 hours ago and has been getting worse. He denies fever, recent trauma, or dysuria and he is not sexually active. On exam, you note significant swelling and bluish discoloration of the left testicle. He won’t let you touch the testicle since it is so tender and you are unable to elicit a cremasteric reflex on that side. The most appropriate next step is to: • Obtain a urinalysis • Obtain a CBC • Immediately call a urology consult • Start antibiotics for a possible infection • Discharge him with NSAIDs for pain and an athletic supporter for sports

21. A 13 year old male presents to the emergency room complaining of left testicular pain which woke him from sleep 2 hours ago and has been getting worse. He denies fever, recent trauma, or dysuria and he is not sexually active. On exam, you note significant swelling and bluish discoloration of the left testicle. He won’t let you touch the testicle since it is so tender and you are unable to elicit a cremasteric reflex on that side. The most appropriate next step is to: • Obtain a urinalysis • Obtain a CBC • Immediately call a urology consult • Start antibiotics for a possible infection • Discharge him with NSAIDs for pain and an athletic supporter for sports

22. Answer: C. This patient has testicular torsion until proven otherwise. Acute onset of pain with significant swelling, discoloration, and tenderness along with loss of cremasteric reflex is most consistent with torsion. Urology should be contacted immediately. Since this is an obvious case of torsion, the urologist may defer an ultrasound and take him immediately to the operating room to detorse the testicle. Remember, with torsion, time is of the essence.

23. A 15 year old male presents to the emergency room complaining of acute onset testicular pain. You immediately think of testicular torsion as a possible etiology. Which of the following examination signs is most consistent with testicular torsion? • Minimal swelling of affected testicle • Loss of cremasteric reflex on affected side • Mass resembling a bag of worms above the affected testicle • Some relief of pain with elevation of the affected testicle • Vertical lying testicle • Both B & D

24. A 15 year old male presents to the emergency room complaining of acute onset testicular pain. You immediately think of testicular torsion as a possible etiology. Which of the following examination signs is most consistent with testicular torsion? • Minimal swelling of affected testicle • Loss of cremasteric reflex on affected side • Mass resembling a bag of worms above the affected testicle • Some relief of pain with elevation of the affected testicle • Vertical lying testicle • Both B & D

25. Answer: B. Testicular torsion is a urological emergency and must be recognized and managed surgically immediately. Any delay in diagnosis or management increases the risk of testicular necrosis. Signs of torsion include unilateral testicular swelling, bluish discoloration, and elevation of the affected testicle. Affected testicles may also lie in a horizontal position (compared to a normal vertical position). Elevating the testicle does not relieve any of the pain (Prehn’s Sign negative); this is compared to patients with epididymitis in whom there is some pain relief with elevation of the affected testicle (positive Prehn’s sign). Loss of cremasteric reflex is one of the most sensitive indicators of torsion. A cremasteric reflex is elicited by stroking the upper thigh and watching the ipsilateral testis. The reflex is intact if the ipsilateral testis elevates. The mass resembling a bag of worms in the spermatic cord (superior to the testicle) is consistent with a varicocele, caused by dilation of the pampiniform plexus. It is a fairly common finding in adolescent males and tends to be asymptomatic.

26. An 18 year old male presents to the office with testicular pain for the past 2 days which has been getting worse. He has no past medical history and reports mild dysuria but no fever, discharge, nausea, vomiting, or abdominal pain. He also denies recent trauma. He is sexually active with multiple female partners and uses condoms most of the time. On exam, you note mild swelling of the left testicle, with no discoloration. Pain is localized to the posterior aspect of the left testicle but is relieved with elevation of the testicle and cremasteric reflex is intact. Which of the following is the most likely etiology for his pain? • A. Chlamydia • B. Testicular torsion • C. Testicular tumor • D. Urinary tract infection • E. Torsion of the appendix testis

27. An 18 year old male presents to the office with testicular pain for the past 2 days which has been getting worse. He has no past medical history and reports mild dysuria but no fever, discharge, nausea, vomiting, or abdominal pain. He also denies recent trauma. He is sexually active with multiple female partners and uses condoms most of the time. On exam, you note mild swelling of the left testicle, with no discoloration. Pain is localized to the posterior aspect of the left testicle but is relieved with elevation of the testicle and cremasteric reflex is intact. Which of the following is the most likely etiology for his pain? • A. Chlamydia • B. Testicular torsion • C. Testicular tumor • D. Urinary tract infection • E. Torsion of the appendix testis

28. Answer: A. This patient has epididymitis which, in sexually active males, is most often caused by Chlamydia. Torsion presents with more acute and more diffuse pain which is not relieved by elevation (Prehn’s sign negative). Patients with torsion usually have unilateral swelling, may have unilateral loss of cremasteric reflex, and may have a bluish discoloration, be elevated above the contralateral testis, and lie horizontally (compared to the normal vertical lie). Dysuria is also not very common in patients with torsion. Torsion is a urological emergency and must be diagnosed and managed immediately. Testicular cancer is usually nontender and asymptomatic. UTIs tend to present with dysuria without testicular pain and it is not common for a male with no past medical history to present with an initial UTI as a teenager. Torsion of the appendix testis usually presents with more acute pain which is localized to the superior pole of the testicle and is not relieved with elevation. On exam, a small blue dot may be present.

29. A 20 year old male presents to the emergency room complaining of testicular pain for the past day. He rates it about 5/10 now. He also reports tactile fevers and dysuria but denies discharge. His exam is remarkable for mild swelling of the left testicle and pain localized to the posterior aspect of the testicle. You suspect epididymitis and send him for an ultrasound which supports the diagnosis of epididymitis. Which of the following is the most appropriate next step in management? • Discharge him home on bedreset with NSAIDS for pain control • Give him an ice pack to help with swelling • Send a urine specimen for gonorrhea and chlamydia testing and treat him if the results are positive • Empirically treat him for gonorrhea and chlamydia with doxycycline and ceftriaxone

30. A 20 year old male presents to the emergency room complaining of testicular pain for the past day. He rates it about 5/10 now. He also reports tactile fevers and dysuria but denies discharge. His exam is remarkable for mild swelling of the left testicle and pain localized to the posterior aspect of the testicle. You suspect epididymitis and send him for an ultrasound which supports the diagnosis of epididymitis. Which of the following is the most appropriate next step in management? • Discharge him home on bedreset with NSAIDS for pain control • Give him an ice pack to help with swelling • Send a urine specimen for gonorrhea and chlamydia testing and treat him if the results are positive • Empirically treat him for gonorrhea and chlamydia with doxycycline and ceftriaxone

31. Answer: D. Sexually active males with epididymitis should be empirically treated for gonorrhea and chlamydia with ceftriaxone 250mg IM once (coverage for gonorrhea) and doxycycline 100mg PO BID for 10 days (coverage for chlamydia). Bedrest and NSAIDs may be helpful for pain control but the infection must be treated before discharge.

32. Recommended Reading Brenner JS, Ojo A. Causes of Scrotal Pain in Children and Adolescents. UpToDate Online. Updated April 2009. Gatti JM, Murphy JP. Current Management of the acute scrotum. Semin Pediatr Surg. 2007;16:58-63. Gatti JM, Murphy JP. Acute Testicular Disorders. Pediatr Rev. 2008 Jul;29(7):235-41.