Chapter 11

Acute testicular pain represents approximately 0.5% of the complaints presenting to an emergency department each year.1 Causes of acute testicular pain include trauma, epididymitis, orchitis, torsion of the testicular appendage, and hemorrhage; however, testicular torsion is the diagnosis of the greatest concern in the emergency setting.

Previously, most young men who presented to an emergency or urgent care setting with a complaint of acute onset testicular pain were suspected of having testicular torsion.2 Since the 1990s, this misconception has been dispelled and it is now known that the most common etiology of acute testicular pain is epididymitis.2 The evaluation of acute testicular pain still presents a considerable challenge for emergency physicians since fully 50% of young men presenting to an emergency department with testicular torsion have already waited over 6 hours and are well on their way toward losing the torsed testicle.3

The issue of acute testicular pain is further complicated by the high potential for litigation associated with infertility after testicular loss due to torsion or disruption of the testicle from severe trauma. When the diagnosis of testicular torsion is missed, the majority of patients have been incorrectly classified as having epididymitis.4 Despite the fact that the two disease processes would seem to be easily differentiated on the basis of history and physical examination, research and practice have demonstrated this not to be the case.4

The most important concern with testicular torsion is the potential for loss of the testicle or infertility. Other disease processes that may present with scrotal pain include torsion of the testicular appendage, epididymitis, orchitis, testicular trauma, hemorrhage into a testicular mass, and herniation of abdominal contents into the scrotum. High-resolution color Doppler ultrasonography has become widely accepted as the test of choice for evaluating acute scrotal pain, replacing scintigraphy in most institutions.5 While scintigraphy requires less technical skill on the part of the radiologist consulted to evaluate the patient, there are major drawbacks to the technique. Scintigraphy is a time-consuming process that can add an hour or more to the evaluation of a patient who may already be several hours into the testicular torsion process.5 Furthermore, the resultant hyperemia of the scrotal skin during testicular torsion can mask a lack of blood flow to the testicle itself and lead to a misdiagnosis in less experienced hands.6 This nuclear medicine study also provides no information regarding testicular anatomy, a potentially critical issue if pathology other than torsion is present.

A careful history and physical examination are important and have been thought to enable an emergency physician to virtually exclude the diagnosis of testicular torsion without further testing in the majority of cases.3 In practice, historical features of several disease processes can overlap. For example, duration of pain in testicular torsion, epididymitis, orchitis, and torsion of a testicular appendage frequently overlap.7 In up to 20% of cases, testicular torsion is ...

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