Testicular torsion must be the primary consideration in any male (in any age group) complaining of testicular pain. Pain usually occurs suddenly, is severe, and is felt in the lower abdominal quadrant, the inguinal canal, or the testis. The pain may be constant or intermittent but is not positional because torsion is primarily an ischemic event. Although symptom onset tends to occur after exertion, the testicle also may twist from unilateral cremasteric muscle contraction during sleep. Early in presentation, the affected testicle is firm, tender, elevated, and in a transverse lie compared to the contralateral testicle. The most sensitive finding (99% sensitive) in torsion is the unilateral absence of the cremasteric reflex.
Diagnosis and Differential
In indeterminate cases, color-flow duplex ultrasound and, less commonly, radionuclide imaging may be helpful. In addition, urinalysis is typically ordered, but pyuria does not rule out testicular torsion.
Torsion of the appendages is more common than testicular torsion but is not dangerous because the appendix testis and appendix epididymis have no known function. If the patient is seen early, diagnosis can be supported by the following: pain is most intense near the head of the epididymis or testis; there is an isolated tender nodule; or the pathognomonic blue dot appearance of a cyanotic appendage is illuminated through thin prepubertal scrotal skin. If normal intratesticular blood flow can be demonstrated with color Doppler, immediate surgery is not necessary because most appendages calcify or degenerate over 10 to 14 days and cause no harm. The differential for testicular torsion also includes epididymidis, inguinal hernia, hydrocele, and scrotal hematoma.
Emergency Department Care and Disposition
When the diagnosis is obvious, urologic consultation is indicated for exploration because imaging tests can be too time consuming. Testicular salvage is related to duration of symptoms with excellent salvage rates with < 6 hours of symptoms.
The emergency physician can attempt manual detorsion. Most testes twist in a lateral to medial direction, so detorsion is performed in a medial to lateral direction, similar to the opening of a book. The endpoint for successful detorsion is pain relief; urologic referral is still indicated.
Urology is consulted early in the patient's course even when confirmatory testing is planned. When the diagnosis of testicular torsion cannot be ruled out by diagnostic studies or examination, urologic consultation is indicated.
Epididymitis is characterized by gradual onset of pain due to inflammatory causes. Bacterial infection is the most common, with infecting agents dependent on the patient's age. In patients younger than 40 years, epididymitis is due primarily to sexually transmitted diseases; culture or DNA probe for gonococcus and Chlamydia is indicated in males younger than 40 years even in the absence of urethral discharge. Common urinary pathogens predominate in older men. Epididymitis causes lower abdominal, inguinal canal, scrotal, or testicular ...