Protecting the Family Jewels:

Testicular Emergencies
Alberto S. Carranza, M.D.
Baylor College of Medicine/Childrens Hosp of San Antonio

Disclaimer

"This presentation contains scenes that some viewers

may find disturbingLOL
"Viewer discretion advised.OMG
"Intended for mature audiences only. Hopefully
"Contains scenes of a sexual nature." Unintended
"This presentation contains strong language. Not
really

Anatomy

Testicles suspend in
scrotum via spermatic
cord (artery, vein, vas
deferentia) and are
wrapped by tunica
vaginalis

Blood Supply

Abdominal Aorta
Testicular Arteries
Enter Internal Inguinal
Canal
Become part
of Spermatic Cord
(artery, vein, vas
deferentia)
Supply
Testicles

Differential Diagnosis:
Testicular Pain

Testicular Torsion*
Epididymitis*
Torsion testicular
appendage*

Traumatic Rupture/
Hematoma*

Hydrocele

Varicocele
Spermatocele
Hernia
Idiopathic Infarction
Orchitis
HSP

Testicular Pain:
Differential Diagnosis

Testicular Torsion

Testicular Torsion:
Definition

Acute vascular event

where spermatic cord
twists on its axis leading
to ischemia, infarction
and loss of testicle

Testicular Torsion:
Epidemiology

Average age: (unlucky #)13 years old

1:4000 Malesof course
Left testicle more frequent
2/3 Medial rotation: 1/3 Lateral Rotation

Testicular Torsion:
Etiologies

Bell Clapper Deformity

Pubertal Changes: Increased Testosterone
Increased Testicular size
movement along axis

Cryptoorchidism
External Factors

Increased

Cremasteric response:
Winter, Physical Activity (Weight lifting)

Testicular Torsion:
Pathophysiology

Intravaginal*

More common

Pubescent

Occurs at level
external ring

Horny teenager
wants to be
intravaginal

Extravaginal

Less common

Perinatal

Bell Clapper
Deformity

Baby to be born
and wants to be
extravaginal

Testicular Torsion:
Pathophysiology

Text

Testicular Torsion:
History

Acute onset testicular

pain, constant

Acute onset testicular

swelling/discoloration

Acute Abdominal pain

Acute Vomiting

Testicular Torsion:
Physical Exam

Exquisite tenderness to palpation

High riding, discolored testicle
Transverse orientation
Absent Cremasteric Reflex
Negative Prehn sign: Elevate scrotum, no
pain relief (vs Epididymitis)

Testicular Torsion:
Workup

Call Urology Stat-correct answer on

boards*

NPO
PIV
Doppler Ultrasound: Limitations include

slow to obtain, operator dependent. May

be 88% sensitive if adequate technique.

Testicular Torsion:
Workup

Why call Urology

immediately?

<6hrs pain: 100%

surgical success

6-12 hrs pain: 50%

surgical success

12-24 hrs pain: 20%

surgical success

Testicular Torsion:
Normal Sonogram

Homogenous
echotecture

Same as unaffected
testicle

Peak and troughs on

Doppler

Blood flow inside and

outside testicle equal

Testicular Torsion:
Normal Sonogram

Testicular Torsion:
Abnormal Sonogram

Heterogenous
Echotecture*:

Increased testicular and

epididymal size

Hydrocele

Hyperechoic
(hemorrhage)
Hypoechoic(necrosis)

Different than unaffected

testicle*

Thickening Scrotal Skin

Abnormal doppler*: No
peaks and troughs, no
blood flow in testicle,
increased blood flow
outside testicle

Testicular Torsion:
Abnormal Sonogram

Testicular Torsion:
Treatment
Surgical treatment
If no Urologist available for prolonged period of
time, consider attempt Open Book reduction
with patient standing up: Successful 30-80%

R Testicle: Counter Clockwise: 180 degrees

L Testicle: Clockwise: 180 degrees

Testicular Torsion:
Surgery

Orchiopexy: Untwisting
of testicle and fastening
testicle to scrotum via
absorbable sutures

Testicular Torsion:
Prognosis

<6hrs pain: 100% surgical success

6-12 hrs pain: 50% surgical success
12-24 hrs pain: 20% surgical success
24 hrs+: 10% surgical success

Testicular Torsion:
Complications

Loss of Testes
Chronic Testicular Pain secondary to
surgical procedure

Decreased Fertility secondary to:

Ischemia and Re-perfusion Injury
Antisperm Antibody Production

Epididimytis

Epididimytis:
Anatomy

Epididymis is a

coiled tubular
structure located
posterior to
testes that serves
as storage sperm

Epididymitis:
Definition

Inflammation and/or infection of

epididymis.

Acute: <6 weeks

Chronic: >6 weeks

Epididymitis:
Epidemiology

1:1000 males
600,000 medical visits per year
Most common cause intra-scrotal
inflammation

Epididymitis:
Etiology/Pathophysiology

Not entirely known but theories

include:

Retrograde passage of urine

from urethra via ejaculatory
ducts to epididymis

Valsalva may be responsible

for similar mechanism

Infections

Bacterial: E.Coli, Proteus,

Pseudomonas,
Mycoplasma. Only 4%
positive Urine Cultures

Viral: Mumps,
Coxsackivirus

Chlamydia is most
common cause in sexual
active men <35 age

Epididymitis:
History

Gradual onset of
symptoms (days)*
No Nausea or Vomiting

Chills

* Differentiate from
testicular torsion

Pain waxes and wanes*

Important pieces of
information may include
recent UTI, Sexual
Activity, or Surgical
Instrumentation

Scotum not indurated*

Dysuria
Fever

Epididymitis:
Physical Exam

Tenderness to Palpation epididymal head

+ Prehn sign: + relief of pain upon
elevation of testicle

Normal cremasteric reflex

Epididymitis:
Workup

Urinalysis (pyuria 50%)

Urine Culture (low

incidence UTI in
Pediatric cases)

CBC/CRP (rarely
needed) to distinguish
between

Doppler Ultrasound/
Urology consult if
diagnosis is unclear and
you have concerns for
testicular torsion

Gram Stain if Urethral

Discharge

GC/Chlamydia/HIV/RPR
if Sexual Active

Epididymitis:
Sonogram

Normal

Abnormal

Epididymitis:
Prognosis/Complications

Usually self limiting in Pediatric patients and/or easily

treated with antibiotics for bacterial causes. Symptomatic
care includes scrotal elevation to alleviate discomfort,
NSAIDs for pain/anti-inflammatory effect

Pain typically lasts 3 days

Bilateral epididymitis may lead to sterility secondary to

tubular fibrosis

Induration may last weeks to months

May progress to epididymo-orchitis, testicular abscess and
sepsis if not treated adequately

Torsion of Testicular
Appendage

Torsion of Testicular
Appendage: Anatomy
The appendix testis is present in 92% of all
testes.
Usually located at the superior testicular pole
in the groove between the testicle and the
epididymis.

Torsion of Testicular
Appendage: Pathophysiology

Torsion of the appendage leads to ischemia

and infarction.

Necrosis causes pain, inflammation of the

surrounding tunica vaginalis and epididymis.

Torsion of Testicular
Appendage: Epidemiology

Ages 7-14, most common 10 years age

Retrospective studies on pediatric ER visits

for scrotal pain reveal incidence may range

from 46-71%, meaning its the leading cause
of acute scrotum in children.

Torsion of Testicular
Appendage: History

Acute onset pain in hemiscrotum

No nausea or vomiting
No urinary symptoms
No fever

Torsion of Testicular
Appendage: P.E.

Scrotum may appear

normal*

Thickening of scrotal
wall

Tenderness to palpation
upper pole

Reactive hydrocele

Paratesticular nodule
Blue dot sign: 21%
Vertical orientation of
testicles, normal

Enlargement (Apparent)
of head of epididymis (as
when torsion occurs, it
appears to be adjacent
to epididymis)

Torsion of Testicular
Appendage: Workup

CBC and UA (not

usually needed)

Ultrasound

Decreased
echogenicity

If appendage
edematous, it will
appear to be adjacent
to epididymis

Torsion of Testicular
Appendage: Treatment

NSAIDs
Scrotal Support
Surgery usually not indicated, unless
refractory testicular pain

Torsion of Testicular
Appendage: Prognosis

Excellent, long term sequelae usually

nonexistent

Pain usually lasts about 1 week

Necrotic tissue usually reabsorbs. If it
doesnt, may risk abscess

Greatest mortality results from missed

testicular torsion and delay of treatment

Scrotal trauma

Scrotal Trauma
Types
Blunt Trauma
Penetrating Trauma
Avulsion Injuries

Scrotal Trauma
Epidemiology

Most related to: Sports,

MVA, Assaults, Animal
bites

<1% of all traumas,

reason why we dont
know what to do many
times

More common between

10-30 years of age

Scrotal Trauma
History

Testicular pain
Swelling
Bruising
Difficulty voiding
Abdominal and/or pelvic pain
Nausea/Vomiting

Scrotal Trauma
Physical Examination

Important to document

Location of trauma
Ecchymosis
Skin loss
Entry/Exit point
Testicular Location

Cremasteric reflex
Testicular torsion

Scrotal Trauma

hematoma

avulsion, and yes

something else is
missing

Scrotal Trauma
Workup

Urinalysis

CT Abdominal/Pelvis:
eval for testicular
dislocation

Retrograde
urethrography: eval for
urethral injury

Urine culture
Wound Culture
Ultrasound: Eval for
testicular hematoma,
torsion or rupture,
spermatic cord
thrombosis, etc

Scrotal Trauma
Ultrasound

Doppler Ultrasound

Hematoma with
Intact Tunica
Albuginea is the
ONLY finding that
precludes surgical
exploration-all others
shall be explored

Scrotal Trauma
CT
free air penile shaft
testicular dislocation

Scrotal Trauma
Complications

Loss of testicle
Sterility
Infection/Abscess

Fourniers Gangrene:
necrotizing gangrene of
perineum caused by
mixed aerobic and
anaerobic organisms.
Treatment includes
surgical debridement,
broad spectrum
antibiotics, hyperbaric
treatment.

Scrotal Trauma
Treatment

Antibiotics

Field injuries such

as hunting, farming:
Clindamycin and
Nafcillin to cover C.
Tetani infections
Animal bites:
Amoxicillin/Clav for
Pasteurella multocida

Medical/Surgical Care

Supportive: Minor
blunt traumas

Surgical: for
testicular ruptures,
lacerations,
dislocations,
penetrating injuries.

References
Ringdahl E, Teague L. Testicular torsion. Am Fam Physician. Nov 15
2006;74(10):1739-43
Gatti JM, Patrick Murphy J. Current management of the acute
scrotum. Semin Pediatr Surg. Feb 2007;16(1):58-63.
Karmazyn B, Steinberg R, Livne P, Kornreich L, Grozovski S,
Schwarz M, et al. Duplex sonographic findings in children with
torsion of the testicular appendages: overlap with epididymitis
and epididymoorchitis. J Pediatr Surg. Mar 2006;41(3):500-4

Santillanes G, Gausche-Hill M, Lewis RJ. Are antibiotics

necessary for pediatric epididymitis?. Pediatr Emerg Care. Mar
2011;27(3):174-8.
Rakha E, Puls F, Saidul I, Furness P. Torsion of the testicular
appendix: importance of associated acute inflammation. J Clin
Pathol. Aug 2006;59(8):831-4.
King P, Sripathi V. The acute scrotum. Ashcraft KW et al. Pediatric
Surgery. 2005:717-22

Images

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Cest fini
Thank you!