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Probability diagnosis

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Trauma including haematoma, haematocele

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Torsion of a testicular appendage

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Varicocele

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Epididymitis

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Post vasectomy

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Serious disorders not to be missed

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Vascular:

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  • testicular torsion

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Infection:

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  • acute epididymo-orchitis/orchitis

  • fulminating necrotising cellulitis (Fournier’s gangrene)

  • psoas abscess

  • tuberculosis

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Cancer:

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  • testicular neoplasm

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Other:

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  • strangulated inguinoscrotal hernia

  • acute hydrocele

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Pitfalls (often missed)

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Referred pain (e.g. spine, ureteric colic, abdominal aorta)

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Rarities:

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  • idiopathic scrotal oedema

  • polyarteritis nodosa

  • filariasis

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Key history

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Determine any pre-existing predisposing factors such as lumps or history of trauma. Check travel history, sexual history.

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Key examination

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  • Examine and contrast both sides of the scrotum, including the inguinal and femoral hernial orifices, the spermatic cord, testis and epididymis

  • Examine the patient standing and supine

  • A painful testis should be elevated gently to determine if the pain improves

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Key investigations

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Useful investigations include:

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  • FBE

  • urine analysis, microscopy and culture

  • Chlamydia detection tests

  • ultrasound

  • technetium-99m scan.

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Diagnostic tips

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  • Torsion of the testis is the most common cause of acute scrotal pain in infancy and childhood.

  • Think of it with lower abdominal pain and/or vomiting.

  • A varicocele can cause testicular discomfort—examine the patient in the standing position.

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Red flags:

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  • sudden onset pain

  • non-reductible hernia

  • erythema of scrotum or perineum

  • systemic vascular symptoms, e.g. hypotension, pallor.

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