With torsion of the testicle there is pain of sudden onset, described as a severe, aching, sickening pain in the groin that may be accompanied by nausea and vomiting. With epididymo-orchitis the attack usually begins with malaise and fever and is often associated with a urinary infection. The testicle soon becomes swollen and acutely tender; however, elevation and support of the scrotum usually relieves pain in this condition (Prehn sign) while tending to increase it with a torsion. A comparison of the clinical presentations is given in TABLE 111.2.
Table 111.2Clinical presentations of torsion of testis and acute epididymo-orchitis ||Download (.pdf) Table 111.2 Clinical presentations of torsion of testis and acute epididymo-orchitis
| ||Torsion of testis ||Epididymo-orchitis |
|Typical age ||Early teens, average range 5–15 years ||Young adults |
| || ||Elderly |
|Onset ||Usually sudden but can be gradual ||Gradual |
|Severity of pain ||Very severe ||Moderate |
|Associated symptoms ||Vomiting ||Fever |
| ||Groin pain ||± Dysuria |
| ||Possibly abdominal pain || |
|Examination of scrotum ||Very tender and red ||Swollen, tender and red; can be tender on rectal examination |
| ||Testis high and transverse ||Possibly an acute hydrocele |
| ||Scrotal oedema || |
| ||Possibly an acute hydrocele || |
|Effect of gentle scrotal elevation ||No change to pain or worse pain ||Relief of pain |
|Investigations ||Technetium-99m scan (if available, time permits and diagnosis doubtful) ||Leucocytosis |
| || ||Possibly pyobacteria of urine |
Radiology as a diagnostic aid
Ultrasound, particularly colour Doppler, is useful in distinguishing a cystic scrotal lump (such as a hydrocele) from a solid tumour. Its use to distinguish between a torsion and epididymo-orchitis is controversial as it cannot reliably detect changes that are diagnostic of early torsion. Since the investigation can involve unnecessary delay in treatment it is generally not recommended. A technetium-99m scan can differentiate between the two conditions: in torsion the testis is avascular while it is hyperaemic in epididymo-orchitis.
At surgery the testicle is untwisted and if viable an orchidopexy is performed. A gangrenous testicle is removed (see FIG. 111.2).
Torsion of the testis resulting in gangrene after 12 hours from onset of pains. The testis was excised and the other normal testis ‘anchored’
Many testicles are lost because of inappropriate delays with referral for an ultrasound. The patient should be referred immediately to a surgeon or surgical centre. Teenage boys presenting with acute right iliac fossa pain, nausea and vomiting are sometimes misdiagnosed as having acute appendicitis.
Torsion of a testicular appendage
Torsion of one of the testicular appendages (most commonly the hydatid of Morgagni) accounts for 60% of cases of acute scrotal pain in children1 (torsion of the testis accounts for 30%, and epididymo-orchitis, idiopathic and other causes comprise the remaining 10%). Vestigial remnants to the testis or the epididymis are present in 90% of the male population.1 Torsion of a testicular appendage has a similar presentation to that of torsion of the testis but is less severe (see FIG. 111.1).
Torsion of a testicular appendage can be diagnosed by the appearance of a dark blue nodule at the upper pole of the testis called the ‘blue dot sign’(provided that it is not masked by an associated hydrocele).3 Surgical exploration may be needed to distinguish this from torsion of the testis.
SCROTAL PAIN AT VARIOUS AGES
Apart from mumps, acute epididymo-orchitis is usually caused by sexually transmitted pathogens, notably Chlamydia trachomatis (in particular), Mycoplasma genitalium and Gonococcus, in sexually active young males and by urinary tract pathogens in older males. In older men, it usually follows urinary tract obstruction and infection or instrumentation of the lower genitourinary tract.
|Blood cell count: ||leucocytosis |
|Urine microscopy and culture: ||pyuria, bacteria and possibly Escherichia coli |
| ||a sterile culture suggests the possibility of a chlamydial or gonorrhoeal infection4 |
|NAAT/PCR: ||Chlamydia, Gonococcus, Mycoplasm genitalium |
|Swabs of discharge: ||Gonococcus (in particular) |
|Ultrasound: ||can differentiate a swollen epididymis from a testicular tumour |
Sexually active men should be treated empirically for chlamydial or gonorrhoeal infection:
use ceftriaxone 500 mg (in 2 mL of 1% lignocaine) IM (or 500 mg IV) as a single dose
azithromycin 1 g (o) as a single dose
another dose of 1 g azithromycin a week later, or doxycycline 100 mg bd for 14 days
Associated with urinary infection:
trimethoprim 300 mg (o) daily (child 4 mg/kg) for 14 days
cephalexin 500 mg (child 12.5 mg/kg) (o) 12-hourly for 14 days
amoxycillin/clavulanate 500/125 mg (child 12.5/3.1 mg/kg) (o) 12-hourly for 14 days or (if resistance to above suspected or proven)
norfloxacin 400 mg (child 10 mg/kg up to 400 mg) (o) 12-hourly for 14 days
If severe infection, administer parenteral gentamicin + ampicillin followed by norflaxin.5
Acute orchitis is invariably due to mumps and occurs during late adolescence. Mumps orchitis has become relatively rare with vaccination. It is usually unilateral (see FIG. 111.3) but may be bilateral.
Mumps orchitis with a swollen, tender testicle