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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.
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Radiology as a diagnostic aid
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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.
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At surgery the testicle is untwisted and if viable an orchidopexy is performed. A gangrenous testicle is removed (see FIG. 111.2).
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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.
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Torsion of a testicular appendage
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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).
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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.
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SCROTAL PAIN AT VARIOUS AGES
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Acute epididymo-orchitis
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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.
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Sexually active men should be treated empirically for chlamydial or gonorrhoeal infection:
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use ceftriaxone 500 mg (in 2 mL of 1% lignocaine) IM (or 500 mg IV) as a single dose
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plus
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azithromycin 1 g (o) as a single dose
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plus either
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another dose of 1 g azithromycin a week later, or doxycycline 100 mg bd for 14 days
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Associated with urinary infection:
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trimethoprim 300 mg (o) daily (child 4 mg/kg) for 14 days
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or
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cephalexin 500 mg (child 12.5 mg/kg) (o) 12-hourly for 14 days
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or
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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)
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norfloxacin 400 mg (child 10 mg/kg up to 400 mg) (o) 12-hourly for 14 days
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If severe infection, administer parenteral gentamicin + ampicillin followed by norflaxin.5
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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.
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