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Serious problems include testicular torsion, strangulation of an inguinoscrotal hernia, a testicular tumour and a haematocele, all of which require surgical intervention. A varicocele can cause discomfort—examine in standing position.
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Useful investigations include:
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FBE
urine analysis, M&C
Chlamydia detection test
ultrasound
technetium-99m scan
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TORSION OF THE TESTIS VERSUS EPIDIDYMO-ORCHITIS
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With torsion of the testicle there is pain of sudden onset, described as 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. The testicle soon becomes swollen and acutely tender; however, elevation of the scrotum usually relieves pain in this condition while tending to increase it with a torsion.
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Key facts about torsion of the testis
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The commonest cause of acute scrotal pain in childhood.
Is the diagnosis, until proved otherwise, of a boy or young man with intense inguinal pain and vomiting.
Must be corrected within 4–6 h to prevent gangrene of the testis.
US and a scan is helpful but time usually precludes this and surgical exploration is safest. Beware of delays. Note: Failure to diagnose, leading to loss of the testicle is a common cause of medical litigation.
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ACUTE EPIDIDYMO-ORCHITIS
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<35 yrs: usually STI pathogens—Chlamydia, gonococcus
>35 yrs: urinary tract pathogens—E. coli, other enteric G-negative bacteria
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Ceftriaxone 500 mg IM or IV as a single dose plus
Azithromycin 1 g (o) as a single dose plus either
Doxycycline 100 mg (o) bd for 14 days or another dose of 1 g azithromycin (o) 7 days later
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Associated with urinary infection—all for 2 wks
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Cephalexin 500 mg (o) qid or
Amoxicillin/clavulanate 875/125 mg (o) bd or
Trimethoprim 300 mg (o) daily or
Norfloxacin 400 mg (o) bd
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If severe: amoxi(ampicillin) IV + gentamicin IV.