Allison Eliscu, MD, FAAP

Rev. Aug 2012

 True Urologic Emergency
 Occurs in 1/4000 males
 Typically <25 years old (mostly 12-18yo)
 92-96% with no prior trauma or recent
intense activity
 50% with prior transient torsion/detorsion
 Usually caused by bell-clapper deformity
 Anomaly whereby testicle is not fixed to scrotum
Twisting of testicle around spermatic
cord
↓
Venous drainage hindered
↓
Venous pressure rises
↓
Venous pressure equalizes arterial
pressure
Note the horizontal lie, elevation,
↓ of the affected testicle
and edema

Compromised arterial flow

↓
Testicular ischemia
This slide best viewed in slide show format
 Acute onset of testicular pain
 Pain is severe and constant
 May be associated with recent trauma or
vigorous activity
 Associated Sxs:
 Nausea/vomiting (20-30%)
 Abdominal pain (20-30%)
 Fever (16%)
 Urinary frequency (4%)
 Unilateral swelling
 Erythema or darkening of testicle
 Loss of rugae on affected side
 Elevated testicle
 Horizontal lie (compared to normal vertical lie)
 Pain and tenderness of testicle
 Unilateral loss of cremasteric reflex
 No relief of pain with elevation of testicle
 Negative Prehn Sign
 Clinical suspicion based on history and
physical
 Clinically evident cases require emergent
urology consult
 CBC and UA may help narrow differential
diagnosis but SHOULD NOT DELAY
MANAGEMENT
 Consider
if diagnosis uncertain AND WILL
NOT DELAY MANAGEMENT

 Doppler Ultrasound – Test of Choice

 Check doppler flow to testes
 88-100% sensitivity, 90-100% specificity

 Nuclear Medicine Scintography

 100% sensitivity, specificity 89-97%
 **Takes much longer, more expensive, harder
to read
 Manual detorsion (26-80% success)
 Should be done by urologist
 Patient should be sedated
 Most effective before significant edema present
 Rotate testicle up and away from midline (twds thigh)

 Surgical detorsion with bilateral orchiopexy

 Bilaterally correction required since deformity usually
bilaterally
 Surgical correction required even if manually detorsed
 Testicular
viability related to time since
onset of pain
 Within 6 hours – 90-100% viable
 At 12 hours – 20-50% viable
 At 24 hours – 0-10% viable

 Donot delay surgery b/c of assumed

nonviability based on duration of
symptoms
 Incidence 1/1000 men/year

 Most common 15-30 yo males

 Risk Factors: STDs, UTIs

Twisting of testicle around spermatic
cord
↓
Venous drainage hindered
↓
Venous pressure rises
↓
Venous pressure equalizes arterial
pressure
Note the horizontal lie, elevation,
↓ of the affected testicle
and edema

Compromised arterial flow

↓
Testicular ischemia
This slide best viewed in slide show format
 Bed Rest with scrotal elevation

 NSAIDS for pain control

 Empiric treatment with antibiotics

 Prepubertal – target UTI organisms
 Postpubertal/sexually active – GC/CT

 Excellent prognosis with pain relief in 3

days
 Twistingof small vestigial structure on
anterosuperior aspect of testis
 Most common in 7-13 year old males
 History:
 Acute unilateral pain, erythema, and swelling
 Pain is less severe than torsion

 Physical Exam:
 Tenderfocal mass at superior pole of testicle
 Blue Dot Sign in 21% of cases (necrotic
appendix)
 Normal cremasteric reflex
 May have reactive hydrocele
 Diagnosis:
 Clinical diagnosis
 Can get ultrasound to rule-out torsion of testis
 Ultrasound may be normal or have increased blood flow to
the affected area

 Management:
 Supportive care
 Treat with bed rest, scrotal support, and NSAIDS
 Pain resolves in 5-10 days
 Summary of Testicular Pain
Onset Most
Commonly Pain Cremasteric
Of Affected UA
Location Reflex
Symptoms Age

Early Diffuse
Torsion Acute testicular Negative Negative
Puberty pain

Torsion
Of Localized to Positive
Subacute Prepuberty upper pole Negative
Appendix of testicle (Intact)
Testis
Epididymal Positive
(posterior + Positive
Epididymitis Gradual Adolescent or
superior to (Intact)
testis) Negative
A 13 year old male presents to the emergency room complaining of left testicular
pain which woke him from sleep 2 hours ago and has been getting worse. He denies
fever, recent trauma, or dysuria and he is not sexually active. On exam, you note
significant swelling and bluish discoloration of the left testicle. He won’t let you
touch the testicle since it is so tender and you are unable to elicit a cremasteric reflex
on that side. The most appropriate next step is to:

A. Obtain a urinalysis
B. Obtain a CBC
C. Immediately call a urology consult
D. Start antibiotics for a possible infection
E. Discharge him with NSAIDs for pain and
an athletic supporter for sports
A 13 year old male presents to the emergency room complaining of left testicular
pain which woke him from sleep 2 hours ago and has been getting worse. He denies
fever, recent trauma, or dysuria and he is not sexually active. On exam, you note
significant swelling and bluish discoloration of the left testicle. He won’t let you
touch the testicle since it is so tender and you are unable to elicit a cremasteric reflex
on that side. The most appropriate next step is to:

 Obtain a urinalysis
 Obtain a CBC
 Immediately call a urology consult
 Start antibiotics for a possible infection
 Discharge him with NSAIDs for pain and
an athletic supporter for sports
 Answer: C. This patient has testicular torsion
until proven otherwise. Acute onset of pain with
significant swelling, discoloration, and tenderness
along with loss of cremasteric reflex is most
consistent with torsion. Urology should be
contacted immediately. Since this is an obvious
case of torsion, the urologist may defer an
ultrasound and take him immediately to the
operating room to detorse the testicle.
Remember, with torsion, time is of the essence.
A 15 year old male presents to the emergency room complaining of
acute onset testicular pain. You immediately think of testicular torsion
as a possible etiology. Which of the following examination signs is
most consistent with testicular torsion?

A. Minimal swelling of affected testicle

B. Loss of cremasteric reflex on affected
side
C. Mass resembling a bag of worms above
the affected testicle
D. Some relief of pain with elevation of the
affected testicle
E. Vertical lying testicle
F. Both B & D
A 15 year old male presents to the emergency room complaining of
acute onset testicular pain. You immediately think of testicular torsion
as a possible etiology. Which of the following examination signs is
most consistent with testicular torsion?

A. Minimal swelling of affected testicle

B. Loss of cremasteric reflex on affected
side
C. Mass resembling a bag of worms above
the affected testicle
D. Some relief of pain with elevation of the
affected testicle
E. Vertical lying testicle
F. Both B & D
 Answer: B. Testicular torsion is a urological emergency
and must be recognized and managed surgically
immediately. Any delay in diagnosis or management
increases the risk of testicular necrosis. Signs of torsion
include unilateral testicular swelling, bluish discoloration,
and elevation of the affected testicle. Affected testicles
may also lie in a horizontal position (compared to a normal
vertical position). Elevating the testicle does not relieve
any of the pain (Prehn’s Sign negative); this is compared to
patients with epididymitis in whom there is some pain relief
with elevation of the affected testicle (positive Prehn’s
sign). Loss of cremasteric reflex is one of the most
sensitive indicators of torsion. A cremasteric reflex is
elicited by stroking the upper thigh and watching the
ipsilateral testis. The reflex is intact if the ipsilateral testis
elevates. The mass resembling a bag of worms in the
spermatic cord (superior to the testicle) is consistent with a
varicocele, caused by dilation of the pampiniform plexus. It
is a fairly common finding in adolescent males and tends to
be asymptomatic.
An 18 year old male presents to the office with testicular pain for the
past 2 days which has been getting worse. He has no past medical
history and reports mild dysuria but no fever, discharge, nausea,
vomiting, or abdominal pain. He also denies recent trauma. He is
sexually active with multiple female partners and uses condoms most
of the time. On exam, you note mild swelling of the left testicle, with
no discoloration. Pain is localized to the posterior aspect of the left
testicle but is relieved with elevation of the testicle and cremasteric
reflex is intact. Which of the following is the most likely etiology for
his pain?

 A. Chlamydia
 B. Testicular torsion
 C. Testicular tumor
 D. Urinary tract infection
 E. Torsion of the appendix testis
An 18 year old male presents to the office with testicular pain for the
past 2 days which has been getting worse. He has no past medical
history and reports mild dysuria but no fever, discharge, nausea,
vomiting, or abdominal pain. He also denies recent trauma. He is
sexually active with multiple female partners and uses condoms most
of the time. On exam, you note mild swelling of the left testicle, with
no discoloration. Pain is localized to the posterior aspect of the left
testicle but is relieved with elevation of the testicle and cremasteric
reflex is intact. Which of the following is the most likely etiology for
his pain?

 A. Chlamydia
 B. Testicular torsion
 C. Testicular tumor
 D. Urinary tract infection
 E. Torsion of the appendix testis
 Answer: A. This patient has epididymitis which, in
sexually active males, is most often caused by Chlamydia.
Torsion presents with more acute and more diffuse pain
which is not relieved by elevation (Prehn’s sign negative).
Patients with torsion usually have unilateral swelling, may
have unilateral loss of cremasteric reflex, and may have a
bluish discoloration, be elevated above the contralateral
testis, and lie horizontally (compared to the normal vertical
lie). Dysuria is also not very common in patients with
torsion. Torsion is a urological emergency and must be
diagnosed and managed immediately. Testicular cancer is
usually nontender and asymptomatic. UTIs tend to present
with dysuria without testicular pain and it is not common
for a male with no past medical history to present with an
initial UTI as a teenager. Torsion of the appendix testis
usually presents with more acute pain which is localized to
the superior pole of the testicle and is not relieved with
elevation. On exam, a small blue dot may be present.
A 20 year old male presents to the emergency room complaining of
testicular pain for the past day. He rates it about 5/10 now. He also
reports tactile fevers and dysuria but denies discharge. His exam is
remarkable for mild swelling of the left testicle and pain localized to
the posterior aspect of the testicle. You suspect epididymitis and send
him for an ultrasound which supports the diagnosis of epididymitis.
Which of the following is the most appropriate next step in
management?

A. Discharge him home on bedreset with NSAIDS

for pain control
B. Give him an ice pack to help with swelling
C. Send a urine specimen for gonorrhea and
chlamydia testing and treat him if the results
are positive
D. Empirically treat him for gonorrhea and
chlamydia with doxycycline and ceftriaxone
A 20 year old male presents to the emergency room complaining of
testicular pain for the past day. He rates it about 5/10 now. He also
reports tactile fevers and dysuria but denies discharge. His exam is
remarkable for mild swelling of the left testicle and pain localized to
the posterior aspect of the testicle. You suspect epididymitis and send
him for an ultrasound which supports the diagnosis of epididymitis.
Which of the following is the most appropriate next step in
management?

A. Discharge him home on bedreset with NSAIDS

for pain control
B. Give him an ice pack to help with swelling
C. Send a urine specimen for gonorrhea and
chlamydia testing and treat him if the results
are positive
D. Empirically treat him for gonorrhea and
chlamydia with doxycycline and ceftriaxone
 Answer: D. Sexually active males with
epididymitis should be empirically treated
for gonorrhea and chlamydia with
ceftriaxone 250mg IM once (coverage for
gonorrhea) and doxycycline 100mg PO
BID for 10 days (coverage for chlamydia).
Bedrest and NSAIDs may be helpful for
pain control but the infection must be
treated before discharge.
 Brenner JS, Ojo A. Causes of Scrotal Pain
in Children and Adolescents. UpToDate
Online. Updated April 2009.
 Gatti JM, Murphy JP. Current Management
of the acute scrotum. Semin Pediatr
Surg. 2007;16:58-63.
 Gatti JM, Murphy JP. Acute Testicular
Disorders. Pediatr Rev. 2008
Jul;29(7):235-41.