John Chambers, 19, arrives at the emergency department with left-sided scrotal pain. Knowing that scrotal or testicular pain can signal a serious condition, you immediately assess him. As you gather more details from the patient, you suspect he has epididymitis, an inflammation of the epididymis—the structure on the posterior surface of the testicle where sperm mature.
But another possibility is testicular torsion, a twisting of the spermatic cord that suspends the testis. This condition, which can easily be mistaken for epididymitis, is an emergency that requires immediate surgery. In this article, I'll discuss how to assess your patient's condition and intervene appropriately.
The spermatic cord is composed of veins, arteries, lymphatic vessels, nerves, and the ductus deferens, which transports sperm from the epididymis to the ejaculatory duct. Because testicular torsion cuts off the testicle's blood supply, delay in diagnosis and treatment can result in loss of a testicle.
Although most cases of testicular torsion occur between ages 12 and 18, the diagnosis should be considered in any patient age 12 to 30 with scrotal pain. Both epididymitis and testicular torsion are painful, but the pain is sudden and severe for testicular torsion, gradual and less severe for epididymitis. A focused history and physical exam are key to distinguishing between the two disorders (see Can you tell the difference between testicular torsion and epididymitis?).
Testicular torsion: An emergency
Normally, the testes are held in a fixed position in the scrotum by a serous membrane called the tunica vaginalis, which partially surrounds the testes and prevents the spermatic cord from twisting. Alterations in normal anatomy can let torsion occur. In most cases, only one testis is affected; bilateral torsion is possible but rare. Torsion can occur at rest or when the patient is engaged in a physical activity, such as sports.
Torsion threatens the blood supply to the testicle and surrounding scrotal structures. The degree of spermatic cord torsion determines the degree of obstruction. Edema can build from a partially rotated spermatic cord. Complete loss of blood supply occurs as twisting of the spermatic cord continues, causing tissue ischemia and necrosis.
Time is of the essence because the duration and extent of torsion determines the amount of testicular damage. Patients who seek treatment within 6 hours of pain onset have an 80% to 100% chance of saving the testicle; the rate drops markedly after 6 to 8 hours. After 12 hours, the testicle probably can't be saved.
The hallmark of testicular torsion is sudden onset of severe, unilateral testicular and scrotal pain. (Rarely, the pain may develop more gradually.) Pain usually is followed by inguinal or scrotal edema. The patient's scrotal area on the affected side is tender and enlarged. The involved testis may be higher in the scrotum than the unaffected one, reflecting the twisting and shortening of the spermatic cord. However, this classic physical finding may be masked by edema. Up to 41% of patients report a history of similar pain and swelling that resolved spontaneously, called intermittent torsion and detorsion.
A useful but imperfect sign in differentiating between testicular torsion and epididymitis is the cremasteric reflex, the retraction of the scrotum and testicle as the skin on the same side of the inner thigh is lightly stroked. Because of nerve compression when the testicle twists on its spermatic cord, this reflex is almost always absent in testicular torsion, but present in epididymitis.
About one-third of patients also experience gastrointestinal symptoms, such as abdominal pain, nausea, and vomiting, possibly related to the severe pain. Some patients feel light-headed and faint because of severe pain. Fever and urinary symptoms (such as dysuria) usually are absent.
Diagnosis is based on patient history and clinical examination. Imaging studies such as ultrasound may be ordered to differentiate torsion from other conditions. Color Doppler ultrasound is the study of choice because it's specific, rapid, and usually more practical than radioisotope scans. The Doppler study can show arterial blood flow to the testis and provide information about scrotal anatomy. Ultrasound also identifies or rules out other causes of testicular pain, such as a tumor. In some cases, a radionuclide scan is performed to assess testicular blood flow.
Treating testicular torsion
A patient with testicular torsion needs immediate surgical exploration of the scrotum and bilateral orchiopexy to anchor the testes. While the patient is being prepared for surgery, the health care provider may attempt manual detorsion as a temporary measure.
In the operating room, the surgeon untwists the affected testis and places fixation sutures around both testes to prevent future torsion. The procedure can be done through the scrotum or via an inguinal approach. If the testis can't be salvaged due to necrosis, the surgeon removes it. A prosthetic testicle may be inserted so the scrotum looks and feels normal.
When the patient is discharged, instruct him to seek immediate medical attention if he experiences scrotal or testicular pain or swelling. Reassure him that one functioning testis is enough for normal sexual activity and fertility. Advise him to protect his scrotum when participating in contact sports.
Epididymitis: Pathogens on the loose
Scrotal pain associated with acute epididymitis is usually gradual in nature, with symptoms frequently peaking within 24 hours of onset. In most cases, epididymitis is caused by retrograde passage of infected urine from the prostatic urethra through the ejaculatory ducts and vas deferens to the epididymis. The infection can spread to the testis, a condition called epididymo-orchitis.
Bacteria typically cause epididymitis, with the etiology varying by age. In postpubertal males under 35, epididymitis most often is related to sexually transmitted diseases (STDs) such as chlamydia and gonorrhea. Men over 35 can also develop epididymitis from STDs, but the more likely culprit is coliform bacteria related to obstructive urinary disease. Recent urinary tract infections and transurethral instrumentation (such as a cystoscopy) also are risk factors, especially in older men.
Because epididymitis progresses gradually, the patient may have only lower abdominal, flank, or groin pain, the result of inflammation starting in the vas deferens. As the inflammation descends to the tail of the epididymis, the pain may become more localized to the scrotum. Elevating the scrotum generally helps to relieve the pain. Symptoms of urinary tract irritation, such as voiding frequency or dysuria, may precede or accompany the pain.
Other symptoms may include fever, chills, nausea, and other flulike symptoms. Some patients may have urethral discharge or may experience tenderness in the lower abdomen, groin, and scrotum. This scrotal pain and edema may make assessing the scrotum difficult.
The lab studies ordered usually include:
- urinalysis. Half of patients have pyuria or bacteriuria, suggesting epididymitis, although a negative urinalysis doesn't rule out the condition.
- urine culture. A urine culture can help diagnose epididymitis and identify the causative organism if the urinalysis is positive.
- Gram's stain of urethral discharge, if present. This helps identify STDs.
- complete blood cell count. This may show leukocytosis in the range of 10,000 to 30,000 cells/mm3.
Imaging studies may include color Doppler ultrasound, which can show a thickened, enlarged epididymis. Radionuclide scan tends to show increased or normal testicular perfusion, which helps differentiate epididymitis from testicular torsion.
As soon as the diagnosis is established, administer antibiotic therapy and analgesics as ordered, even if lab results aren't back. Doxycycline or tetracycline typically are prescribed for younger patients with epididymitis due to urethritis; trimethoprim-sulfamethoxazole (Bactrim), levofloxacin, or norfloxacin are usually prescribed for patients over age 35 whose epididymitis is associated with bacteriuria.
Supportive care includes scrotal support and elevation, ice packs to the affected area, sitz baths, and possibly a spermatic cord block to help relieve pain in severe cases.
At discharge, teach the patient about the importance of follow-up care. If appropriate, provide information on STD prevention; the patient's sexual partner or partners also should be treated for STDs.
Epididymitis usually is managed on an outpatient basis unless the patient has intractable pain, sepsis (especially in an immunocompromised patient), a scrotal abscess, or poor response to outpatient therapy during the first 72 hours; or if he needs intravenous fluids because of nausea and vomiting.
The acute inflammatory process should resolve in about 2 weeks, although the epididymis may take a month or more to return to normal size. Remind the patient to limit his activities and to immobilize the scrotum as much as possible. In the acute phase, he should avoid sexual and physical activity or strain, which can aggravate symptoms.
Teach the patient about his antibiotic therapy, including the importance of completing the course as directed.
Helping Mr. Chambers
Mr. Chambers also has scrotal edema and tenderness. He said he had similar pain a couple days ago, but it didn't last long and resolved on its own. This time, however, the pain has been constant since it started 2 hours ago. When you elevate his scrotum, he has more pain. The urinalysis is negative.
Based on his age, history, and signs and symptoms, Mr. Chambers is diagnosed with testicular torsion. A color Doppler ultrasound rules out other causes of his testicular pain. When manual detorsion by the surgeon isn't successful, Mr. Chambers undergoes surgery, and the affected testis is saved. He's discharged home 2 days later after an uneventful recovery. Teach him about his pain medications and to contact his health care provider if he develops scrotal or testicular pain or edema. He should protect his scrotal area when playing contact sports.
By knowing the differences between testicular torsion and epididymitis, you can evaluate your patient's scrotal pain rapidly and accurately, and help him get prompt and effective treatment.