Reviewed by Jonathan Loomes-Vrdoljak
Stem 1 of 5
Stephen is a 12 year old male who presented to A&E with an acute onset of severe left sided testicular pain radiating to the abdomen, nausea and vomiting. On examination he is apyrexic with left testicular enlargement.
What is the most likely diagnosis
Stem 2 of 5Given the likely diagnosis what else would you find on examination?
Positive Prehn's sign
Lost cremaster reflex
Stem 3 of 5
What structure is first involved in this pathology?
Genital brach of genitofemoral nerve
Internal spermatic fascia
All the above anatomy is found in the spermatic cord. An easy way to remember this is the Rule of 3:
- 3 arteries: testicular, deferential, cremasteric
- 3 nerves: genital branch of the genitofemoral, cremasteric nerve*, sympathetic nerve fibres
- 3 fascias: external spermatic fascia, cremasteric fascia, internal spermatic fascia
- 3 other things: ductus deferens, pampiniform plexus, lymphatic vessels
During testicular torsion the veins are occluded first. This is because veins have a thinner wall and are easier to occlude versus the thicker, stronger and more elastic arteries. Subsequently this causes decreased venous return, pooling of blood, oedema and arterial compromise resulting in testicular ischemia and necrosis.
Stem 4 of 5Which one of the following would you use to confirm diagnosis?
Urine dip stick
None: Clinical diagnosis
Stem 5 of 5In the absence of any further complications, what is the definitive treatment for this patient?
External manual testicular rotation
If it has self resolved before do nothing as it will do so again
To manage these patients the scrotum is opened and the testis is de-torted. A viable testicle will become a red colour indicating good blood flow and a orchidoplexy is performed (fixation of testicle to the tunica vaginalis).
If the testicle remains pale, dusky or black, although blood flow is restored, necrosis has occurred therefore the damage cannot be repaired and the testicle needs to be removed (orchidectomy)
Most commonly, testicular torsion is caused by the bell-clapper abnormality (intravaginal abnormality where there is a higher insertion point of the tunica vaginalis to the testis causing a lack of fixation of the posterolateral testicle to the scrotum). This is a bilateral abnormality and there is a high risk that the unaffected testicle may also become affected. Consequently, a bilateral orchidopexy is performed prophylactically.
Stem 1 of 5
David is a 16 year old male who has presented to A&E with a gradual onset of severe left sided testicular pain radiating to the abdomen for the past four days. On examination has a swollen, tender, hot and erythematous left scrotum.
What important questions would you ask to differentiate David's presentation from Stephen's to make a diagnosis?
History of testicular cancer
Any blood in urine?
Are you sexually active?
Any recent dysuria?
Consequently it is important to assess risk factors for epididymo-orchitis within the history. Most commonly in this age group the most common cause are local infections from the lower urinary tract.
Stem 2 of 5Given the likely diagnosis what is likely found on examination?
Positive Prehn’s sign
Negative cremaster reflex
Bloody urethral discharge
Lump originating from testicle
Cremaster reflex: As the spermatic cord is not affected, upon stroking the medial thigh the scrotum will elevate greater than 0.5cm proximally signifying this is not a testicular emergency.
When palpating the scrotum a lump may be felt however this will be an enlargement of the epididymis or testicle rather than presenting as a discrete lump.
Stem 3 of 5Given David's age what is the most likely cause of this infection?
In those older than 35 years of age presenting with similar symptoms it is much more likely to be caused by enteric infections such as E. coli.
Stem 4 of 5What is the management for the likely causative agent?
Ceftriaxone 500mg IM and Doxycycline 100mg PO O.D for 10-14 days
Doxycycline 100mg PO B.D 7 days
Penicillin G 2.4 MU IM single dose
Ciprofloxacin 500mg PO OD
Ceftriaxone 1g IM
Ceftriaxone 500mg IM and Doxycycline 100mg PO O.D for 10-14 days (and no sexual activity for 14 days) is recommended when the causative organism is unknown.
Ceftriaxone is used to treat gonorrhoea.
Stem 5 of 5Prior to David's discharge, what other management should be done?
Social services referral
Request patient to use condoms during treatment
Request patient to abstain from sex during treatment
Further STI screens
Diagnosis and management of testicular torsion from Kumar and Clarke’s Clinical Medicine, 10th Ed., Men’s Health (Ch 40, pp 1477-1486). Clinical Key Link