1. Evaluating Testicular Pain Kaveh Mansuripur Ambulatory Medicine Clerkship 4/9/09 Kaveh Mansuripur Ambulatory Medicine Clerkship 4/9/09

2. Learning Objectives By the end of the session, be able to:  List the differential dx for testicular pain  Label or draw the relevant anatomy  Describe the physical examination appropriate for a patient with testicular pain  Select appropriate testing for patients with testicular pain in context of specific sxs and signs  Select the most appropriate treatment for patients with specific causes of testicular pain By the end of the session, be able to:  List the differential dx for testicular pain  Label or draw the relevant anatomy  Describe the physical examination appropriate for a patient with testicular pain  Select appropriate testing for patients with testicular pain in context of specific sxs and signs  Select the most appropriate treatment for patients with specific causes of testicular pain

3. Anatomy

4. Case 1: Patient T.R. What is the Differential Diagnosis? HPI: 21 yo man presents with 3 hours of intense, constant testicular pain Began several hours after college track meet Associated nausea and vomiting PMH: None Meds: Glucosamine, condroitin, creatine supplements Alls: PCN FH: Non-contributory SH: Sexually active, multiple partners HPI: 21 yo man presents with 3 hours of intense, constant testicular pain Began several hours after college track meet Associated nausea and vomiting PMH: None Meds: Glucosamine, condroitin, creatine supplements Alls: PCN FH: Non-contributory SH: Sexually active, multiple partners

5. Differential Diagnosis  Testicular Torsion  Appendiceal Torsion  Epididymitis  Trauma  Inguinal Hernia  Henoch-Schonlein Purpura  Mumps  Fournier’s Gangrene  Referred Pain  Testicular Torsion  Appendiceal Torsion  Epididymitis  Trauma  Inguinal Hernia  Henoch-Schonlein Purpura  Mumps  Fournier’s Gangrene  Referred Pain

6. Case 1: Patient T.R.  Exam:

7. Case 1: Patient T.R. What is the Next Step? Exam:  Right testicle higher than left  Long axis oriented horizontally  Significant swelling  No cremasteric reflex on either side  No relief of pain on elevation Exam:  Right testicle higher than left  Long axis oriented horizontally  Significant swelling  No cremasteric reflex on either side  No relief of pain on elevation

8. Case 1: Patient T.R. Next Step If Diagnosis Certain (Torsion):  To the OR.  Outcomes directly related to length of time from onset  Irreversible ischemia at mean of 12 hours If Diagnosis Less Obvious  Doppler Ultrasound  Test 82% sensitive, 99% specific for torsion (loss of flow) If Diagnosis Certain (Torsion):  To the OR.  Outcomes directly related to length of time from onset  Irreversible ischemia at mean of 12 hours If Diagnosis Less Obvious  Doppler Ultrasound  Test 82% sensitive, 99% specific for torsion (loss of flow)

9. Case 1: Patient T.R. Operation:  testicular detorsion and fixation  Unilateral or bilateral? Why? Operation:  testicular detorsion and fixation  Unilateral or bilateral? Why?

10. Case 1: Patient T.R. Operation  testicular detorsion and fixation  Unilateral or bilateral? Why? ANSWER: Bilateral-- Torsion associated with absence/insufficeincy of gubernaculum. Often bilateral. What if surgery not an option? Operation  testicular detorsion and fixation  Unilateral or bilateral? Why? ANSWER: Bilateral-- Torsion associated with absence/insufficeincy of gubernaculum. Often bilateral. What if surgery not an option?

11. Case 1: Patient T.R. Non-operative: Manual detorsion  2/3 of cases are torsed medially, 1/3 laterally  Success marked by decreased pain, return to normal position.  If unsuccessful, apply ice (successful in animal models) Non-operative: Manual detorsion  2/3 of cases are torsed medially, 1/3 laterally  Success marked by decreased pain, return to normal position.  If unsuccessful, apply ice (successful in animal models)

12. Testicular Torsion  40% over 21  Associated with physical activity/sleep  Exam  Absent cremasteric  Doppler  Surgical Emergency  40% over 21  Associated with physical activity/sleep  Exam  Absent cremasteric  Doppler  Surgical Emergency

13. Case 2: Patient F.J. HPI:  11 year old boy presents with 3 days of increasing scrotal pain  Localizes tenderness to anterior superior pole of right testicle  dDx? HPI:  11 year old boy presents with 3 days of increasing scrotal pain  Localizes tenderness to anterior superior pole of right testicle  dDx?

14. Case 2: Patient F.J. Exam

15. Case 2: Patient F.J. Exam:  Tender as reported  Transillumination: hydrocele at AS pole  Cremasteric reflexes intact bilaterally  Discoloration visible externally as sub- centimeter dot at site Exam:  Tender as reported  Transillumination: hydrocele at AS pole  Cremasteric reflexes intact bilaterally  Discoloration visible externally as sub- centimeter dot at site

16. Case 2: Patient F.J.

17. Further tests?

18. Case 2: Patient F.J. Further tests?  Ultrasound will show focus of decreased echogenicity at site Treatment? Further tests?  Ultrasound will show focus of decreased echogenicity at site Treatment?

19. Case 2: Patient F.J. Further tests?  Ultrasound will show focus of decreased echogenicity at site Treatment?  Conservative  Ice, anti-inflammatory medications  Pain resolves in weeks-months  Residual nodule  Operative  Low risk  Recovery in days Further tests?  Ultrasound will show focus of decreased echogenicity at site Treatment?  Conservative  Ice, anti-inflammatory medications  Pain resolves in weeks-months  Residual nodule  Operative  Low risk  Recovery in days

20. Appendiceal Torsion  80% between 7-14 years  Leading pediatric scrotal pathology  Gradual onset  Tenderness localized to AS aspect  Intact cremasteric reflex  “Blue Dot” sign in 21%  80% between 7-14 years  Leading pediatric scrotal pathology  Gradual onset  Tenderness localized to AS aspect  Intact cremasteric reflex  “Blue Dot” sign in 21%

21. Case 3: Patient J.D. CC: 31 yo man with Testicular Pain HPI  5 days, waxing/waning. Began several hours after exercise. No previous episodes.  Left testicle, some radiation to L. inguinal fold, L. gluteal region  “Achy” in quality; 4-8/10  No N/V/F/C or other associated symptoms  ED visit 3 days ago. Clean U/A at time. Told to FU outpatient if pain unresolved. CC: 31 yo man with Testicular Pain HPI  5 days, waxing/waning. Began several hours after exercise. No previous episodes.  Left testicle, some radiation to L. inguinal fold, L. gluteal region  “Achy” in quality; 4-8/10  No N/V/F/C or other associated symptoms  ED visit 3 days ago. Clean U/A at time. Told to FU outpatient if pain unresolved.

22. Case 3: Patient J.D. PMH Noncontributory Meds None Allergies NKDA FH/SH HTN, MI in father 1ppd, social EtOH, bisexual. PMH Noncontributory Meds None Allergies NKDA FH/SH HTN, MI in father 1ppd, social EtOH, bisexual.

23. Case 3: Patient J.D. Exam  Mild swelling around left testicle  Normal lie  Tenderness localizes to PS pole WHAT IS DIFFERENTIAL DIAGNOSIS? Exam  Mild swelling around left testicle  Normal lie  Tenderness localizes to PS pole WHAT IS DIFFERENTIAL DIAGNOSIS?

24. Case 3: Patient J.D. Exam  Mild swelling around left testicle  Normal lie  Tenderness localizes to PS pole Diagnosis:  Epididymitis Exam  Mild swelling around left testicle  Normal lie  Tenderness localizes to PS pole Diagnosis:  Epididymitis

25. Case 3: Patient J.D. Bacterial Epididymitis  What to give and why? Bacterial Epididymitis  What to give and why?

26. Case 3: Patient J.D. Bacterial Epididymitis  What to give and why?  C. trachomatis and N. Gonorrhea most common in men under 35 Bacterial Epididymitis  What to give and why?  C. trachomatis and N. Gonorrhea most common in men under 35

27. Case 3: Patient J.D. Bacterial Epididymitis  What to give and why?  C. Trachomatis and N. Gonorrhea most common in men under 35  Doxycycline 100mg PO BID x10 days  Ceftriaxone 250mg IM x1 Bacterial Epididymitis  What to give and why?  C. Trachomatis and N. Gonorrhea most common in men under 35  Doxycycline 100mg PO BID x10 days  Ceftriaxone 250mg IM x1

28. Case 3: Patient J.D. Bacterial Epididymitis  What to give and why?  C. Trachomatis and N. Gonorrhea most common in men under 35  Doxycycline 100mg PO BID x10 days  Ceftriaxone 250mg IM x1  Coliforms? Bacterial Epididymitis  What to give and why?  C. Trachomatis and N. Gonorrhea most common in men under 35  Doxycycline 100mg PO BID x10 days  Ceftriaxone 250mg IM x1  Coliforms?

29. Case 3: Patient J.D. Bacterial Epididymitis  What to give and why?  C. Trachomatis and N. Gonorrhea most common in men under 35  Doxycycline 100mg PO BID x10 days  Ceftriaxone 250mg IM x1  Coliforms?  Quinolones (ofloxacin 300mg PO BID x10 days) Bacterial Epididymitis  What to give and why?  C. Trachomatis and N. Gonorrhea most common in men under 35  Doxycycline 100mg PO BID x10 days  Ceftriaxone 250mg IM x1  Coliforms?  Quinolones (ofloxacin 300mg PO BID x10 days)

30. Epididymitis  Mostly subacute  ABX  Evaluate recurrent cases for GU malformation  Acute more common in older men, prostatitis  Fever, chills, GU symptoms  Mostly subacute  ABX  Evaluate recurrent cases for GU malformation  Acute more common in older men, prostatitis  Fever, chills, GU symptoms

31. References  Edelsberg, JS, Surh, YS. The acute scrotum. Emerg Med Clin North Am 1988; 6:521.  Eyre, RC. Evaluation of the acute scrotum in adult men. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2008.  Fisher, R, Walker, J. The acute paediatric scrotum. Br J Hosp Med 1994; 51:290.  Edelsberg, JS, Surh, YS. The acute scrotum. Emerg Med Clin North Am 1988; 6:521.  Eyre, RC. Evaluation of the acute scrotum in adult men. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2008.  Fisher, R, Walker, J. The acute paediatric scrotum. Br J Hosp Med 1994; 51:290.