It’s the middle of the night and a 24yo male, presents to your care setting with 12hr history of scrotal pain and swelling.
This type of patient is a common presentation in primary and acute care settings, but what are the causes and how do we manage them?
This, our first #AlfaMedCPD blog post will discuss the bad and the down right ugly of acute (<2wk duration) scrotal pain and swelling.
Testicular torsion is definitely not one to miss with 3-4k cases/ year (two thirds being children <12yrs). It can occur at any age but any male <30yr old are the highest risk. If not promptly identified and treated will lead to necrosis and loss of the testis. (90% viability <6hrs, 50% viability <12hrs, >24hrs unlikely salvageable). Don’t rely on clinical signs alone, as this HSIB investigation demonstrates CLICK HERE
Testicular torsion usually presents with abrupt onset of severe unilateral testicular pain (since bilateral torsion is rare ~2% cases) or lower abdominal pain +/- vomiting. There may be a history of previous transient episodes of severe pain that subsided and can suggest spontaneous resolution. Trauma is often cited as a common trigger, although only accounts for <7% of cases. Most are spontaneous!
Clinical findings– Systemically well (if unwell suspect infection), there may be testicular swelling or scrotal discolouration but not always, you may be able to identify the testicle in transverse lie or retracted up in the scrotum. In nearly all cases the cremasteric reflex is absent and highly suggestive of torsion (gentle stroking of inner thigh nr the groin usually causes scrotal contents to lift) (NICE, 2020). Positive Prehns sign should not be relied upon to exclude torsion (where lifting testicle relieves pain), but if Prehn sign is negative (pain unchanged/ worsens on lifting testicle) torsion is more likely.
Bottom line, no single clinical sign is sufficiently sensitive to exclude torsion of the testicle. Have a low threshold for considering torsion in any male with abrupt onset of severe or unrelenting testicular pain. Immediate referral to urological/ paediatric surgeons if alternative diagnoses are less likely than torsion.
Epididymitis is more common than torsion and usually present with gradual onset of pain often in the top of the testicle, but may cause diffuse testicular inflammation (orchitis) as it develops. Broadly speaking, men <35yo who are sexually active should be suspected of having gonorrhoea/ chlamydia, although low risk sexual history should make this less likely. In >35yo coliform bacteria infection more likely (e.g e-coli) but high risk sexual history would make you consider STI.
There may be lower urinary tract symptoms (LUTS) as the inflammation worsens, but absence of LUTS or negative urine dip isn’t sufficient to exclude it. There is usually an inflamed/ tender epididymal swelling, but generalised testicular swelling would suggest orchitis or epididymo-orchitis. Purulent urethral discharge and urethritis are common in gonorrhoea but not exclusively (sexual history is key).
A positive Prehn sign and intact cremasteric reflex in the context of gradual onset testicular pain is more likely to suggest epididymitis (+/- orchitis) than torsion.
Orchitis that occurs 4-8 days after parotid gland swelling would lead to the suspicion of mumps, especially in individuals without mumps vaccinations.
Most patients are well and can be treated in the community with antibiotics (e.g ciprofloxacin), analgesia and scrotal support (snug fitting underwear sufficient usually) but admit those who are systemically unwell (fever, sepsis) or where torsion can’t be excluded. If STI is suspected the patient should be referred to GUM, or blind treatment and send urine to lab for gonorrhoea + chlamydia testing if access to GUM will be significantly delayed (e.g at the weekend). As with UTI, recurrent epididymal infection should prompt out patient referral for urological opinion to investigate causation.