Testicular Pain

The protocol for Testicular Pain:

Testicular Pain

 

Let’s break it down!

This protocol is for a chief complaint, not a definitive diagnosis.  That means that you’re going to have to look out for several different things that could be causing this.  In a bullet-style fashion, let’s go through the possibilities one by one:

  • Testicular Torsion: This an emergency in which the testicle literally rotates and twists the spermatic cord, cutting off the necessary blood supply to the testicle.  Has an annual incidence of testicular torsion is 3.8 per 100,000 males younger than 18 y old
  • Epididymitis: The epididymis is a little sac located at the top of the testicles, essentially providing safe storage for sperm cells.  Epididymitis is simply the inflammation of this sac and it’s usually caused by an STI (sexually transmitted infection) or a UTI (urinary tract infection).
  • Orchitis: Simply refers to the inflammation of one or both testicles.  Like epididymitis, this typically occurs with STIs and UTIs, but also with viruses like the Mumps virus.
  • STI’s: Sexually transmitted infections are notorious for causing testicular pain, but which ones are we looking for?  The two big culprits are chlamydia and gonorrhea
  • Hernias: The big hernia that we’re referring to is an inguinal hernia, which occurs when the small intestine breaks through a weak spot in the abdominal muscle lining, causing the intestines to push into the scrotum.  While not necessarily dangerous, it’s very painful and it needs to be surgically corrected
  • Masses: Testicular cancer is an obvious one that you should be suspicious of, but there are other benign masses that can cause testicular pain or discomfort.  These include hydrocele (basically a build-up of fluid around the testicle), varicocele (over-dilation of testicular blood vessels), and spermatocele (a painless cystic mass that usually grows above or behind the testis).  You probably won’t be able to differentiate these things, but just know that they exist
  • Trauma: Typically not a long-lasting problem, but certainly not impossible.  Straddle injuries, projectile injury, a kick to the nuts…..all can cause testicular pain

 

But remember…..

 All testicular pain is testicular torsion until proven otherwise! 

For a summary of testicular pain differentials, check out the video below:

 

The only two things that we can actually treat in the field setting are Testicular Torsion and Epididymitis. So let’s break those down:

Testicular Torsion

  • It’s going to be a sudden onset of pain.  A soldier will know right away when his precious stone is being twisted
  • Abdominal pain and nausea/vomiting are common with acute testicle injuries. This is because prior to birth, testicles are actually formed in the abdominal region.  After they descend, they still maintain the same nerve connections.  
  • Elevation of the affected testicle will increase the pain significantly. As the spermatic cord twists, it’s going to sort of “crunch up” and elevate, just like if you were to twist a shoestring.  The testicle that is elevated higher than the other testicle is likely the affected one.

  • Physical activity is a common cause of spontaneous testicular torsion, though it’s not uncommon for torsion to occur while sleeping.

  • Loss of cremasteric reflex is 99% sensitive for the diagnosis of testicular torsion.  That’s pretty good!  If you’re wondering what a “cremasteric reflex” is, this video will show you:

The videos below show patients with interesting presentations of testicular torsion:

Epididymitis

  • The pain will be gradual compared to the sudden onset of testicular torsion
  • The presence of a fever is a good way to differentiate between this and testicular torsion, although an elevated temperature typically only occurs during the more serious infections. 
  • Dysuria (pain or discomfort urinating) is indicative of an inflamed bladder/urethra, which often goes hand-in-hand with epididymitis

  • Trauma isn’t required for an infection, but a recent traumatic event always has the potential to make way for an infection.

Below is a video of what epididymitis actually looks like from a surgical perspective:

Before you evacuate someone with testicular torsion, you should at least make one attempt to manually detorse it. The “open the book” procedure is outlined below:

  • With torsion of the left testis, hold the testicle with the right thumb and forefinger and then rotate the testicle clockwise 180 degrees.  This manipulation may need to be repeated 2-3 times, because testicular torsion may involve rotations of 180-720 degrees.  These repeated attempts should be guided by resolution of pain and return to normal anatomy
  • For torsion of the right testicle, the procedure is similar except that the testicle is held using the left thumb and forefinger and the testicle is rotated in a counter-clockwise direction

Adam Rosh, MD on Twitter: "Testicular detorsion #MedEd… "

Now if you suspect that this is NOT testicular torsion because the patient’s testicular pain is gradual, the testicle is lying normally, etc. then we have to empirically treat it as a UTI or an STI (Both of which are covered in the Urinary Tract Infection protocol)

And of course, this is painful, so be sure to treat generously for pain under the Pain Management protocol

A testicle will die if blood flow is impinged for greater than 6 hours. Although testicular torsion can be fixed without advanced equipment, an ultrasound will be needed to confirm full detorsion. The high-risk nature of this disease warrants an Urgent evacuation. If epididymitis is suspected, the patient can be safely observed throughout antibiotic treatment…but you better be sure it’s not torsion!

 

Good luck out there!

 

References

Brandon Simpson, PA-C
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