Testes and Epididymis

TESTICULAR TORSION The differential diagnosis of acute scrotal pain includes testicular torsion, torsion of the appendix testis, appendix epididymis, and epididymitis. Testicular torsion must be the primary consideration ( Fig, 91-7). While the peak incidence of intravaginal torsion occurs at puberty in conjunction with maximal hormonal stimulation, it may occur at any age.

Appendix Testis Torsion
FIG. 91-7. Diagrams of testicular torsion and torsion of the appendix testis.

Torsion of the testis or spermatic cord results from bilateral maldevelopment of fixation between the enveloping tunica vaginalis and the posterior scrotal wall. Characteristically, the at-risk testis is aligned along a horizontal rather than a vertical axis. The axis of alignment can be determined only with the patient in an upright position, and even then the determination may be difficult.

Frequently there is a history of an athletic event, strenuous physical activity, or trauma just prior to the onset of scrotal pain. However, a fair number occur during sleep. Unilateral cremaster muscle contraction results in testicular torsion. The pain usually occurs suddenly, is severe, and is usually felt in either lower abdominal quadrant, the inguinal canal, or the testis. While the pain may be constant or intermittent, it is not positional in nature as testicular torsion is primarily an ischemic event that becomes inflammatory only after the testis has infarcted.

In obvious cases of testicular torsion, emergent urologic consultation and surgical exploration are recommended. The often quoted 4-h warm-ischemia time for testicular salvage comes from controlled animal studies and cannot be extrapolated to clinical medicine. There are no readily available clinical or laboratory parameters to judge either the degree or the duration of testicular ischemia. Therefore, no matter how long the patient has been symptomatic and no matter what the presenting physical examination suggests, if testicular torsion cannot be excluded by history and physical examination, emergency scrotal exploration is the definitive diagnostic test and procedure of choice.

Color-flow duplex Doppler ultrasound and radionuclide scintigraphy are two imaging modalities used to evaluate patients with indeterminate clinical presentations. Both may be useful, but their routine clinical use is limited by timely availability and operator experience in interpreting the images. These studies are considered "positive" for testicular torsion when they demonstrate absent or clearly reduced blood flow to the painful side when compared to the opposite testicle, and "negative" when flow is normal or increased. Both studies have nearly identical reported sensitivity (80 to 90 percent) and specificity (75 to 95 percent) for testicular torsion.

Ultrasound has the advantage of demonstrating scrotal anatomy (which may indicate alternate diagnosis) but has the disadvantage of the greater number of indeterminate results when compared to scintigraphy. Within these limitations, both modalities may be useful when promptly available for patients with unclear clinical presentations but should never delay attempted manual detorsion and scrotal exploration.

While awaiting transportation of the patient to the operating room, the emergency physician should attempt manual detorsion of the affected testis. Most testes torse in a lateral to medial fashion. Therefore, detorsion should initially be done in a medial to lateral motion. It must be explained to the patient that detorsion is a painful procedure and while local anesthesia of the affected spermatic cord can initially make the patient more comfortable, it also removes an important endpoint of the detorsion maneuver, i.e., relief of pain. Detorsion is done in a manner similar to opening a book ( Fig 91-8). If one were to stand at the patient's feet, the patient's right testis would be rotated in a counterclockwise fashion (Fig ,9.1z9); the patient's left testis in a clockwise fashion ( Fig 91-10). Any relief of pain is a positive endpoint. A

worsening of the patient's pain would dictate that detorsion be done in the opposite direction. Successful detorsion converts an emergent procedure to an elective one, but one that must be done to correct a potential bilateral anatomic disaster. The timing of the elective surgical correction should depend on the patient's compliance and responsibility.

FIG. 91-8. Testicular detorsion. This procedure is best done standing at the foot of or on the right side of the patient's bed. The torsed testis is detorsed in a fashion similar to opening a book (Fig 91-8). That is, the patient's right testis is rotated counterclockwise ( Fig . 91-9), the left testis is roated clockwise (Fig 91-10).

FIG. 91-9. Testicular detorsion. This procedure is best done standing at the foot of or on the right side of the patient's bed. The torsed testis is detorsed in a fashion similar to opening a book (Fig 91-8). That is, the patient's right testis is rotated counterclockwise ( Fig .9.1-9), the left testis is roated clockwise (Fig 91-10).

FIG. 91-10. Testicular detorsion. This procedure is best done standing at the foot of or on the right side of the patient's bed. The torsed testis is detorsed in a fashion similar to opening a book (Fig 91-8). That is, the patient's right testis is rotated counterclockwise (Fig . .. 91-9), the left testis is roated clockwise (Fig 91-10).

Young boys may present to the emergency department with nonspecific abdominal pain suggestive of gastroenteritis only to return one to two days later with testicular torsion. Whether these patients had undisclosed testicular torsion at their initial evaluation is not known, but emergency physicians must think about testicular torsion in the differential diagnosis of any male presenting with a complaint of abdominal pain!

TORSION OF THE APPENDAGES The appendages of the epididymis and testis have no known physiologic function. These pedunculated structures are, however, capable of torsion, and in prepubertal boys probably torse more often than the testes. If the patient is seen early, the pain is more intense near the head of the epididymis or testis, and an isolated tender nodule can often be palpated. When the involved infarcted appendage is brought close to the thin, prepubertal nonhormonally stimulated scrotal skin, a blue reflection may be seen when light shines upon it. This "blue dot sign" is pathognomonic of torsion of the appendix testis or epididymis. If the diagnosis can be absolutely assured and confirmed by color Doppler ultrasound showing normal intratesticular blood flow to the involved testis, immediate surgery is not necessary, because most appendages will calcify or degenerate over 10 to 14 days and cause no harm. If late in the process and testicular swelling is present, or if the color Doppler ultrasound is equivocal, then urologic consultation and surgical exploration may be necessary to exclude testicular torsion.

EPIDIDYMITIS The onset of pain in epididymitis or epididymo-orchitis is usually more gradual than that of testicular torsion because of its inflammatory etiology. Bacterial infection is the most common cause and tends to be age-dependent. In young boys with documented epididymitis or epididymo-orchitis, congenital anomalies of the lower urinary tract in addition to chemical epididymitis secondary to retrograde reflux of sterile urine into the globus minor (tail of the epididymis) must be considered. In patients less than 40 years of age, epididymitis is primarily due to sexually transmitted diseases (STDs) or their complications, i.e., urethral stricture. In gay men with epididymitis or epididymo-orchitis, fungal infection of the lower urinary tract in addition to the more common STD organisms must be considered. In patients over 40 years of age, epididymitis is caused by common urinary pathogens such as Escherichia coli and Klebsiella. These patients will most often have pyuria on urinalysis, but the absence of white cells or bacteria does not exclude the diagnosis. Older men with epididymitis due to infected urine must be evaluated for the cause of their lower urinary tract infection, i.e., benign prostatic hypertrophy (BPH) or urethral stricture disease. Oftentimes the answer may be found by passing a 14F or 16F Foley or Coudé catheter into the bladder. Easy passage precludes a stricture. A large residual urine should alert the physician to outlet obstruction as the cause of the patient's infection.

Epididymitis causes lower abdominal, inguinal canal, scrotal, or testicular pain alone or in combination. The retrograde progression of infection from the prostatic urethra to the epididymis explains the location and progression of pain. Patients with epididymitis are more prone to lower urinary tract irritative voiding symptoms and may note transient relief of their pain in the recumbent position with scrotal elevation, due to the inflammatory nature of the disease. Initially, isolated firmness and nodularity of the affected globus minor is noted on examination. As the disease progresses, the sulcus between the epididymis and testis becomes obliterated, and

Exerc Cios Para PanturrilhaScrotal Sulcus

the inflammatory epididymal mass may become contiguous with the testis, producing a large, tender scrotal mass (epididymo-orchitis) that cannot be differentiated from testicular torsion or carcinoma. At this stage the patient may appear toxic and require admission for IV antibiotic therapy (see JabJe 91-2). Adjunctive diagnostic modalities such as color-flow duplex Doppler sonography or radionuclide scintigraphy will demonstrate increased or preserved blood flow to the testes.

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