3-83
subside Chronic (>48 hr): History of acute onset of pain. Testis pain is improved but not gone.
Objective: Signs
Using Basic Tools: Extreme, diffuse tenderness of the entire testis; edema; vomiting.
Using Advanced Tools: Lab: Urinalysis: Strongly heme or leukoesterase positive sample suggests kidney
stone or infection.
Assessment:
Differential Diagnosis
Orchitis - fatigue, muscle aches, sore throat or other flu-like symptoms with gradual onset and normal
spermatic cord. Mumps orchitis is extremely rare with modern vaccinations.
Severe epididymo-orchitis - voiding symptoms with leukoesterase and nitrite positive urine.
Testis tumor - considered when there is a mass with mild to moderate pain
Torsion of the appendix testis/epididymis - point tenderness on the superior portion of the testis/epididymis
with the remaining testis being non-tender.
Ruptured testis - history of trauma
Spermatic cord torsion - tender testis with a non-palpable vas deferens.
Kidney stone - especially if lodged just below the kidney will present with scrotal pain, but a non-tender,
normal scrotal exam.
Incarcerated hernia - most of the discomfort will be above the testis. A hydrocele may be present, making it
difficult to examine the testis. If omentum is in the hernia, there may not be any bowel symptoms.
Plan:
Treatment
Primary: Manual detorsion, with or without injection of the spermatic cord with local anesthesia. Torsion
may be 180-720° (2 full twists).
- Attempt to detorse the testis first by rotating the testis outward (like opening a book). If the pain worsens
or does not improve, rotate the other direction. The torsion may be 2 full twists. If the testis hangs lower
but pain persists, continue untwisting the cord. - If lidocaine is available, inject into the cord using a long needle or spinal needle in the spermatic cord.
This can be accomplished by straddling the cord on the affected side between two fingers just as the cord
crosses over the pubic bone lateral and superior to the penis. Make multiple passes through the cord and
down to the pubic bone injecting a total of 10 cc of 1% lidocaine local anesthetic. This should numb the
testis. This may relieve the pain, causing the cremasteric muscles to relax and may result in spontaneous
de-torsion. If the pain is gone, check the testis for descent to the normal position and if the testis has
become less tense. Also try to palpate the vas deferens posteriorly. This tube is about the consistency
and size of uncooked spaghetti and is located behind and is easily separable from the bulk of the
spermatic cord. If the tube is in its normal location, spermatic cord torsion is unlikely. You can use the
vas deferens as a guide to untwist the cord. The vas deferens should lie posteriorly to the cord. Palpate
the vas high in the scrotum and try to follow it down. - If unable to detorse the testis, treat with narcotics and empirically with antibiotics (Cipro 500 mg po bid or
Keflex 500 mg po qid or Septra DS 1 po bid) until pain has resolved. Most pain from a dead testis will
improve after 48 hours. Increasing pain would suggest the presence of infection or testis tumor or rupture
of testis (suspect if there is a history of blunt trauma).
Patient Education
General: Wear a scrotal support and await definitive surgery to prevent recurrence.
Activity: Light activity with supporter until problem surgically corrected.
Diet: NPO if surgery is imminent
Prevention and Hygiene: Preventive surgery is required to avoid similar torsion on the opposite side.
Examine testis regularly.
No Improvement/Deterioration: Prompt evacuation and surgical correction.