00:01
Thank you for joining me
on this discussion of testicular pain
in the section of urology.
00:09
Let's go over the anatomy of a testicle briefly.
00:13
On the center of the screen
is a typical schematic of a testicle.
00:17
Note, highlighted in a green box is a tunica vaginalis.
00:21
It’s particularly important when we discuss
torsion of the testicle.
00:26
Squiggly line about the left upper quadrant of that picture
is the vas deferens.
00:30
And, of course, dead center is the testicle itself.
00:34
Now, let's move on to a discussion of testicular torsion.
00:38
Testicular torsion involves torsion
of the spermatic cord structures.
00:43
As the picture demonstrates,
normal on the left,
twisted or torsed testicle on the right.
00:50
As the torsion happens,
the spermatic cord, which produces
the blood supply to the testicle,
is all also compromised.
00:58
As a result, there's a risk
of ischemia to the testicle.
01:02
This can cause a lot of pain.
01:04
The pathophysiology behind
testicular torsion is important.
01:08
We recognize that the tunica
vaginalis is not securely attached
to the posterior lateral aspect of the testicle.
01:14
Recall another disease process where the attach –
anatomic attachments are important?
That's right. Colonic volvulus.
01:22
If the attachment of the tunica
vaginalis is too high or insufficient,
the spermatic cord is to freely
floating and, as a result, can twist.
01:32
What are some physical findings?
As you can imagine, there can
be severe unilateral testicular pain
associated with scrotal swelling
and a reflexive nausea or vomiting.
01:42
Additionally, during testicular torsion,
patient may lose their cremasteric reflex.
01:48
As a reminder, the cremasteric muscles
are extensions of the internal oblique muscle fibers.
01:54
The cremasteric reflex is normally elicited
by touching the inner thigh
and watching if the testicle rises.
02:01
With testicular torsion, this reflex is lost.
02:04
Additionally, as a major differentiating point
between testicular torsion and epididymitis,
there's usually no relief of pain
with the elevation of the testicle in torsion.
02:16
Routine laboratory values are of little consequence
and are not indicative of testicular torsion.
02:22
Frankly, not necessary.
02:26
But ultrasounds are useful, specifically duplexes.
02:31
Ultrasound duplex assesses
your flow of the spermatic vessels.
02:35
And, of course, the lack of spermatic
vessel flow is indicative of torsion
and indicative of high risk for ischemia.
02:42
Remember, only obtain an ultrasound
if low suspicion of torsion.
02:46
Otherwise, you should rush to the
operating room for surgical exploration.
02:50
Every minute counts!
Now, let’s discuss the surgery.
02:54
Remember, very importantly,
a delay in the de-torsion
may lead to testicular ischemia.
03:00
Therefore, don't proceed to a duplex
unless you have some question or a
suspicion that it's actually not a torsion.
03:06
Scrotal fixation is necessary after the de-torsion.
03:10
As you can remember, the tunica vaginalis
is inappropriately seated.
03:14
And if the testicle is not viable,
you may actually have to remove it.
03:19
Now, let's move on to epididymitis.
03:22
Epididymitis is also a common cause for testicular pain.
03:26
Remember that the epididymitis, as the name implies,
is an inflammation of the epididymis.
03:32
Retrograde passage of urine
can occur from the prostatic urethra
to the epididymis
via the ejaculatory ducts and vas deferens.
03:42
As a result, epididymitis can occur.
03:45
There is some association with
chlamydia and urine organisms
and you should just be
aware of this association.
03:53
Physical findings are very similar to testicular torsion.
03:57
Unilateral testicular pain,
scrotal swelling
and a reflexive nausea/vomiting.
04:02
Therefore, it's important to have differentiating
factors between torsion and epididymitis.
04:08
As you can imagine,
when the testicular –
when the testicle is involved,
it’s pretty difficult to examine the patient.
04:15
With epididymitis,
there can also be a loss of cremasteric reflex.
04:20
However, there's generally some
modicum of relief of pain on elevation.
04:24
This is called the Prehn’s Sign.
04:26
Again, laboratories may not be helpful,
although as a sign of increased inflammation,
there may be elevated white blood cell count.
04:33
But don't count on that.
04:35
How do we treat epididymitis?
Unlike torsion, which is a surgical emergency,
epididymitis can be treated medically.
04:42
Especially if an STD or sexual transmitted disease is
related, particularly in chlamydia or gonorrhea,
you should offer the patient
ceftriaxone and doxycycline.
04:51
Otherwise, it's largely supportive care
with non-steroidals,
analgesics and sometimes ice packs can help.
04:58
Now, it's time to remind you of some important
clinical pearls and high-yield information.
05:03
Remember, elevation of the testicle
relieves pain in epididymitis,
whereas does not in torsion.
05:09
Although this is classic teaching,
frankly, it’s impractical in clinical care.
05:13
When a patient has testicular pain,
it generally hurts no matter what you do.
05:17
And remember, testicular torsion
is a urologic emergency.
05:22
Don't wait for additional diagnostic studies
unless you suspect, in fact,
that it's not testicular torsion.
05:30
Thank you very much for joining me
on this discussion of testicular pain.