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Testicular Emergencies
Alberto S. Carranza, M.D.
Baylor College of Medicine/Childrens Hosp of San Antonio
Disclaimer
Anatomy
Testicles suspend in
scrotum via spermatic
cord (artery, vein, vas
deferentia) and are
wrapped by tunica
vaginalis
Blood Supply
Abdominal Aorta
Testicular Arteries
Enter Internal Inguinal
Canal
Become part
of Spermatic Cord
(artery, vein, vas
deferentia)
Supply
Testicles
Differential Diagnosis:
Testicular Pain
Testicular Torsion*
Epididymitis*
Torsion testicular
appendage*
Traumatic Rupture/
Hematoma*
Hydrocele
Varicocele
Spermatocele
Hernia
Idiopathic Infarction
Orchitis
HSP
Testicular Pain:
Differential Diagnosis
Testicular Torsion
Testicular Torsion:
Definition
Testicular Torsion:
Epidemiology
Testicular Torsion:
Etiologies
Cryptoorchidism
External Factors
Increased
Cremasteric response:
Winter, Physical Activity (Weight lifting)
Testicular Torsion:
Pathophysiology
Intravaginal*
More common
Pubescent
Occurs at level
external ring
Horny teenager
wants to be
intravaginal
Extravaginal
Less common
Perinatal
Bell Clapper
Deformity
Baby to be born
and wants to be
extravaginal
Testicular Torsion:
Pathophysiology
Text
Testicular Torsion:
History
Testicular Torsion:
Physical Exam
Testicular Torsion:
Workup
NPO
PIV
Doppler Ultrasound: Limitations include
Testicular Torsion:
Workup
Testicular Torsion:
Normal Sonogram
Homogenous
echotecture
Same as unaffected
testicle
Testicular Torsion:
Normal Sonogram
Testicular Torsion:
Abnormal Sonogram
Heterogenous
Echotecture*:
Hydrocele
Hyperechoic
(hemorrhage)
Hypoechoic(necrosis)
Testicular Torsion:
Abnormal Sonogram
Testicular Torsion:
Treatment
Surgical treatment
If no Urologist available for prolonged period of
time, consider attempt Open Book reduction
with patient standing up: Successful 30-80%
Testicular Torsion:
Surgery
Orchiopexy: Untwisting
of testicle and fastening
testicle to scrotum via
absorbable sutures
Testicular Torsion:
Prognosis
Testicular Torsion:
Complications
Loss of Testes
Chronic Testicular Pain secondary to
surgical procedure
Epididimytis
Epididimytis:
Anatomy
Epididymis is a
coiled tubular
structure located
posterior to
testes that serves
as storage sperm
Epididymitis:
Definition
Epididymitis:
Epidemiology
1:1000 males
600,000 medical visits per year
Most common cause intra-scrotal
inflammation
Epididymitis:
Etiology/Pathophysiology
Infections
Viral: Mumps,
Coxsackivirus
Chlamydia is most
common cause in sexual
active men <35 age
Epididymitis:
History
Gradual onset of
symptoms (days)*
No Nausea or Vomiting
Chills
* Differentiate from
testicular torsion
Important pieces of
information may include
recent UTI, Sexual
Activity, or Surgical
Instrumentation
Epididymitis:
Physical Exam
Epididymitis:
Workup
CBC/CRP (rarely
needed) to distinguish
between
Doppler Ultrasound/
Urology consult if
diagnosis is unclear and
you have concerns for
testicular torsion
GC/Chlamydia/HIV/RPR
if Sexual Active
Epididymitis:
Sonogram
Normal
Abnormal
Epididymitis:
Prognosis/Complications
Torsion of Testicular
Appendage
Torsion of Testicular
Appendage: Anatomy
The appendix testis is present in 92% of all
testes.
Usually located at the superior testicular pole
in the groove between the testicle and the
epididymis.
Torsion of Testicular
Appendage: Pathophysiology
Torsion of Testicular
Appendage: Epidemiology
Torsion of Testicular
Appendage: History
Torsion of Testicular
Appendage: P.E.
Thickening of scrotal
wall
Tenderness to palpation
upper pole
Reactive hydrocele
Paratesticular nodule
Blue dot sign: 21%
Vertical orientation of
testicles, normal
Enlargement (Apparent)
of head of epididymis (as
when torsion occurs, it
appears to be adjacent
to epididymis)
Torsion of Testicular
Appendage: Workup
Ultrasound
Decreased
echogenicity
If appendage
edematous, it will
appear to be adjacent
to epididymis
Torsion of Testicular
Appendage: Treatment
NSAIDs
Scrotal Support
Surgery usually not indicated, unless
refractory testicular pain
Torsion of Testicular
Appendage: Prognosis
Scrotal trauma
Scrotal Trauma
Types
Blunt Trauma
Penetrating Trauma
Avulsion Injuries
Scrotal Trauma
Epidemiology
Scrotal Trauma
History
Testicular pain
Swelling
Bruising
Difficulty voiding
Abdominal and/or pelvic pain
Nausea/Vomiting
Scrotal Trauma
Physical Examination
Important to document
Location of trauma
Ecchymosis
Skin loss
Entry/Exit point
Testicular Location
Cremasteric reflex
Testicular torsion
Scrotal Trauma
hematoma
Scrotal Trauma
Workup
Urinalysis
CT Abdominal/Pelvis:
eval for testicular
dislocation
Retrograde
urethrography: eval for
urethral injury
Urine culture
Wound Culture
Ultrasound: Eval for
testicular hematoma,
torsion or rupture,
spermatic cord
thrombosis, etc
Scrotal Trauma
Ultrasound
Doppler Ultrasound
Hematoma with
Intact Tunica
Albuginea is the
ONLY finding that
precludes surgical
exploration-all others
shall be explored
Scrotal Trauma
CT
free air penile shaft
testicular dislocation
Scrotal Trauma
Complications
Loss of testicle
Sterility
Infection/Abscess
Fourniers Gangrene:
necrotizing gangrene of
perineum caused by
mixed aerobic and
anaerobic organisms.
Treatment includes
surgical debridement,
broad spectrum
antibiotics, hyperbaric
treatment.
Scrotal Trauma
Treatment
Antibiotics
Medical/Surgical Care
Supportive: Minor
blunt traumas
Surgical: for
testicular ruptures,
lacerations,
dislocations,
penetrating injuries.
References
Ringdahl E, Teague L. Testicular torsion. Am Fam Physician. Nov 15
2006;74(10):1739-43
Gatti JM, Patrick Murphy J. Current management of the acute
scrotum. Semin Pediatr Surg. Feb 2007;16(1):58-63.
Karmazyn B, Steinberg R, Livne P, Kornreich L, Grozovski S,
Schwarz M, et al. Duplex sonographic findings in children with
torsion of the testicular appendages: overlap with epididymitis
and epididymoorchitis. J Pediatr Surg. Mar 2006;41(3):500-4
Images
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Cest fini
Thank you!