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Wednesday, October 10, 2007

Nursing Reference: Evaluation of Testicular Pain

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Nursing Reference: Evaluation of Testicular Pain Slide Transcript
Slide 1: Evaluation of Testicular Pain February 28, 2007 Marcos Machado, M.D. Michael Macksood, D.O.

Slide 2: Embryology Descent of the testes •Gubernaculum 2mo 3mo shortening •Vaginal process becomes serous bilaminar structure ant to testis 7mo 9mo •Upper part of vaginal process obliterated in 1st year of life->tunica vaginalis

Slide 3: Anatomy • Spermatic cord (Begins at internal ring and ends at testis) – testicular artery – pampiniform plexus – vas deferens – artery of vas deferens – lymphatic vessels – genitofemoral nerve branches – sympathetic hypogastric plexus – remnant of processus vaginalis.

Slide 4: Anatomy – blood supply • Aorta->Testicular artery • Pampiniform plexus of the spermatic cord

Slide 5: Acute vs. Chronic Pain • Acute • Chronic – Pain onset seconds to – Pain lasting more than hours 3 months – Insidious onset

Slide 6: Acute Pain • Onset seconds to • Onset in hours minutes. – Strangulated Inguinal Hernia – Testicular Torsion – Torsion of Testicular – Traumatic injury to Appendage scrotum – Epididymitis / Orchitis – Torsion of testicular appendage

Slide 7: Acute Pain – Rare causes • Testicular Cancer (5% of • Inguinal Hernia testicular pain cases) • Torsion of Spermatocele • Torsion of Cavernous • Familial mediterranean Lymphangioma fever • Acute Appendicitis • Pancreatitis • Lumbar Radiculopathy • Tick bite or venomous bite • Local hemorrhage • Henoch Schonlein Purpura – Associated with Testicular Cancer • Diverticulitis – Associated with testicular • Cysticercosis appendage

Slide 8: Chronic Testicular Pain • Idiopathic in 25% of cases • Intermittent Testicular Torsion • Post-genitourinary surgery • Sperm granuloma (post-Vasectomy) • Varicocele • Testicular Cancer (painless in 60% of cases) • Genitourinary infection (e.g. STD) • Referred pain – Nephrolithiasis in the mid-ureter (most common) – Radiculopathy – Genitofemoral and ilioinguinal nerves (T10-L1)

Slide 9: Topics for today • Acute problems – Torsion – Trauma – Strangulated Inguinal Hernia – Epididymitis / Orchitis • Chronic problems – Testicular CA – STD – Varicocele

Slide 10: Testicular Torsion • Actually torsion of spermatic cord – Surgical emergency due to strangulation of blood supply • Peak incidence at 13 yrs old but occurs at any age

Slide 11: Testicular Torsion • History and symptoms – Acute onset, pain and swelling, N/V – Lower abdominal pain – Sometimes preceded by straining – Hx of self-resolving intermittent torsion – Absence of dysuria, fever, STD

Slide 12: Testicular Torsion • PE – Tender, swollen, high in scrotum – Absent cremasteric reflex on affected side – -Prehn’s sign (+ in epididymitis) • Labs – Normal UA – No leukocytosis

Slide 13: Testicular Torsion • Doppler – If clinical signs equivocal – 80-90% Sn, 75-90% Sp

Slide 14: Testicular Torsion • Treatment – Manual detorsion (open like a book) – Surgical – Both with orchipexy • Bilateral ochipexy b/c other side is likely to torse • Rate of salvage <6hrs – 85-97% 6-12hrs – 55-85% 12-24hrs – 20-80% >24hrs - <10%

Slide 15: Torsion of Testicular Appendage • Appendix testes is a Mullerian duct remnant – Torses easily • Must be differentiated from torsed testicle. • MCC of peds scrotal pain – Usually pre-pubertal • Onset 12-24 hours.

Slide 16: Torsion of Testicular Appendage • PE – Tiny, tender, palpable mass at upper pole – "Blue dot" sign (21%) • Ischemic appendage visible through the scrotum – Testes and epididymis not diffusely tender or swollen. – Cremasteric reflex usually intact. – If +Blue-dot sign & normal, nontender testes • Can exclude testicular torsion – Image if uncertain • Typical course: 7-14 days • Management – NSAIDs – Necrotic tissue reabsorbed w/o sequelae

Slide 17: Testicular Trauma • Color doppler to dx extent of injury • Range of injury – Hematocele (hematoma within tunica vaginalis) – Intratesticular hematoma – Rupture (disruption of tunical albuginea)

Slide 18: Testicular Trauma • Rupture – Usually from crushing between external object and pubic symphysis. – Signs & Sx • Acute, severe pain +/- N/V • Hematoma or ecchymosis of overlying skin – Imaging • U/S 75% specific, 64% sensitive

Slide 19: Testicular Trauma • Surgery – Scrotal exploration indicated if high degree of suspicion – Orchiectomy rate <10% if evacuation/debridement begun within 72 hours

Slide 20: Strangulated Inguinal Hernia • Indirect Inguinal Hernia (persistent processus vaginalis) • Not really testicular pain, but must differentiate from it. – Pain can refer to testes secondary to encroachment on testicular blood supply and egress

Slide 21: Strangulated Inguinal Hernia • Incarcerated hernia • Strangulated hernia – Painful enlargement of a – Incarcerated hernia with previous hernia or defect toxic appearance – Cannot be manipulated – Systemic toxicity secondary through the fascial defect to ischemic bowel poss. – N/V, sx of bowel obstruction – Strangulation probable if (possible) pain and tenderness of incarcerated hernia persist after reduction.

Slide 22: Strangulated Inguinal Hernia • PE – Inguinal canal exam • Inguinal U/S – Mass vs. hernia • Tx – Broad-spectrum antibiotics – Herniorrhaphy – Resection of necrotic bowel if necessary.

Slide 23: Epididymitis • Hx – 1-2day onset, unilateral pain & swelling – Dysuria, urethral d/c • PE – Resembles torsion – Painful indurated epididymis – Pyuria – +Prehn’s sign (pain better with elevation) • Labs – UA & C/S, CBC, GC/Chlam cx

Slide 24: Epididymitis • Most Common Causes – Young boys – congenital anomalies – <40 yr old - GC/Clamydia – >40 yr old – enterobacteria more common – Homosexual – STD & fungal UTI

Slide 25: Epididymitis • Treatment – Mild - outpatient • GC/Clamydia – ceftriaxone 250mg IM x1 then doxycycline 100mg PO BID x 10d • Enterobacteria – cipro 500mg BID until C/S – Mod to severe – inpatient • Intractable pain, failed outpatient tx • Broad spectrum Abx, urology consult, U/S to r/o abscess formation and assess blood flow

Slide 26: Epididymitis • Complications – Sepsis – Infertility – Scrotal abscess – Epididymo-orchitis (involving testis) – Fournier gangrene

Slide 27: Testicular Cancer • MC tumor in men 15-34yo • Rarely painful – Painless testicular masses are CA until proven otherwise • “heaviness” in scrotum • Solid or indurated mass • Generally intratesticular

Slide 28: Testicular Cancer • PE – Palpation for tissue texture anomalies and extratesticular extensions – Transillumination for cystic qualities • Lab – Monitor endocrine markers like AFP, hCG • Imaging – Scrotal U/S

Slide 29: Testicular Cancer • Tx – No biopsy – straight to radical orchiectomy • Prognosis – Limited disease – usually complete cure – Advanced disease – 70-80% cure

Slide 30: Varicocele • Dilation of pampiniform plexus • Often regress 40% • Sx – Pain, ipsilateral testicular atrophy, infertility – L>R. R rare w/o L • PE – Small ->fullness; Larger ->”bag of worms” • Tx – Supportive unless <20yo or infertility – Surgical repair

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