A 19-year-old student presents to his local A&E department with testicular pain.
“I’ve got this awful pain in my left testicle”
- Site – Where is the pain?
- Onset – When did the pain start? How did the pain start? Any trauma?
- Character – What is the pain like?
- Radiation – Does it move anywhere?
- Associated symptoms – dysuria/discharge/fever/vomiting
- Timing – How long has it been there for?
- Exacerbating & alleviating factors – e.g. Is it better if you support the testicle?
- Severity scale – 1-10 score?
“The pain came on all of a sudden whilst I was sitting doing my university work. Its been there for two hours. It’s a constant terrible ache that I feel most in my left testicle but it moves towards my belly button. It’s making me feel sick but I don’t have a temperature and my waterworks are otherwise ok. Nothing really makes it better or worse and the pain is a 10!”
- Past medical history:
- Medical conditions
- Previous surgery (i.e. operations on testicles/abdomen)
- Sexual history (i.e. STIs are a possible cause of epididymo-orchitis)
- Social history
- When did the patient last eat or drink? – important to know if considering surgery
“I’m fit and well normally and don’t take any medications. I think I have an allergy to penicillin but I’m not sure what reaction I have. I’ve not had any unprotected sex in the last 3 months and I haven’t had any symptoms. I’m a student, I drink 15-20 units a week and I don’t smoke. I’ve not eaten anything since 1 o’clock.”
- Inspect for swelling, redness, lumps, scars
- Palpate testicles (normal first) using a bimanual technique for swellings, lumps, epididymis and cord
- Check cremasteric reflex and Prehn’s sign
Findings on clinical examination
The left testicle is red and mildly swollen. It is so tender that the patient can’t tolerate you fully examining it but the left testicle is globally tender. There are no palpable lumps. The cremasteric reflex is absent and you ask the patient to elevate their own testicle and this doesn’t help the symptoms.
Urine/urethral swabs for MC&S (microscopy, culture and sensitivity) should be sent to help rule out an infective cause.
Blood tests including FBC, U&E, CRP and Coagulation studies would not necessarily help narrow the differential diagnosis, but they are useful to obtain if the patient is potentially going to theatre.
Torsion is often a clinical diagnosis but colour doppler ultrasound (reduced arterial flow in the testicular artery) may help. Generally, doppler ultrasound is used when torsion isn’t the main differential diagnosis, as surgical exploration should be performed if torsion is suspected.
Most likely diagnosis = testicular torsion
Other differentials diagnoses:
- Torsion appendix testis (hydatid of Morgagni)
- Testicular cancer
- Renal colic (referred pain)
- Chronic scrotal pain
- If torsion is suspected then immediate surgical exploration of the testes needs to be carried out. Surgical fixation of both testis is performed to prevent future recurrence.
- Simple analgesia and supportive underwear.
- Age of patient – torsion is most frequent amongst 10-30 year olds
- Onset of symptoms – torsion is often sudden onset severe pain whereas epididymo-orchitis is more insidious onset
- Associated symptoms:
- Epididymo-orchitis is often associated with urinary symptoms and high risk sexual history.
- Torsion is often associated with nausea/vomiting from the pain.
- Examination findings:
- Torsion – asymmetric high riding testicle, extremely tender, negative Prehn’s sign, absent cremasteric reflex.
- Epidimo-orchitis – epididymis may be focally tender, Prehn’s sign positive, cremasteric reflex present.
- Torsion can present in a number of ways and should always be excluded by experienced clinician.