Diagnosis
Comments
Testicular torsion
Tender and swollen testicle that is displaced superiorly; mass may be felt in spermatic cord, absent cremasteric reflex, nausea, vomiting
Torsion of testicular or epididymal appendage (appendix testis)
Common cause of acute painful hemiscrotum in a child; the epididymal appendage (appendix testis) is located at the head of the epididymis; blue-dot sign is a classic finding; onset of pain is more gradual; cremasteric reflex is maintained
Epididymitis and/or orchitis
Scrotal pain relieved by supporting the scrotum, dysuria, induration, classically from mumps, more commonly bacterial
Hydrocele
Fluid in the tunica vaginalis, will transilluminate, increase in size with valsalva, often spontaneously resolve by 1 year of age
Varicocele
Tortuous dilation of pampiniform plexus, does not transilluminate, increase in size with valsalva, described as a “bag of worms”
Appendicitis
Anorexia, vague periumbilical abdominal pain, vomiting, localized right lower quadrant pain (McBurney’s point), Rovsing’s sign, psoas sign
Fournier’s Gangrene
Severe necrotizing infection in the perineal and scrotal region occurring most commonly in uncontrolled diabetic patients and immunocompromised
Traumatic testicular rupture
Patients have history of trauma to scrotum, scrotal pain, hematocele; results from a disruption to the connective tissue enveloping the testicle (tunica albuginea)
Testis tumor
Presents as firm, painless testicular mass that cannot be transilluminated; seminomas (germ cell tumors) are the most common type and are malignant
What Is the Most Likely Diagnosis for this Patient?
In a 13-year-old patient with a sudden onset of scrotal pain; with a swollen, superiorly displaced testicle; and with absent cremasteric reflex, the most likely diagnosis is testicular torsion.
History and Physical
Which Type of Testicular Trauma Is Most Common?
Blunt testicular trauma is responsible for 85 % of cases. Of those, sports-related injuries are implicated in most of those traumas. Blunt trauma is usually associated with unilateral injuries, while penetrating trauma can involve both testes.
What Is the Cremasteric Reflex?
The cremasteric reflex is an elevation of the ipsilateral testicle by the cremasteric muscle in response to a stroking motion at the medial aspect of the upper thigh. When the medial thigh is stroked, sensory fibers from the femoral branch of the genitofemoral nerve (L1-L2) are stimulated. The sensory input travels to the spinal cord, where it synapses with the motor nerve from the genital branch of the genitofemoral nerve (L1-L2) to activate the cremasteric muscle and cause ipsilateral elevation of the testis.
What Would Cause an Absent Cremasteric Reflex?
The cremasteric reflex is absent with upper and lower motor neuron disorders, with spinal cord injury at L1-L2 (genitofemoral nerve), and usually in patients with testicular torsion. It is important to note that although the reflex is almost always absent in patients with testicular torsion, a present reflex does not exclude the possibility of testicular torsion.
What Is Prehn’s Sign? Is It Reliable?
Prehn’s sign is positive when patients report pain relief with elevation of scrotal contents and negative when this does not relieve any pain. Classically, patients with epididymitis have a positive Prehn’s sign, while testicular torsion patients have a negative sign. However, Prehn’s sign is not a reliable distinguishing feature between testicular torsion and epididymitis, as a positive sign does not exclude the diagnosis of testicular torsion. Prehn’s sign has been shown to be inferior to Doppler ultrasound to rule out testicular torsion.
What Is the Blue-Dot Sign?
This is a pathognomonic sign (Fig. 52.1) for torsion of testicular or epididymal appendage (appendix testes). Palpation of the testes reveals a small firm and tender nodule near the head of the epididymis that appears to have a blue discoloration.
Fig. 52.1
Blue-dot sign (With kind permission from Springer Science+Business Media: Atlas of Clinical Urology, Office Urology, 2003, p 3, Kaplan et al., Fig. 1.4b)
What Are the Four Cardinal Symptoms and Signs of Testicular Torsion?
Nausea/vomiting, testicular pain duration of less than 24 hours, a superiorly displaced testicle, and an absent cremasteric reflex.
What are the Important Differences Between Testicular Torsion and Appendix Testes Torsion?
Type
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