This is the beginning of a new series – the focus will be limited to the 50% of the population – but, in reading the theme I think you’ll understand why we left the girls out. The first post will focus on how to do an effective H&P focused on acute testicular and scrotal pain.
First and foremost you’ll want to know about the acuity – did the pain start gradually or was it abrupt. More abrupt should worry you about torsion – but could also suggest epididymitis, or torsion of the appendix testis/epididymis, Was there trauma? Most patients will remember… If there has been a change in size it could be due to increased testicular volume or fluid in the scrotal sac (hydroceles and hernias will increase in size with Valsalva). If a patient sexually active think epididymitis/orchitis. Patients with testicular pain and difficulty voiding should worry you about UTI, trauma or mass. Kidney stones have pain that radiates to the groin. Especially when the pain increases nausea and vomiting will often be seen in patients with testicular torsion.
Let’s be honest. Most patients aren’t excited about standing and coughing. I don’t care so much about the coughing, but the standing is important. If the patient can do so please have them stand for the exam. This will give you a better assessment of the anatomy and any asymmetry. Always get a chaperone if you and/or the patient are uncomfortable. respect the patient’s privacy and close doors and curtains. You’ll want to make sure you assess and address the following:
Normally the left hangs lower. Also testicular volume should be relatively symmetric. As torsion occurs venous outflow is the first thing that is compromised – so you’ll see unilateral swelling.
The testicle is normally in a more vertical orientation. The bell clapper deformity describes a horizontally oriented testicle which is due to incomplete posterior anchoring to the gubernaculum. The testicle can become horizontally oriented because it is free to swing in the tunica vaginalis. It occurs in 1/125 males and peaks around adolescence.
Gentle vertical stroking of the inner thigh will cause elevation of the ipsilateral hemiscrotum. The muscle innervation is L1-L2, and thus spinal cord pathology at that level will also impact the reflex. Its absence is concerning for cases of torsion, but not pathognomonic. According to Paul et al, 2004 in children under 11 years, the sensitivity was 75%, specificity 83.9%, accuracy 83.3%, while boys ≥11 years had a sensitivity of 100%, specificity 89%, and accuracy of 90.1%.
Also don’t forget to examine the:
- Inguinal folds
- Penis and urethra
- Pubic hair
- Femoral pulses
In upcoming posts we’ll look at specific diagnoses more in depth – namely torsion, torsion of the appendix testis and appendix epididymis and epididymitis.