Testicular torsion / Epididymitis

Three main differential Dx of painful testis: Testicular torsion, epididymitis, orchitis

Testicular torsion:
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Symp:
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High riding testicle
{mem tip: 말려 올라갔으니까}

No pain relief upon elevation of scrotum
{mem tip: 벌써 올라가있으니까 - 내가 올려본다}
(if pt experience pain relief with elevation of the testis (Prehn sign) -> suggests epididymitis more than torsion)

Absent cremasteric reflex(elevation of the testis in response to stroking of the upper inner thigh)
(it also may be absent in boys without torsion, particularly if they are younger than six months)
{mem tip: 벌써 올라가있으니까 - 환자의 근육이 올린다}

The testis may be lying horizontally, displacing the epididymis from its normal posterolateral position.

Scrotal swelling/edema

Nausea vomiting
(Nearly 90 percent of patients may have associated nausea and vomiting)


Dx:
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Scrotal ultrasound (Collour doppler)

Abnormal urinalysis suggests epididymitis/orchitis more than testicular torsion

Rx:
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- Analgesia

- immediate urological consultation for emergency scrotal exploration

   Typical rates of viability:
   * Detorsion within 4 to 6 hours — 100 percent viability
   * Detorsion after 12 hours — 20 percent viability
   * Detorsion after 24 hours — 0 percent viability


- if surgery is not available within 6 hours [13] or while preparations for surgery are being made -> manual de-torsion

Manual de-torsion is a temporising measure. The technique involves rotating the right testicle counter-clockwise and the left testicle

clockwise. In other words, the affected testicle is rotated as if opening a book, hence the 'open book' method.



Epididymitis
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Symps
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Pain and swelling typically develops over the course of a few days (unlike testicular torsion, which is usually of sudden onset).

The affected testis has a normal vertical lie

Pt may experience pain relief with elevation of the testis (Prehn sign)

Painful micturition (uncommon)

urethral discharge (uncommon)

Epididymitis is caused by organisms causing UTI/STI.


Rx:
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Sexually transmitted:
-cetriaxone 250 mg IMI stat AND
-doxycycline 100 mg BD PO for 14 days
(NOTE: Doxycycline is not approved for use in children younger than the age of eight years)

Not sexually transmitted:
-empiric quinolone: ofloxacin 300 mg BD PO for 10 days OR levofloxacin 500 mg dly PO for 10 days
(NOTE:  Fluoroquinolones are not approved for use in patients younger than 18 years of age when other effective alternatives are available)

Prog
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Swelling of testis from epididymitis may takes a month or more to subside