Testicular Pain Examination: Differential Diagnosis in Primary Care

Scrotal pain is a frequent complaint in primary care settings, as well as emergency departments, accounting for approximately 0.5% of all emergency visits. Among the various causes of scrotal pain, testicular torsion stands out as a critical urologic emergency. Prompt and accurate diagnosis is paramount to prevent irreversible testicular damage and potential loss. This article aims to provide primary care physicians with a comprehensive guide to the examination and differential diagnosis of testicular pain, focusing on testicular torsion and other common conditions. Early identification and appropriate management strategies are crucial in optimizing patient outcomes.

Understanding Testicular Torsion: Etiology and Epidemiology

Testicular torsion occurs when the spermatic cord, which provides blood supply to the testicle, twists. This twisting obstructs venous outflow, subsequently impeding arterial inflow, leading to ischemia and potential infarction of the testicle if not promptly addressed.

The underlying anatomical predisposition for intravaginal testicular torsion is often the “bell clapper deformity.” In this condition, the tunica vaginalis, instead of being firmly attached to the posterolateral aspect of the testicle, has a higher attachment, allowing the testicle and spermatic cord to move freely and twist within the tunica vaginalis. This bell clapper deformity is frequently bilateral, occurring in up to 40% of cases.

Neonates may experience extravaginal torsion, where torsion occurs outside the tunica vaginalis because it has not yet adhered to the gubernaculum. While neonatal torsion is managed differently, it’s crucial to recognize that intravaginal torsion can also occur in this age group. It’s also worth noting that, in rare instances, testicular torsion can be associated with testicular malignancy in adult patients.

Testicular torsion predominantly affects adolescents, coinciding with periods of rapid growth, but it can occur across all age groups, from prenatal to older adults. It remains the most significant cause of testicular loss due to acute scrotal conditions.

Pathophysiology of Testicular Torsion

The twisting of the spermatic cord in testicular torsion initiates a cascade of events that compromise testicular blood supply. Initially, venous drainage is obstructed, leading to venous congestion and ischemia. The affected testicle becomes tender, swollen, and may exhibit erythema. As the torsion progresses, arterial blood flow is compromised, exacerbating ischemia and potentially leading to necrosis if blood flow is not restored quickly.

In most cases, the testicle rotates between 90 to 180 degrees, sufficient to impede blood flow. Complete torsion, while less frequent, drastically reduces testicular viability. Testicular salvage is highly probable if intervention occurs within 6 hours of symptom onset, but becomes increasingly unlikely beyond 24 hours.

History and Physical Examination in Testicular Pain

A thorough history and physical examination are vital in the initial assessment of testicular pain. Testicular torsion typically presents with a sudden onset of severe unilateral scrotal pain. This pain may be constant or intermittent but is not influenced by position. Patients may also report associated symptoms such as nausea and vomiting. Importantly, some patients might present with lower abdominal or inguinal pain, overshadowing the scrotal pain.

On physical examination, the affected testicle may be positioned abnormally, often lying transversely or higher than usual in the scrotum. It may be swollen, erythematous, and exquisitely tender to palpation. The cremasteric reflex, elicited by lightly stroking the inner thigh to observe testicular elevation, is often absent in testicular torsion. However, it’s crucial to note that the cremasteric reflex is not entirely reliable, particularly in infants under one year old, and its presence does not rule out torsion.

The Prehn sign, which involves pain relief upon elevation of the testicle, is traditionally associated with epididymitis but is not a dependable indicator to differentiate torsion from other causes of scrotal pain.

Differentiating testicular torsion from torsion of the testicular appendages is important in primary care. Torsion of the testicular appendages, such as the appendix testis or appendix epididymis, is more common and benign. Early in its presentation, appendage torsion may be distinguished from testicular torsion by pinpoint tenderness near the head of the epididymis or testis, a palpable tender nodule, and potentially a “blue dot” sign on the testis – a bluish discoloration visible through the scrotal skin due to the cyanotic appendage. Testicular appendage torsion typically resolves spontaneously over about two weeks, often without surgical intervention.

Differential Diagnosis of Testicular Pain in Primary Care

The differential diagnosis of acute testicular pain is broad and includes several conditions that primary care physicians should consider:

• Epididymitis: Inflammation of the epididymis, often caused by bacterial infection (especially sexually transmitted infections in sexually active individuals) or urinary tract infections. Pain typically develops more gradually than in torsion, and may be associated with urinary symptoms. Physical exam may reveal epididymal tenderness and swelling, and the cremasteric reflex is usually present.
• Orchitis: Inflammation of the testicle, often viral (e.g., mumps orchitis) or bacterial. Similar to epididymitis in presentation, but tenderness is more directly testicular.
• Inguinal Hernia: Incarcerated inguinal hernias can present with scrotal pain and swelling. Examination may reveal a palpable mass extending into the inguinal canal or scrotum.
• Hydrocele: A collection of fluid within the tunica vaginalis, usually painless but can cause discomfort or pressure, and can be symptomatic.
• Testicular Tumor: While usually painless, a testicular tumor can present with acute pain due to intratumoral hemorrhage or torsion, although this is less common as a primary presentation of acute pain.
• Scrotal Hematoma: Trauma to the scrotum can result in hematoma formation, leading to pain and swelling. History of trauma is usually evident.
• Henoch-Schönlein Purpura (HSP): This systemic vasculitis can involve the scrotum, presenting as acute scrotal pain and swelling, often accompanied by purpuric rash, abdominal pain, and joint pain.

Evaluation and Diagnostic Tools

In primary care, when evaluating acute testicular pain, the initial clinical assessment is crucial. The TWIST (Testicular Workup for Ischemia and Suspected Torsion) scoring system can be a useful tool to risk-stratify patients for testicular torsion. The TWIST score assigns points based on clinical findings:

• Testicular Swelling: 2 points
• Testicular Hardness: 2 points
• Absent Cremasteric Reflex: 1 point
• Nausea/Vomiting: 1 point
• High-Riding Testicle: 1 point

A higher TWIST score indicates a greater likelihood of testicular torsion. While ultrasound with Doppler is the definitive imaging modality for diagnosing testicular torsion, it may not always be immediately accessible in primary care settings. For patients with a high TWIST score, immediate referral to the emergency department or urologist is warranted for urgent surgical evaluation. For those with low TWIST scores, point-of-care ultrasound (POCUS), if available and the primary care physician is trained, can be a valuable initial step.

Ultrasound is highly sensitive (around 93%) and specific (nearly 100%) for detecting testicular torsion in experienced hands. It assesses testicular blood flow using color Doppler. In testicular torsion, reduced or absent blood flow to the affected testicle is a key finding. However, it’s important to remember that even with ultrasound, particularly in neonates, absence of color flow may not always be present in torsion.

Urinalysis is typically part of the workup for acute scrotal pain to evaluate for pyuria, which may suggest epididymitis, orchitis, or urinary tract infection. However, the presence of pyuria does not exclude testicular torsion.

Management and Primary Care Considerations

Testicular torsion is a surgical emergency. The window for testicular salvage is generally within 6 hours of symptom onset. In primary care, if testicular torsion is suspected based on history, physical exam, or TWIST score, immediate urological consultation is critical. Delays in diagnosis and treatment can lead to irreversible testicular damage and loss.

If urological intervention is not immediately available, and testicular torsion is highly suspected, manual detorsion can be attempted in the primary care setting as a temporizing measure while arranging for urgent surgical referral. Manual detorsion involves rotating the affected testicle in a medial to lateral direction (like opening a book) by 180 degrees. If pain increases, rotation in the opposite direction should be attempted. Serial bedside ultrasounds, if feasible, can help assess for return of blood flow after manual detorsion. However, manual detorsion should not delay definitive surgical management.

In neonates with suspected testicular torsion, bilateral scrotal exploration is the standard approach. Contralateral orchiopexy (fixation of the opposite testicle) is always performed to prevent future torsion in either testicle. For patients who undergo orchiectomy (testicular removal) due to a non-viable testis, a testicular prosthesis can be considered for cosmetic reasons, typically inserted several months after the initial surgery once inflammation has subsided.

Prognosis and Potential Complications

The prognosis for testicular salvage in torsion has improved significantly over time, largely due to increased awareness and earlier diagnosis. However, outcomes are still less favorable in certain populations, including African Americans, younger patients, and those with limited access to healthcare. The best outcomes are associated with surgical intervention within 8 hours of symptom onset.

Potential complications of testicular torsion and its management include:

• Testicular Loss (Orchiectomy): Despite best efforts, testicular loss remains a significant risk, especially with delayed presentation.
• Infection: Post-surgical infection is a potential complication.
• Infertility: While unilateral orchiectomy generally does not cause infertility, there is potential for reduced fertility, particularly if there is damage to the contralateral testis or if bilateral torsion occurs.
• Cosmetic Deformity: Orchiectomy results in the absence of a testicle, which can be a cosmetic concern for some patients, although prosthesis insertion is an option.
• Diminished Endocrine and Exocrine Function: Loss of a testicle can potentially impact hormone production and sperm production.

Enhancing Healthcare Team Outcomes in Testicular Torsion

Effective management of testicular torsion requires a coordinated interprofessional team approach, particularly in the emergency department setting where these cases often present. In primary care, recognizing the urgency and initiating prompt referral pathways are crucial.

Triage nurses play a vital role in initial identification by recognizing symptoms suggestive of testicular torsion. Rapid assessment and prompt notification of the physician are essential. Emergency department physicians should promptly consult radiology for ultrasound and urology for surgical evaluation. Nurses should prepare the patient for potential surgery, including NPO status and pre-operative blood work.

Open communication among all team members—primary care physicians, emergency physicians, nurses, radiologists, and urologists—is vital to optimize outcomes. Patient and family education is also critical, particularly regarding potential complications like testicular loss and infertility, and the importance of adherence to post-operative care and follow-up. Avoiding pain medication administration prior to urological assessment in suspected torsion cases is important to prevent masking symptoms and delaying diagnosis.

Conclusion

Testicular pain is a common presenting complaint in primary care. While many conditions can cause scrotal pain, testicular torsion is a time-sensitive urological emergency requiring prompt diagnosis and intervention to prevent testicular loss. Primary care physicians are at the forefront of initial assessment and play a crucial role in recognizing potential testicular torsion, initiating timely evaluation, and ensuring rapid referral for definitive management. A thorough understanding of the differential diagnosis, coupled with efficient utilization of clinical tools like the TWIST score and point-of-care ultrasound when available, can significantly enhance the care of patients presenting with testicular pain in primary care settings, improving the likelihood of testicular salvage and optimal patient outcomes.

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