In his daily clinical practice, the pediatrician is often confronted with a perplexing diagnostic dilemma -the boy with the painful testicle. Is it torsion, infection, trauma? These, among other possibilities, must be immediately considered, and the pediatrician must develop a differential approach to the problem of testicular pain. Delay in diagnosis and institution of proper treatment may result in testicular damage or loss. What follows is a purely clinical approach, geared to the busy pediatrician in his office. The primary conditions that account for most causes of painful testicle will be discussed. Although they will be described here separately, all should be considered when a diagnosis is sought.
This entity, though most often referred to as "torsion of the testicle," is in fact a torsion or twist of the spermatic cord. Inasmuch as the arterial and venous blood supply to the testicle runs through the spermatic cord, it is apparent that a twisting of this structure upon itself will impair the blood supply to the testicle and epididymis. If this is not relieved, infarction and a gangrenous testicle will result. Its peak incidence is in the lO-to-14-year-old age group, although a second peak, in the newborn to age one year, has been reported.1
The first symptom of torsion is usually sudden onset of pain in the affected testicle. While onset is usually preceded by physical activity, it has been known to occur during sleep. The pain is usually localized to the affected testicle, although it may be referred along the spermatic cord to the lower abdomen. Intermittent or recurrent torsion is a definite entity, and previous episodes of a similar type of pain lasting a few hours are often reported. Nausea and vomiting may be present. As you watch the patient enter your office - walking slowly with a bent-over, straddling gait - the diagnosis will suggest itself even before the history is obtained. On physical examination, these observations are most often made: The scrotum will be asymmetrical, with the painful side enlarged. The scrotal skin may be edematous and reddened. The affected testicle may be higher than normal and, when seen early in its course, the epididymis may be palpated elsewhere than in its normal posterior location. Raising the scrotal contents may increase the discomfort rather than decrease it; in the case of epididymitis or orchitis, the reverse applies. As time passes, a reactive fluid may accumulate within the tunica vaginalis. This acute hydrocele will make it difficult to delineate and examine the testicle and epididymis. In the newborn child, a hard scrotal mass suggests intrauterine torsion.
Results of urinalysis, particularly under the microscope, will be negative for WBCs and RBCs. Fever may be present; it is not, however, a feature of the process.
Unfortunately, because of the difficulty in manually examining such a testicle, many of the physical findings mentioned are hard to ascertain. The child is in pain, fearful, and naturally reluctant to allow anyone to touch and palpate the area. Reassurance and extreme gentleness are prime requisites in overcoming the patient's resistance to examination.
In very early cases, where edema is minimal, spontaneous detorsion or detorsion by manipulation is sometimes possible.2 Even if preoperative manipulation of the testicle has been successful in relieving the torsion, it must be followed by bilateral operative fixation. The basic developmental defect that predisposes to torsion is present bilaterally, and the contralateral testicle must be fixed.3 Generally, however, the interval between the onset of symptoms and physical examination by the physician is often considerable, and too much edema may have already occurred, precluding successful resolution by manipulation. If the duration of symptoms is less than 24 hours, surgical correction will usually result in a viable functioning testicle in 63 to 75 per cent of cases.4*5 If a longer period has elapsed, there is little chance of saving the afflicted testicle and orchiectomy must be performed. Surgical treatment is directed at saving the testicle even if its viability is questionable. The interstitial cells have a much greater tolerance to ischemia and, though spermatogenesis may be lost, androgen function may be preserved.6
When torsion is high in the differential diagnosis, urologie consultation must be made as early as possible. If the diagnosis is not definite, it is customary for the urologist to err on the side of conservatism and to explore the scrotal contents. Vigilance is necessitated by the knowledge that an acute epididymitis will probably resolve to normal, whereas an infarcted testicle will result in atrophy or loss. If orchiectomy is required, there is a good testicular prosthesis that can later be placed in the scrotum permanently.
TORSION OF THE APPENDIX TESTES
It would seem that the only function of this vestige of the mullerian duct is to confuse the clinician in differentiating between its torsion and that of the testicle. The age incidences are about the same. The symptoms are similar but generally less severe in the case of appendix testes. A reactive hydrocele may also develop, and a pea-size bluish mass may be palpable and at times actually visible. The degree of swelling of the scrotal skin is usually less than the woody edema found in torsion of the testes. If one is sure of the diagnosis and can be available for frequent observation and re-evaluation, conservative treatment utilizing ice packs and scrotal support can be instituted. If the entity cannot be definitely differentiated from testicular torsion, surgical exploration of the scrotum is mandatory. Even though spontaneous resolution will eventually occur, operation may be the quickest path to recovery. When in doubt, seek a surgical consultation!
Although a common disease process in adults, epididymitis rarely appears in prepubertal boys. Urologists have always been somewhat surprised at the number of children who are referred with the diagnosis of epididymitis. In fact, this should carry a lower index of suspicion in the differential diagnosis. It has occasionally been observed in this age group following urethral instrumentation, particularly in association with urologie workups for chronic urinary tract infections.
Epididymitis is more frequently seen in pubertal boys. When it occurs, the history is generally that of unilateral testicular pain, somewhat slower in onset than that in torsion and associated with fever, chills, and ipsilateral inguinal pain. Lower urinary tract symptoms of dysuria and frequency may be present. An examination of the urinary sediment often shows pyuria; urine cultures may be positive, with Escherichia coli the most common organism isolated. On physical examination, the scrotal skin may be reddened and often parchmentlike, but it is not usually edematous. The epididymis is in its normal posterior position and painfully discrete from a normal-size, nontender testicle. The epididymis itself is indurated and painful. Elevation of the scrotal contents usually offers some relief of the discomfort.
If the testicle is involved in the infectious process, the term "epididymal orchitis" is applied. In this case, the testicle is enlarged, indurated, and painful to the touch, with some pain referred along the spermatic cord to the lower abdomen. An acute hydrocele may have developed, making accurate examination of the testicle and epididymis more difficult. It is at times impossible to clinically decide when epididymitis ends and orchitis begins; both require prompt insitution of antibiotics such as the ampicillins or, in the pubertal and postpubertal youngster, the oxytetracyclines. The scrotum should be elevated with a suspensory, and hot tub baths offer relief. The use of appropriate doses of oxyphenbutazone (Tandearil®) may help reduce inflammation and discomfort. Urines for culture and sensitivity studies should be submitted before institution of antibiotics, and appropriate changes in medication should be made according to the results. If the urine cultures are positive, an intravenous pyelogram should be considered to rule out underlying urologie pathology
It is frequently impossible to differentiate between a torsion of the testicle that has gone on to infarction and an acute epididymal orchitis. The advanced state of either can be treated with antibiotics, ice packs. and scrotal support, with surgery resorted to only if the testicle becomes suppurative. The diagnosis will be made in retrospect: If the end result is an atrophic testicle, a torsion occurred and fixation of the opposite side is required. If the testicle returns to normal, an epididymal orchitis was present.
Epididymitis and orchitis secondary to gonorrhea are rarely seen; when they do occur, it is in the sexually active adolescent. In these instances, the symptoms of gonorrheal urethritis (profuse urethral discharge, frequency, and dysuria) are initially prominent and will alert the examining physician. Examination of the urethral secretions for gram-negative intracellular cocci and positive culture of Neisseria gononhoeae will substantiate the diagnosis. Aqueous procaine penicillin, administered in conjunction with probenecid (Benemid<81), remains the most effective treatment. Use of doxycycline or minocycline in patients allergic to penicillin is also effective.
This entity is almost never seen in the prepubertal age group but is seen in pubertal and postpubertal males. It usually follows, in four to six days, the onset of parotitis, although it has been known to occur without parotid involvement. In most instances, it is unilateral. The symptoms (pain, swelling, fever, and chills) are the same as in other forms of interstitial orchitis. Treatment is largely supportive, as the disease is self-limiting in seven to 10 days. Bed rest, scrotal support, and hot and cold soaks are suggested. Cortisone has been employed but, while its use may offer subjective relief, the course of the disease is unaltered and there is no apparent change in later incidence of sterility and atrophy.
Trauma to the testicle is probably the second most common cause of scrotal pain that the pediatrician will encounter. A recent mishap is almost invariably cited: a direct blow from a foot or a ball or a fall brings the anguished mother rushing to the doctor with her frightened son. Physical examination often reveals the scrotal skin to be ecchymotic and swollen, with the ecchymosis often extending to and including the penis. Because of the presence of an acute hydrocele or hematocele, the testicle and epididymis may be difficult to palpate. The general treatment is conservative, with ice packs for the first 48 hours followed by hot tub baths. Scrotal support and analgesics help alleviate the discomfort. The acute hydrocele or hematocele should not be aspirated, as secondary infection may result. They will usually resorb in time; if they fail to do so, hydrocelectomy can be performed later.
Strangulated hernia often presents with the sudden onset of progressive inguinal and scrotal pain. If the intestinal contents have entered the scrotum and strangulation has occurred, pain, nausea, and vomiting may be present. Physical examination will reveal the scrotal compartment on the affected side to be full and enlarged. The path of the cord from the external ring distally will be swollen, and the testicle may be palpated as distinct from the hernial contents. If early reduction of the hernial contents is not possible, surgical intervention becomes mandatory.
TUMORS OF THE TESTICLE
Tumors of the testicle will not be discussed in this review, as they are the subject of another article in this issue and pain is only rarely a presenting symptom. They are occasionally unexpectedly discovered as a result of examination of the testicle for pain secondary to trauma; of course, they should always be suspected whenever a testicular mass is found.
The greatest dread experienced by the physician examining a child with a painful testicle is that the diagnosis of a torsion will be missed. This is an appropriate concern, since an unrecognized torsion will result in a loss of spermatogenic testicular function or the testicle itself. All other entities in the differential diagnosis must be weighed against torsion. When in doubt, refer it out! Allow the urologist to see the child at the earliest possible time so that a final diagnostic decision can be made. Only after torsion has been definitively ruled out can the pediatrician comfortably treat whatever nonsurgical disease has been diagnosed. The testicles have often been referred to as "the family jewels." We must guard them both as though they were!
1. Skoglund. R. W.. McRoberts. W. J.. and Ragde. H. Torsion of the spermatic cord. J. Urol. 104 (1970). 604.
2. Frazier. W. J.. and Buey, J. G. Manipulation of torsion of the testicle. J. Urol. 114 (1975), 410.
3. Jones, P. Torsion of the testis and its appendages during childhood. Arch.Dis. Child. 37 (1961 ). 214.
4. Moharib. N. H., and Krahn, H. P. Acute scrotum in children, with emphysis on torsion of the spermatic cord. J. Urol. 104 (1970). 601.
5. Korbel. El. Torsion of the testes. J. Urol. 111 (1974), 521.
6. Smith, G. I. Cellular changes from gradual testicular ischemia. J. Urol. 73 (1955). 335.