On inspection, look for erythema, swelling, discoloration, skin integrity, and position of the testicle

Family Medicine 27: 17-year-old male with groin pain

Learning Objectives

The student should be able to:

Elicit focused history of patients presenting with scrotal pain.

Demonstrate the ability to perform proficient testicular examination and to elicit signs specific to identify or exclude testicular torsion.

Develop a differential diagnosis for adolescent male presenting with scrotal pain.

Identify appropriate laboratory and radiological studies as it relates to the differential diagnosis of scrotal pain. Outline the algorithmic approach to testicular pain.

Discuss management of testicular torsion.

Recognize sexually transmitted infections as a cause of testicular pain among adolescent males.

Discuss the importance of counseling to prevent sexually transmitted infections.

Discuss epidemiology and USPSTF recommendations for screening for common testicular cancers.

Knowledge

Important Features of the History for a Patient in Pain

The following acronym can be helpful: LAQ CODIERS:

Location

Associated symptoms

Quality

Character

Onset

Duration

Intensity

Exacerbating factors Relieving factors other Symptoms

HEEADSSS Adolescent Interview

Home

Education / Employment

Eating

Activities

Drugs

Sexuality

Suicide / Depression Safety / Violence

Scrotal Exam Findings

Cremasteric reflex

Cremasteric reflex can be assessed by lightly stroking or pinching the superior medial aspect of the thigh. An intact cremasteric reflex causes brisk ipsilateral testicular retraction. Absence of the cremasteric reflex is a sensitive but nonspecific finding for testicular torsion. It can be absent on physical exam in normal testes. It should be assessed after inspection and before palpation of the testicles.

Blue dot sign

Tenderness limited to the upper pole of the testis suggests torsion of a testicular appendage, especially when a hard, tender nodule is palpable in this region. A small bluish discoloration known as the “blue dot sign”, may be visible through the skin in the upper pole. This sign is virtually pathognomonic for appendiceal torsion when tenderness is also present.

Prehn sign

Prehn reported that physical lifting of the testicles relieves the pain caused by epididymitis but not pain caused by testicular torsion. A positive Prehn sign is pain that is relieved by lifting of the testicle; if present this can help distinguish epididymitis from testicular torsion.

Causes of Testicular Torsion

Congenital anomaly

A congenital anomaly that results in failure of normal posterior anchoring of the gubernaculum, epididymis, and testis is called a bell clapper deformity because it leaves the testis free to swing and rotate within the tunica vaginalis of the scrotum much like the gong (clapper) inside of a bell, causing an intravaginal torsion. A large mesentery between the epididymis and the testis can also predispose itself to torsion. Contraction of the muscles shortens the spermatic cord and may initiate testicular torsion.

Undescended testes

Although there is little solid evidence, the incidence of testicular torsion is thought to be higher in undescended testes than in normal scrotal testes. Torsion of an undescended testicle often occurs with the development of a testicular tumor, presumably caused by increased weight and distortion of the normal dimensions of the organ.

Recent trauma or vigorous exercise

The patient’s history often indicates recent trauma to the genital area, hard physical work, or vigorous exercise.

Testicular torsion can also occur without any apparent reason.

Complications of Testicular Torsion: Testicular Loss

The most significant complication of testicular torsion is loss of the testis, which may lead to impaired fertility.

Common causes of testicular loss after torsion are:

delay in seeking medical attention (58%)

incorrect initial diagnosis (29%) delay in treatment at the referral hospital (13%)

The viability of a testis depends on the duration of torsion and pain:

Duration of scrotal pain

Percentage of testicular viability

6 hours

90%

more than 12 hours

50%

more than 24 hours

10%

Patient Centered Medical Home

Leading primary care physicians organizations* described the characteristics of the Patient Centered Medical Home as follows:

1.  Personal physician: Each patient should have an ongoing relationship with one personal physician. So when a patient needs medical attention, they rely on a doctor they have established a long-term relationship with who will help them get whatever care they need.

2.  Physician directed medical practice: The personal physician has assistance from the team of individuals at the family practice clinic who collectively take responsibility for ongoing care of patients.

3.  Whole person orientation: The personal physician is responsible for providing all health care needs at all stages of life. Including acute care, chronic care, preventive services, and end of life care.

4.  Care is coordinated and/or integrated: The personal physician doesn’t have the expertise to take care of every medical issue their patients may encounter, so the personal physician needs to understand when to refer for subspecialty care. The personal physician also needs to be able to utilize all domains of the health care system, facilitated by registries, information technology, health information exchange and other means, in order to ensure that the patient gets the indicated care where and when they need it. Furthermore, the personal physician needs to be able to communicate health care issues effectively to family members when appropriate.

Quality and safety are also hallmarks of the medical home.

*Leading primary care physicians organizations: American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic Association (AOA).

Discussing Sexual Risk Behaviors with Adolescents

Many young people engage in sexual risk behaviors that can result in unintended health outcomes.

To reduce sexual risk behaviors and related health problems among youth, physicians can help young people adopt lifelong attitudes and behaviors that support their health and well-being-including behaviors that reduce their risk for HIV, other STIs, and unintended pregnancy.

Counsel youth that abstinence from vaginal, anal, and oral intercourse is the only 100% effective way to prevent HIV, other STIs, and pregnancy. The correct and consistent use of male latex condoms can reduce the risk of STI transmission, including HIV infection. However, no protective method is 100% effective, and condom use cannot guarantee absolute protection against any STD or pregnancy.

In many states, minors can legally consent to certain types of health care on their own—including STI and HIV testing.

Adolescent Health Clinical Recommendations and Guidelines

USPSTF Guidelines

Special Considerations

Depression

Adolescents age 12 to 18 should be screened for major depressive disorder (MDD).

Chlamydia and gonorrhea

Screen all sexually active women age 24 years and younger.

HIV

Screen adolescents at age 15 years (USPSTF).

AAFP recommends starting at age 18.

CDC recommends starting at age 13.

Lipid

Disorders

Insufficient evidence to screen in children and adolescents 20 years and younger.

AAP recommend screening once between 9 and 11, and once between 7 and 21 years of age.

Obesity

Children and adolescents 6 years and older should be screened for obesity.

Syphilis

Screen in adolescents who are at increased risk for infection.

People at increased risk include men who have sex with men, people with HIV, certain racial/ethnic groups, certain geographic and metropolitan areas, history of incarceration, history of commercial sex work, and being male younger than 29 years of age.

Sexually Transmitted Infection in Women

Women should have their first cervical cancer screening at age 21 and can be rescreened less frequently than previously recommended, according to guidelines issued by the American College of Obstetricians and Gynecologists (ACOG).

Moving the baseline cervical screening to age 21 is a conservative approach to avoid unnecessary treatment of adolescents, which can have economic, emotional, and future childbearing implications. Although the rate of HPV infection is high among sexually active adolescents, invasive cervical cancer is very rare in women under age 21. The immune system clears the HPV infection within one to two years among most adolescent women. Because the adolescent cervix is immature, there is a higher incidence of HPV-related precancerous lesions (called dysplasia). However, the large majority of cervical dysplasias in adolescents resolve on their own without treatment.

See this chart prepared by the CDC to compare HPV and cervical cancer screening guidelines of the various professional organizations.

Sexually transmitted infection

Symptoms

Diagnosis

Chlamydia

Dysuria

Discharge (penile or vaginal)

Pain with sex

Abdominal or testicular pain

Nucleic acid amplification test of urine, endocervical sample, or urethral sample

Breakthrough bleeding

May be asymptomatic

Gonorrhea

Dysuria

Discharge (penile or vaginal)

Pain with sex

Abdominal or testicular pain

Breakthrough bleeding May be asymptomatic

Nucleic acid amplification test of urine, endocervical sample, or urethral sample

Gonococcal culture of rectal or pharyngeal specimens

Trichomonas

Vaginal discharge with odor or itching

May be asymptomatic

Saline wet mount rapid antigen testing Trichomonas culture

HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening). Persons at high risk for HIV infection should be screened for HIV at least annually. Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing.

Testicular Cancer: Prevalence, Presentation, & Screening Recommendations

Testicular cancer is the most common malignancy affecting males between the ages 15 and 35, although it accounts for only one percent of all cancers in men.

These tumors could present as a nodule or as a painless swelling of the testicle, 30-40% may present with dull ache or heavy sensation in the lower abdomen, perianal area, or scrotum areas. Acute pain is the presenting symptom in ten percent of cases.

There is no evidence to support routine screening for testicular cancer in asymptomatic adolescents and young adults.

Testicular Tumor Risk Factors

The most common testicular tumor is germ cell tumor. The specific cause of germ cell tumors is unknown, but various factors have been associated with the increased risk.

Genetics play a role in testicular cancer risk. Klinefelter’s syndrome (47xxy) is associated with a higher incidence of germ cell tumors. For first degree relatives of individuals affected there is approximately six to ten- fold increased risk for germ cell tumors. Other conditions such as Down syndrome, testicular feminizing syndrome, true hermaphrodites, persistent mullerian syndrome, and cutaneous ichthyosis are at higher risk for developing germ cell tumors.

Family history also plays an important role in testicular cancer risk. There have been reports of six-fold increased risk among male offspring of a patient with testicular cancer.

Patients with cryptorchidism have 20 to 40-fold increased risk compared with their normal counterparts. Cryptorchidism is the absence of one or both testes from the scrotum, usually as the result of an undescended testis.Orchipexy, even at an early age, appears to reduce the incidence of germ cell tumor only slightly.

Numerous environmental hazards, such as industrial occupations and drug exposures have been implicated in the development of testicular cancer. They include DES, Agent Orange, and solvents used to clean jets and ochratoxin A.

One to two percent of patients with testicular cancer will develop a second primary cancer in the contralateral testicle. This represents a 500-fold increase in risk compared with normal population.

Prior trauma, elevated scrotal temperature, and recurrent activities, such as horseback riding and motorcycle riding do not appear to be related to the development of testicular tumors.

(NSGCT)

Yolk sac tumors (also known as endodermal sinus tumors) are the most common prepubertal GCTs. They may be benign but are most often malignant. Most affected patients require surgery and chemotherapy because of the aggressive nature of the tumors, but the overall prognosis is excellent.

Choriocarcinoma is the most lethal but least common NSGCT (1%)

1. Non-germ cell tumors

Non-germ cell tumors (Leydig cell tumors and Sertoli cell tumors) constitute the remaining 5% of primary testicular tumors; these are rare tumors that are malignant in only about 10% of the cases.

1. Extragonadal

Lymphoma, leukemia, and melanoma are the most common malignancies that metastasize to the testicle (extragonadal tumors).

Clinical Skills

Interviewing with Family Members Present

Special attention should be given to privacy and confidentiality while interviewing an adolescent in the presence of a family member.

There may be ethical dilemmas involving confidentiality and privacy when family members are present with a patient of any age.

Family members might have additional questions or concerns about the patient’s health. The physician must make sure they avoid a potential breach of HIPPA: Patient should agree and not object to their relevant health care information being disclosed.

The patient should have time to communicate privately with the physician at some point during the visit.

There could be legal issues whenever a third party is involved to make financial and legal decisions for the patient, such as the mother of a child or the guardian of an adult who is impaired or has dementia.

Family Interviewing Skills

Make sure you gather data by asking open-ended questions, by prompting facilitation, identifying and exploring clues, responding empathetically, and by reaching common ground.

Core and Advanced Skills of Family Interviewing

Family members can be a valuable source of information and can help in the implementation of a treatment plan, which can result in better patient outcomes.

The presence of a family member strengthens the alliance between the physician and the patient without lengthening the office visit.

Family involvement may have a positive influence on medical encounters.

Core family interviewing skills are used routinely during interviews in which another person accompanies the patient. Core skills are sufficient when family members communicate effectively and when the differences between the family members, patient, and physician are minimal. Using these skills, the physician can conduct an efficient and productive interview that involves everyone present. They include:

Greet and build rapport

Identify each person’s agenda

Check each person’s perspective

Allow each person to speak

Recognize and acknowledge feelings

Avoid taking sides

Respect privacy and maintain confidentiality

Interview the patient separately, if needed

Evaluate agreement with the plan

Advanced family interviewing skills are useful in situations where the family exhibits ineffective communication, as a result of a conflict and intense emotions. The advanced family interviewing skills will help the family in communicating or managing conflicts to address the immediate patient care issues; however, unlike therapy, the use of these skills is not intended to create a permanent change in the family’s interaction patterns. The physician may use the following skills:

Guide communication

Manage conflict

Reach common ground

Consider referral for family therapy

All students can be expected to learn and practice the core skills. The advanced skills are generally learned during residency training and are described in more detail in the article by Lang, et al., listed in the References section, below.

Building Rapport with Adolescents

Building rapport is the most important skill a provider needs in taking care of adolescent patients. A few simple techniques may help reassure the adolescent that his provider is trustworthy:

Introduce yourself to the adolescent first, look him in the eye, shake his hand and sit down during the interview.

Acknowledge the adolescent as your primary patient by directing your questions primarily to him, rather than his parents.

Use conversation icebreakers to allow time for the adolescent to become more comfortable and get a sense of who you are. Allow the adolescent to remain dressed during the interview and sit in a chair rather than on the examination table.

Ensure confidentiality and provide a safe environment for him to be honest.

Practicing reflective listening and take time to listen to what the adolescent is saying and not saying.

Facilitating a comfortable experience for the adolescent by providing adolescent-friendly and easy-to-access office and staff. Interviewing the adolescent without his family present for sensitive questions. Don’t ask an adolescent about sexual activity in front of parents.

Scrotal Exam Techniques

Inspection

On inspection, look for erythema, swelling, discoloration, skin integrity, and position of the testicle.

Palpation

The skin of the scrotum should be palpated for edema, fluid collection, tenderness, and subcutaneous emphysema. Begin palpation of scrotal contents with the unaffected side.

The normal testis is mobile, and the spermatic cord and epididymis are palpable posteriorly.

1.  By gently grasping the testis between the thumb and first two digits, the testicle is examined from its inferior pole, superiorly.

2.  Then palpate the testicle for size, tenderness, (localized or diffuse), lie (high or low within scrotum-the left testicle normally sits slightly lower than the right), and axis (horizontal or vertical).

The epididymis should be examined for size, position, tenderness, and swelling. The epididymis should be palpable as a soft, smooth ridge posterolateral to the testis.

To complete the intra-scrotal evaluation, palpation of all scrotal contents should occur. This includes examination of the spermatic cord to the superficial inguinal ring for tenderness or a “knot” which suggests testicular torsion and any localized fluid collections, such as a hydrocele or spermatocele.

Transillumination

Transillumination may help you determine the etiology of a lesion. For example, a light source shines brightly through a hydrocele.

Management

Treatment of Testicular Torsion

There are two approaches to treating torsion of the testes. Nonsurgical approach

Manual detorsion of the torsed testes, may be attempted, but it is usually difficult because of acute pain during the manipulation. This nonoperative distorsion is not a substitute for surgical exploration.

If the maneuver is successful, orchiopexy (surgical fixation of both testes to prevent retorsion) must still be performed. This should be done in the immediate future, preferably before the patient leaves the hospital.

If full manual reduction of torsion cannot be performed or if there is doubt about the diagnosis and reason to suspect torsion, the scrotum must be explored.

Surgical approach

The testis must be unwound at operation and inspected for viability. If it is not viable, it should be removed. If the testis is viable

then orchiopexy should be performed to prevent recurrence. Whether the affected testis is removed or conserved, the contralateral one should undergo orchiopexy as the risk of recurrence on the other side is otherwise high.

Studies

Diagnosing Testicular Torsion

Color Doppler ultrasonography can confirm testicular torsion if pain is less severe and the diagnosis is in question. If testicular torsion is present, intratesticular blood flow is either decreased or absent which appears as decreased echogenicity, as compared with the asymptomatic testis. In addition, the torsed testicle often appears enlarged.

Radionuclide scintigraphy is a diagnostic test that uses a radioisotope to visualize testicular blood flow. Patients with testicular torsion have decreased radiotracer in the ischemic testis, resulting in a photopenic lesion.

Radionuclide scintigraphy vs color doppler ultrasonography:

Radionuclide scintigraphy procedure has 100% sensitivity, whereas Doppler ultrasonography only has a sensitivity of 88% and a specificity of 98% in detecting testicular torsion.

Although scintigraphy may be more sensitive for testicular torsion, ultrasonography is faster and more readily available. This is a critical consideration in a condition that warrants a rapid diagnosis.

Color Doppler ultrasonography and scintigraphy demonstrate no statistically significant difference in ability to demonstrate testicular torsion in boys with acute scrotal symptoms and indeterminate clinical presentations.

Clinical Reasoning

Differential of Groin Pain in an Adolescent

Trauma

Trauma can cause acute pain and swelling of the scrotum and its contents.

Severity may range from mild contusion to severe testicular fracture or vascular disruption.

Testicular torsion

Testicular torsion, in which the testicle rotates around its vascular supply, is the most serious condition under consideration.

Surgical emergency with a limited window of four to 12 hours (optimally within four to six hours) after the onset of pain to save the testicle by untwisting the spermatic cord. Timely diagnosis and treatment are vital for survival of the testis.

Most common in neonates and post pubertal boys, with the majority of cases of testicular torsion occurring between the ages of 12-18 years.

Relatively uncommon condition. Each year one in 4,000 men younger than 25 years gets it.

Symptoms: scrotal, inguinal, or lower abdominal pain which usually begins abruptly. The pain is severe, and the patient appears uncomfortable. It can occur several hours after vigorous physical activity or minor testicular trauma and there may be associated nausea and vomiting. There may be prior similar episodes that might suggest intermittent testicular torsion.

Symptoms: scrotal, inguinal, or lower abdominal pain which usually begins abruptly. The pain is severe, and the patient appears uncomfortable. It can occur several hours after vigorous physical activity or minor testicular trauma and there may be associated nausea and vomiting. There may be prior similar episodes that might suggest intermittent testicular torsion.

Torsion of the testicular

appendages

Torsion of the testicular appendages (appendix epididymis and appendix testis) occurs less commonly and is

associated with less morbidity than torsion of the testis. Appendix testis is a small vestigial structure (embryonic remnant of Mullerian duct) located on the anterosuperior aspect of the testis.

Typically occurs in younger patients with most cases occurring between the ages of seven and 14 years. Presents with abrupt onset of pain that is typically less severe than in testicular torsion and is localized to the region of the appendix testis without any tenderness in the remaining areas of the testes.

As in epididymitis, the patient may appear comfortable except when examined.

Presence of a bluish discoloration in the scrotum at the upper pole of the testis (blue dot sign) is produced by testicular appendiceal torsion.

Epididymitis

Epididymitis is the most frequent cause of sudden scrotal pain in adults.

Symptoms are typically slowly progressive over several days rather than abrupt.

It is caused by bacterial infection of the epididymis, typically from a urinary tract or sexually-transmitted infection.

The patient may appear comfortable except when examined.

Severe swelling and exquisite pain are present on the involved side, often accompanied by high fever, rigors, and irritative voiding symptoms.

Patients may have had preceding symptoms suggestive of a urinary tract infection or sexually transmitted disease.

On exam, the scrotum is tender to palpation and edematous on the involved side. The cremasteric reflex is usually present, and the testis is in its normal location and position.

Less Likely Diagnoses

Inguinal hernia

An inguinal hernia is a painless swelling in the inguinal region, which can be enhanced by maneuvers that raise intraabdominal pressure, such as cough or Valsalva maneuver. The swelling becomes painful and tender when it is incarcerated.

Indirect hernia: An indirect inguinal hernia develops as a result of a persistent process vaginalis. The inguinal canal begins in the intra-abdominal cavity at the internal inguinal ring, located approximately midway between the pubic symphysis and the anterior iliac spine. The canal courses down along the inguinal ligament to the external ring, located medial to the inferior epigastric arteries, subcutaneously and slightly above the pubic tubercle. Contents of this hernia then follow the tract of the testicle down into the scrotal sac.

Direct hernia: A direct inguinal hernia usually occurs due to a defect or weakness in the transversalis fascia area of the Hesselbach triangle. The triangle is defined inferiorly by the inguinal ligament, laterally by the inferior epigastric arteries, and medially by the conjoint tendon.

Hydrocele

A hydrocele is a cystic painless scrotal fluid collection and is the most common cause of painless scrotal swelling.

Light should be visible through the scrotum when it is illuminated with a strong light source (positive transillumination).

Hydroceles are generally asymptomatic unless associated with trauma or infection, although patients may report a slowly growing mass that causes a pulling or dragging sensation.

HenochSchönlein purpura (HSP)

Henoch-Schönlein purpura (HSP) is characterized by nonthrombocytopenic purpura, arthralgia, renal disease, abdominal pain, gastrointestinal bleeding, and occasionally scrotal pain.

The onset of scrotal pain may be acute or insidious.

In boys who lack other characteristic findings of HSP, sonography can usually distinguish HSP from testicular torsion.

Treatment of HSP is supportive.

Testicular tumor

Testicular tumor presents as scrotal mass that is rarely accompanied by tenderness. The swelling is solid so should not transilluminate.

Varicocele

A varicocele is a collection of dilated and tortuous veins in the pampiniform plexus surrounding the spermatic cord in the scrotum.

Varicoceles occur more commonly on the left side (85-95 percent) because the left spermatic vein enters the left renal vein at a 90 degree angle, whereas the right spermatic vein drains at a more obtuse angle directly into the inferior vena cava, facilitating more continuous flow.

Varicocele is seen commonly in adult men but can be seen in adolescents; approximately 10-25 percent of adolescent boys have a varicocele.

One-third of all males presenting to an infertility clinic have a varicocele.

Varicocele is associated with infertility, although the precise mechanism by which this occurs has been the subject of considerable research and is currently thought to be due to increased testicular temperature.

Patients with varicocele can be asymptomatic or may complain of a dull ache or fullness of the scrotum upon standing.

A varicocele is mass-like and nontender or mildly tender to palpation on exam.

Referred pain

Boys who have the acute onset of scrotal pain without local inflammatory signs or a mass on examination may be suffering from referred pain to the scrotum.

The scrotal pain is caused by three somatic nerves that travel to the scrotum: the genitofemoral, ilioinguinal, and posterior scrotal nerves.

Retrocecal appendicitis is an important and a rare cause of referred scrotal pain in children and adolescents.

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