Testicular Torsion

Troublesome Testes

Many complaints we receive in medisec relate to the misdiagnosis of testicular swelling, pain and discomfort. Here are a few pointers to avoid these occurrences.

Testicular Torsion

The young adult who presents with an acutely painful testicle with severe symptoms of short duration presents little clinical difficulty – he should be referred directly to secondary care for urgent scrotal exploration.

Why is it missed?
Testicular pain and tenderness may be absent in up to a third of the patients. Swelling of the testis or scrotum, oedema or erythema of scrotal skin, and abdominal pain may be the presenting symptom in these cases. Pain may be intermittent (with episodes of torsion and detorsion) or a dull ache of gradual onset; it may also be referred to abdominal or inguinoscrotal regions.

Intermittent Testicular Torsion

It is important to remember that some patients may present with intermittent symptoms due to spontaneous de-torsion. Short periods of acute groin pain, which may or may not be accompanied by vomiting and subsequent spontaneous relief, should alert you to this condition.

Testicular Pain in Children

Acute testicular pain in a young child should be treated as a testicular torsion until proven otherwise. Nausea or vomiting associated with scrotal pain indicates that urgent referral for emergency exploratory surgery is necessary. 
In a screaming male infant, the scrotum may not always be carefully examined to exclude torsion, and this diagnosis may be overlooked as a cause for infant distress.1

Beware of the embarrassed ten year old who may complain of lower abdominal pain, because he is too terrified of a scrotal examination!

Testicular Cancer

Non-resolving testicular pain
While most testicular tumours present as a painless mass, recurring testicular pain and/or discomfort in any male should be investigated promptly with ultrasound to rule out a malignant lesion or subacute recurring torsion. 
Patients presenting with a swelling in the scrotum should be examined carefully and an attempt made to distinguish between lumps arising from the body of the testis and other intrascrotal swellings. An ultrasound should be performed to make a distinction. Those patients suspected of harbouring a testicular malignancy, i.e. a lump in the testis, doubtful epididymo-orchitis or orchitis not resolving within two to three weeks, should be referred urgently for urological assessment.2

Intermittent Testicular Torsion

It is important to remember that some patients may present with intermittent symptoms due to spontaneous de-torsion. Short periods of acute groin pain, which may or may not be accompanied by vomiting and subsequent spontaneous relief, should alert you to this condition.

Rare Occurrence

On average, 132 cases of testicular cancer were diagnosed each year in Ireland between 1994 and 2010. Testicular cancer is relatively rare and makes up less than 2% of all invasive cancers diagnosed in men. However in young patients, it is one of the most common cancers, representing 30% of all cancers in 25-39 year olds. Very few men aged over 50 are diagnosed with testicular cancer (less than 10 per year). Most GPs see a patient with a testicular malignancy only once or twice in their careers.3

Presentation

Patients will usually present with a painless scrotal mass or an enlarged testicle. Some patients will describe a ‘dragging sensation’ in the scrotum, and rarely can present with gynaecomastia or hydrocele.2

Beware Distracting History

Occasionally a patient will present following local trauma to the testes, however, it is not thought that the trauma causes the cancer, but rather that it brings an existing mass to the attention of the patient. Beware therefore of confusing a small mass as post trauma ‘bruising’.3

Epididymo-Orchitis

A diagnosis of Epidiymo-orchitis, which does not resolve in two - three weeks should be referred urgently for urological assessment.2

In Summary

  • If there is any testicular mass, refer promptly for ultrasound, even if it feels benign.
  • Testicular torsion may be difficult to diagnose if symptoms are intermittent or atypical, but it must be considered in all cases of scrotal pain, with careful history and examination.
  • If there is unresolving or recurrent scrotal pain, refer promptly for ultrasound and consider urgent urology opinion.
  • Do not be distracted by a history of recent trauma. Investigate any persisting discomfort or swelling.

References:
1BMJ 2010;341:c3213 BMJ Practice Easily Missed? Testicular torsion BMJ 2010; 341 
2SIGN Guideline No. 124 Management of adult testicular germ cell tumours : A national clinical guideline. 2011 
3National Cancer Registry Ireland ‘Cancer Trends’ 2012.


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