Establish onset, course and duration of pain
Any associated urinary symptoms
Ask about sexual history and history of previous surgery
Examination of the scrotum should be done as well.
Focus on inspection for testicular lie and any signs of inflammation + palpation to find lumps or localised tenderness.
Explain cremasteric reflex
Stroke the proximal and medial aspect of the thigh
Normal response is contraction of the cremaster muscle leading to retraction of tests upwards on the ipsilateral side.
Absence = potential sign of testicular torsion with 88% and 86% in sens and spec respectively.
Explain Prehn's sign
Alleviation of scrotal pain by lifting of the testicle
This is suggestive of the diagnosis of acute epididymitis
It has a sensitivity of 91% and spec of 78%
Urine dipstick + cultures
Urethral swab if STI is suspected
Blood tests mainly FBC, CRP and U&Es
USS of scrotum might be done if uncertainty arise to identify any structural or inflammatory pathology and the patency of blood vessels.
Do not delay scrotal exploration by doing ultrasound if torsion is suspected
Torsion of testicular and epididymal appendages
Explain testicular torsion
Twisting of spermati cord with occlusion of testicualr and cremasteric arteries
This leads to ischaemia and subsequent testicular infarction
Explain torsion of testicular and epididymal appendages
Testicular appendix aka hydatid of Morgagni and epididymal appendix are remnant of embryoligical development.
They can twist leading to unilateral scrotal pain and tenderness
There is often a normal testicular lie and present cremasteric reflex
Examination findigns of Torsion of Testicular and Epididymal Appendages
Blue dot sign (i.e., tender nodule with blue discoloration on the upper pole of the testis) found in the upper half of the hemi-scrotum sign due to infarction of the appendices.
Treatment of Torsion of Testicular and Epididymal Appendages
Surgical exploration is usually required to rule out testicular torsion
Explain referred pain
Anteriolateral aspect of the scrotum is supplied by branches of the genitofemoral and the ilioinguinal nerve
Posterior scrotum is supplied by the perineal branches of the pudendal nerve and posterior femoral cutaneous
Irritation of these nerve can result in referred pain.
E.g. luminal ureteric stones or strangulated inguinal hernia.
What is Henoch-Schönlein purpura
IgA-mediated small vessel vasculitis affecting skin, mucous membranes and kidneys.
Clinical features of HSP
In children with classic triad of purpuric rash on limbs, arthritis and abdo pain.
There might also be scrotal symptoms including pain, erythema and swelling.
Blood tests of HSP
Raised CRP or ESR
Raised serum IgA
Diagnosis is made through biopsy of kidney or skin to identify IgA deposition
Causes of viral orchitis
Most commonly mumps leading to inflammation of the testes.
It casues bilateral acute scrotal pain + swelling
Develop around 4 to 8 days after initial parotitis
Management of viral orchitis
It is self-limiting
Swelling acn persist up to 6 weeks post-infection