Testicular pain may be testicular irradiation or represent a usually retroperitoneal disease. Acute testicular pain should discuss first twisting of the spermatic cord, absolute surgical emergency. Chronic scrotal pain, that is to say manifesting for more than six months, can have multiple causes within a rigorous clinical approach.
Physiology:
“The genital-femoral nerve from the sacral plexus, is divided into two branches, one femoral innervating the skin of the anterior and inner part of the thigh and a genital branch heading to the scrotum. The ilioinguinal nerve, also from the sacral plexus, innervate the groin.
Finally the pudendal nerve supplies the skin of the perineum.
The testes receive sympathetic innervation from the para-aortic nodes and pelvic lymph nodes accessories. “(HenryGray’s Anatomy of the Human Body, 1918).
DIAGNOSTIC:
Examination:
Age and medical or surgical history is essential orientation. The procedure for installing the pain (sudden or gradual, with or without trauma), the existence of previous painful episodes associated symptoms (burning on urination, back pain, nausea, vomiting, fever) should be recorded as the existence of triggers (efforts) or soothing factors (supine sleep).
Physical examination:
The precise clinical examination if pain is testicular, epididymal or sitting at the
cord. Also search hernia, skin changes of the scrotum, and finally DRE essential only in adults (search prostatitis).
The pelvic exam, especially sacroiliac joint and hip joint, spine examination neurological examination but also allow you to specify the search extratesticular causes.
Additional tests :
Search urinary infection strip, ultrasound examination of the scrotum with any Doppler and also the genitourinary system are indispensable complements when the diagnosis is not immediately obvious.
Second line, a CT scan and magnetic resonance allow you to specify a extratesticular origin.
ETIOLOGY TREATMENT:
Testicular pathologies:
Torsion of the spermatic cord:
Diagnostic:
The diagnosis is clinical. Any unilateral scrotal pain and is a twisting of the spermatic cord surgery until proven guilty in a teenager or a young adult.
This is a sharp pain, a scholarship unilateral radiating along the cord to the inguinal region, intense pain, intense, continuous, sometimes associated with nausea or vomiting.
The objective clinical assessment of unilateral signs: increased trading volume, sometimes already inflammatory testis ascended and retracted ring, testis and epididymis very painful. Sometimes it feels round coil of cord, but especially testicular elevation does not alleviate the pain (Prehn sign).
Other signs are negative: no sign of urinary tract infection or urethritis, soft abdomen, free hernia orifice, no concept of mumps, normal testis.
Diagnosis is more difficult in infants and newborns: sudden onset, shouting, agitation, increased trading volume, red and inflammatory, hard gland instead of elastic.
The twist may be more exceptionally in adults, even in old age. We must learn to talk before the late table aseptic necrosis of the testis itself as a bulky purse inflammatory, suggestive of epididymo-orchitis.
The diagnosis is clinical in most cases and doubt, all painful scholarship must be surgically explored in extreme emergency.
Doppler ultrasound, the positive predictive value was 100% and the negative predictive value close to 95%, mainly found its place in the adult or the frequency of epididymo-orchitis far exceeds that of the torsion.
Treatment:
The torsion of the spermatic cord is a surgical emergency. The operation involves opening the purse, untwist the testicle and fix it if it is viable.
Acute epididymo-orchitis:
Diagnostic:
This is an acute inflammation of the male genital tract including the most common cause is infection. This infection can be by ascending or retrograde blood.
Acute epididymo-orchitis is a common pathology observed at any age, mainly in young adults, where it is usually a sexually transmitted disease, or in the elderly because of an obstacle lower urinary tract.
Sexually transmitted Chlamydia trachomatis germs are, and much more rarely Neisseria gonorrhoeae, Candida albicans, Trichomonas.
Epididymitis is usually preceded by an inconstant urethritis accompanied by urethral discharge. DRE is normal and the urine is clear with sterile cytobacteriological examination. The urethral samples demonstrate antigen Chlamydia(immunofluorescence or enzyme immunoassay).
Serodiagnosis of Chlamydia can say a recent infection significantly increased IgM antibody titer levels to 15 days apart.
The mumps orchitis is the third cause of acute epididymo-orchitis: the risk of infertility, exceptional, is related to bilateral involvement with scarring sequelae.
The orchiépididymites tuberculous bilharziennes or filarial are much more rare in our developed societies and are in the chronic form.
Treatment:
Treatment relies on antibiotics for three to six weeks, ofloxacin, doxycycline, macrolides. The measures are related jockstrap, bed rest, treatment of partners, nonsteroidal anti-inflammatory.
Epididymitis accompanied by a urinary tract infection (Escherichia coli, Proteus mirabilis, Pseudomonas and Enterococcus more rarely) justify the same measures with antibiotic therapy adapted to the germ, but also the specific treatment of a new sub-bladder outlet obstruction (treatment of adenoma or urethral stricture).
Testicular trauma:
obvious causes of scrotal acute pain: skin hematoma or subcutaneous voluminous purse on. The surgery in semi-urgent need to repair testicular tunica which is broken. The affirmation of testicular integrity by Doppler ultrasound justify abstention and close clinical and ultrasound monitoring.
Testicular cancer:
It is often accompanied by testicular discomfort, rarely acute pain: painful and inflammatory form, associated with acute tumor necrosis. The existence of a hard testicle, pseudo-tumor associated hypoechoic ultrasound images should lead to surgical exploration inguinal in doubt. Testicular markers (beta-HCG, alpha-fetoproteins and research of inflammatory syndrome) are essential but do not allow a diagnosis.
Vaginal hydrocele, epididymal cyst or cord, spermatocele:
Diagnostic:
They give sluggishness and sometimes functional impairment but not acute pain.
The diagnosis is clinical and ultrasound.
Treatment:
Surgical treatment is only offered if the functional impairment is real, very often linked to volume.
Varicocele:
Diagnostic:
A large varicocele, whose diagnosis is clinically confirmed by Doppler ultrasound, may be responsible for painful heaviness in the scrotum. The discomfort is mainly late in the day, disappear after recumbency.
Treatment:
The phlebotonic drugs often provide symptomatic improvement. The treatment is surgical: occlusion of spermatic vein either endovascular or surgical ligation (laparoscopic or not). The treatment is in any case desirable in the subject of childbearing age to limit the risk of secondary infertility. The pain is usually improved by this treatment.
Extratesticular pathologies:
Renal colic:
Diagnostic:
Acute renal colic reflects the commitment of calculation from a chalice in the urinary tract and downstream is due to the sudden tensioning of the urinary tract and kidney capsule (D11 root, T12, L1, L2) .
The crisis often occurs with the waning of a trip or a sporting activity. Its beginning is generally sudden, unilateral lumbar radiating up and down and forward along the path of the ureter, radiating to the perineum and external genitourinary organs. The testicular irradiation is sometimes predominant. Evolution is by paroxysms without analgesic position. It combine agitation or nausea, vomiting, sometimes with urinary frequency and urinary disorders urgency, signs that the calculation is close to the bladder.
Clinical examination eliminates digestive emergency before a soft abdomen with free hernia orifices, and tracks obstructive renal colic febrile (fever of 40 ° C, chills, general condition altered, particularly painful lumbar pits).
Treatment:
Extreme emergencies are febrile renal colic with septic shock and obstructive anuria justifying the drainage of the urinary tract in emergency. Outside these situations, the first treatment is medical: fluid restriction, nonsteroidal anti-inflammatory drug intravenously (ketoprofen).
Radicular pain, pudendal neuropathy:
They are mentioned in the context of disc herniation, or predisposing circumstances of the compression of the pudendal nerve in the canal of Alcock (especially cycling).
Osteoarthritis:
The testicular irradiation of pain is favored by walking, by external rotation and hip abduction. Hip radiography done easily check, as well as amelioration by an anti-inflammatory treatment.
Sequelae of hernia surgery or vasectomy:
They are a common cause of scrotal chronic pain. We must seek testicular atrophy by injury to the spermatic artery.The anti-inflammatory treatment is often disappointing. The local anesthetic infiltration in the cord are usually temporary but effective.
Aortoiliac aneurysms:
They can cause pain with radicular compression neighborhood. These aneurysms are usually found in the abdominal and pelvic ultrasound.
Appendicitis, hernia strangled on ectopic testis:
In children and infants, we must discuss the diagnostic difficulties with atypical appendicitis, or strangulated hernia associated with ectopic testis.
Rheumatoid purpura:
In the rheumatoid Henoch-Schonlein, isolated scrotal pain can reveal the disease. They are not normally associated with a twist. They can however reveal a ureteral obstruction.
Functional pain idiopathic:
They are especially common in young adults, generating anxiety. The first step is to eliminate any testicular or not testicular pathology before a normal clinical examination. The presence of small epididymal cysts does not explain the pain and should not lead to operate them. The main therapeutic approach is to reassure the absence of tumor pathology. We must also support the commonly associated symptoms: sexual difficulties, pathological anxiety.
The mechanism of this pain is not well known, probably related to functional impairment of the sympathetic system.
Unusually, it was suggested denervation of the spermatic cord, or even epididymectomy or orchiectomy.