Family Medicine 27: 17-year-old male with groin pain User: Lauren Harasymiw Email: [email protected] Date: October 16, 2018 00:23 GMT/UTC 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 LAQ CODIERS: L ocation A ssociated symptoms Q uality C haracter O nset D uration I ntensity E xacerbating factors R elieving factors other S ymptoms 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 non-specific 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. © 2018 Aquifer 1/9

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.