Medicolegal Issues

Malpractice Counsel: A Pain in the…Scrotum

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It is easy for a busy EP to have a differential diagnosis of only two disorders when evaluating a patient for unilateral testicular pain and swelling—in this case, testicular torsion and epididymitis. While these are the most common causes of testicular pain and swelling, this case emphasizes the need to also consider Fournier’s gangrene in the differential. A thorough history and physical examination, coupled with appropriate testing, will usually identify the correct diagnosis. While the differential diagnosis is broader than just these three disease processes (see the Box), we will review the evaluation and management of the three most serious: epididymitis, testicular torsion, and Fournier’s gangrene.


Noninfectious and Bacterial Epididymitis

Epididymitis is the most common cause of acute scrotal pain among US adults, accounting for approximately 600,000 cases each year.1 Infectious epididymitis is typically classified as acute (symptom duration of <6 weeks) or chronic (symptom duration of ≥6 weeks).2

Cases of noninfectious epididymitis are typically due to a chronic condition, such as autoimmune disease, cancer, or vasculitis. Although not as common, noninfectious epididymitis can also occur due to testicular trauma or amiodarone therapy.3,4

Patients with acute bacterial epididymitis typically present with scrotal pain and swelling ranging from mild to marked. These patients may also exhibit fever and chills, along with dysuria, frequency, and urgency, if associated with a urinary tract infection.2 The chronic presentation is more common though, and usually not associated with voiding issues.

Chronic epididymis is frequently seen in postpubertal boys and men following sexual activity, heavy physical exertion, and bicycle/motorcycle riding.2 On physical examination, palpation reveals induration and swelling of the involved epididymis with exquisite tenderness.2 Testicular swelling and pain, along with scrotal wall erythema, may be present in more advanced cases.2 The cremasteric reflex should be intact (ie, scratching the medial proximal thigh will cause ipsilateral testicle retraction). Similarly, the lie of both testicles while the patient is standing should be equal and symmetrical—ie, both testicles descended equally. However, in the presence of moderate-to-severe scrotal swelling, both of these physical findings may be impossible to confirm.

A urinalysis and urine culture should be ordered if there is any suspicion of epididymitis; pyuria will be present in approximately 50% of cases. However, since pyuria is neither sensitive nor specific for epididymitis, in most cases, a testicular ultrasound with Doppler flow is required to exclude testicular torsion. In cases of epididymitis, ultrasound usually demonstrates increased flow on the affected side, whereas in testicular torsion, there is decreased or absent blood flow.

The treatment for epididymitis involves antibiotics and symptomatic care. If epididymitis from chlamydia and/or gonorrhea is the suspected cause, or if the patient is younger than age 35 years, he should be given ceftriaxone 250 mg intramuscularly plus oral doxycycline 100 mg twice a day for 10 days. Patients who practice insertive anal sex should be treated with ceftriaxone, plus either oral ofloxacin 300 mg twice a day or oral levofloxacin 500 mg daily for 10 days.

In cases in which enteric organisms are suspected, the patient is older than age 35 years, or if patient status is posturinary tract instrumentation or vasectomy, he should be treated with either oral ofloxacin 300 mg twice a day or oral levofloxacin 500 mg daily for 10 days.2

For symptomatic relief, scrotal elevation, ice application, and nonsteroidal anti-inflammatory drugs are recommended.

Patients with epididymitis, regardless of etiology, should be instructed to follow-up with a urologist within 1 week. If the patient appears ill, septic, or in significant pain, admission to the hospital with IV antibiotics, IV fluids, and an urgent consult with urology services is required.

Testicular Torsion

Testicular torsion is a time-sensitive issue, requiring early diagnosis and rapid treatment to preserve the patient’s fertility. Most clinicians recommend detorsion within 6 hours of torsion onset because salvage rates are excellent when performed within this timeframe; after 12 hours, the testis will likely suffer irreversible damage due to ischemia.5,6

Testicular torsion can occur at any age, but is most commonly seen in a bimodal distribution—ie, neonates and postpubertal boys. The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25% to 50%.2

Patients with testicular torsion usually describe a sudden onset of severe, acute pain. The pain frequently occurs a few hours after vigorous physical activity or minor testicular trauma.2 Occasionally, the patient may complain of lower quadrant abdominal pain rather than testicular or scrotal pain. Nausea with vomiting can also be present.

On physical examination, significant testicular swelling is usually present. Examining the patient in the standing position will often reveal an asymmetrical, high-riding testis with a transverse lie on the affected side. The cremasteric reflex is usually absent in patients with testicular torsion.

Because of the significant overlap in history and physical examination findings for epididymitis and testicular torsion, a testicular ultrasound with color Doppler should be ordered. Multiple studies have confirmed the high sensitivity and specificity of ultrasound in the diagnosis of testicular torsion.

The treatment for suspected or confirmed testicular torsion is immediate surgical exploration with intraoperative detorsion and fixation of the testes. The EP can attempt manual detorsion (ie, performed in a medial to lateral motion, similar to opening a book). However, this should not delay the EP from consulting with urology services.

Pediatric patients with testicular torsion usually have a more favorable outcome than do adults. In one retrospective study, patients younger than age 21 years had a 70% testicular salvage rate compared to only 41% of patients aged 21 years and older.7 Regardless of age, better outcomes are associated with shorter periods of torsion.

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