Testicular Torsion

The differential diagnosis of acute scrotal pain includes testicular torsion. This usually occurs in
neonates or adolescent males but may be observed in other age groups. The blood supply to the
testicle is compromised due to twisting of the spermatic cord within the tunica vaginalis resulting
in ischemia to the epididymis and the testis. In newborns, an extravaginal torsion also can occur
with twisting of the tunica vaginalis and spermatic cord together. Risk factors for torsion include
undescended testis, testicular tumor, and a "bell-clapper" deformity with poor gubernacular
fixation of the testicles to the scrotal wall.
Clinical history is vital for diagnosis. Patients describe a sudden onset of pain at a distinct point
in time, with subsequent swelling. Physical examination may demonstrate a swollen, asymmetric
scrotum with a tender, high-riding testicle. Children normally have a brisk cremasteric reflex that
usually is lost in the setting of torsion. The diagnosis is made by clinical history and
examination, but can be supported by a Doppler ultrasound which typically shows decreased
intratesticular blood flow relative to the contralateral testis. If an ultrasound is not promptly
available, timely surgical exploration should ensue if there is reasonable suspicion of torsion.
However, besides ruling out other pathologies, an ultrasound can rule out an associated testicular
neoplasm that would necessitate tumor serum marker evaluation and an inguinal, rather than a
scrotal, incision.
Immediate surgical exploration can salvage an ischemic testes. More than 80% of testes can be
salvaged if surgery is performed within 6 hours, which decreases to 20% or less as time
progresses beyond 12 hours.28 At the time of surgery, the contralateral testes also must be
explored and fixed to the dartos fascia due to the possibility that the same anatomic defect
allowing torsion exists on the contralateral side. Midline or bilateral transverse scrotal incisions
are made. Once the testis is detorsed, it should be assessed for viability after being given time for
normal blood flow to resume. The testes are fixed to the dartos fascia with a small,
nonabsorbable suture on their medial and lateral aspects, taking care to ensure that the spermatic
cord is not twisted before doing so. An orchiectomy should be performed to avoid later risk of
abscess formation only if the testis is clearly necrotic because overall testicular function may be
improved with testicular preservation in cases of moderately delayed (15 hours) presentation

Epididymo-Orchitis
Epididymo-orchitis is typically the result of bacterial infection originating in the urinary tract.
However, most men will not show evidence of urinary tract infection. Symptoms are unilateral
painful swelling of the epididymis and/or testis, often with fever. The scrotum may be
erythematous on the side of involvement. The white blood cell (WBC) count often is elevated.
The onset is fairly rapid, but not as sudden as torsion. An ultrasound may provide supporting
evidence such as increased blood flow to the epididymis. A reactive hydrocele may be present.
Intratesticular infection can result in ischemic orchitis, and reduced testicular blood flow can be
seen on ultrasound. Although the clinical history of gradual onset may point to an infectious
etiology, scrotal exploration is necessary when blood flow is reduced to rule out torsion unless
other signs such as pyuria, elevated WBC count, or fevers are present.
Treatment is with oral antibiotics if the patient is not markedly febrile and is otherwise stable.
Hospitalization and parenteral antibiotics are required if the patient has high fevers, significantly
elevated WBC, or hemodynamic instability, as sepsis from epididymo-orchitis is possible.
Intratesticular abscesses may form, and usually result in orchiectomy. The tunica albuginea of the
testis is not compliant, so elevated pressures from intratesticular inflammation can result in
ischemic necrosis of the parenchyma.

Cystitis
Cystitis is an infection in the bladder with common symptoms of dysuria, and urinary frequency
and urgency. Urinary culture (105 colony-forming units) is necessary to make a definitive
diagnosis, although lower thresholds are meaningful if clinical suspicion is high. Urinalysis can
assist with the diagnosis, as leukocyte esterase is a marker of inflammation, and nitrites are
formed from bacterial reduction of nitrates. Risk factors include female gender, urinary
instrumentation, urinary obstruction, diabetes, and neurologic bladder dysfunction.
An uncomplicated episode of cystitis requires a 3-day course of antibiotics. Those with
complicated cystitis require 7 days of antibiotics and possible imaging studies. Asymptomatic
bacteruria does not necessarily need to be treated except if found in a pregnant women, before a
planned urinary tract surgery, or with associated urinary tract obstruction. Patients undergoing
nonurologic surgery also should be considered for treatment, especially those involving cardiac
valves or orthopedic hardware.