What Causes Testicular Pain?

Patient Presentation
A 17-year-old male came to clinic with a 3 week history of what he described as intermittent left testicular pain. It occurred only during the day and would occur randomly, lasting for a few seconds to a few minutes. The pain occurred mainly in the lower abdomen but would come into the upper scrotal area. He described it as a pressure-type pain not a stabbing/cutting pain. He said there was no inguinal masses. He denied sexual activity, masturbation, trauma, or excessive exertion. He denied any inguinal swelling, swelling or erythema of the scrotum, testes or penis and no penile discharge. He was an athlete who wore compression clothing but not a protective cup or athletic supporter. The review of systems showed no fever, chills, nausea, emesis, constipation, diarrhea or dysuria.

The pertinent physical exam showed normal vital signs and growth parameters. His genitourinary examination showed Tanner V pubertal changes with no skin changes, erythema or edema. There was no specific swelling in the inguinal area. His left testicle was slightly higher than the right and was oriented longitudinally. There was no tenderness of the testicle, the epididymis or the anterior or superior area of the testicle. The spermatic cord had no “bag of worms.” Palpation of the area of the inguinal ring re-created the pain. No specific “silk-bag” sign or bulging could be appreciated but the ring seemed slightly larger/looser on the left than on the right. There was a normal cremesteric reflex on both sides. The pallus was normal without discharge. The diagnosis of a probable indirect inguinal hernia with referred intermittent pain was made.

The work-up included a normal urinalysis and screening for sexually transmitted infections that were normal. The patient was referred to a general surgeon and given instructions on when to seek care sooner if the pain intensified or changed.

Discussion

Most inguinal hernias are indirect (i.e. the hernia passes through the internal inguinal ring and down the inguinal canal); only 2% of all hernias in children are direct hernias (i.e. the hernia directly protrudes through the floor of the inguinal canal). Indirect inguinal hernias occur in about 1-5% of infants. They occur on the right side (60%), left side (30%) and bilaterally (10%) and they are more common in premature infants of both sexes. The male : female ratio of inguinal hernias is 4-8 : 1.

The chief complaint of testicular or scrotal pain always raises concerns. The acute scrotum generally has pain, edema, erythema and warmth. Although acute scrotum is considered a surgical emergency because of the need to treat testicular torsion promptly, most cases are nonemergent. The most common causes of acute scrotum are torsion of the appendix testis or epididymitis depending on the study. One 18 year retrospective of surgically confirmed cases found 9.8% of all urological surgical admissions were for acute scrotum. Of these, 74.7% were for torsion of the appendix testis, 8.4% were for testicular torsion, 5.8% were for tunica vaginalis inflammation, 3.7% were for epididymitis, and 7.2% were for other causes.

Prompt referral to urology for evaluation and treatment of an acute scrotum should be made. Ultrasound evaluation can be helpful to aid with diagnosis particularly determining how much blood flow there is to the testes. Other ultrasonic findings can include edema of the epididymis (for epididymitis),

The differential diagnosis of abdominal pain can be found here.
The differential diagnosis of scrotal swelling can be found here.

Learning Point
The differential diagnosis of testicular/scrotal pain includes:

  • Testes
    • Testicular torsion – usually has unilateral severe scrotal pain and may be associated with nausea, emesis, elevation of testes, absence of cremesteric reflex, horizontal positioning of testes, and scrotal edema. Occurs most often in neonates and adolescent boys.
    • Epididymitis – usually has an insidious onset, painful epididymis, and normal placement of testes and cremesteric reflex. It may also be associated with scrotal edema or have dysuria. Common pathogens in younger males are adenovirus, enterovirus and Mycoplasma. In adolescents, Neisseria gonorrhea and Chlamydia trachomatis may occur. E. coli is also common if there are associated anatomic abnormalities.
    • Torsion of the appendix testis – occurs often in school age boys, and has painful superior area point tenderness. There may be a blue-dot sign.
    • Torsion of embryonic remnant of testis or epididymis
    • Tunica vaginalis swelling
    • Trauma
    • Orchitis – classically associated with mumps virus but also associated with sexually transmitted diseases or HIV.
    • Fournier gangrene
    • Testicular infarction
    • Testicular tumor – usually painless
    • Hydrocoele – usually painless
    • Varicoele – usually painless
  • Referred pain
    • Appendicitis
    • Hernia
    • Irritation of innervation of the genitourinary structures – ilioinguinal, iliohypogastric, genitofemoral, pudendal
    • Urolithiasis
  • Other
    • Henoch Schonlein purpura
    • Skin problems – rash, insect bites

Questions for Further Discussion
1. What testing should be considered for an acute scrotum?
2. What is the time period over which a testicle may become non-viable if there is testicular torsion?
3. What is the treatment for epididymitis?

Related Cases

    Symptom/Presentation: Pain

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Testicular Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Yang C Jr, Song B, Liu X, Wei GH, Lin T, He DW. Acute scrotum in children: an 18-year retrospective study. Pediatr Emerg Care. 2011 Apr;27(4):270-4.

Boettcher M, Bergholz R, Krebs TF, Wenke K, Treszl A, Aronson DC, Reinshagen K. Differentiation of epididymitis and appendix testis torsion by clinical and ultrasound signs in children. Urology. 2013 Oct;82(4):899-904.

Munden MM, Williams JL, Zhang W, Crowe JE, Munden RF, Cisek LJ. Intermittent testicular torsion in the pediatric patient: sonographic indicators of a difficult diagnosis. Am J Roentgenol. 2013 Oct;201(4):912-8.

Van Heurn LW, Pakarinen MP, Wester T. Contemporary management of abdominal surgical emergencies in infants and children. Br J Surg. 2014 Jan;101(1):e24-33.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • How Common Is Developmental Dysplasia of the Hip in Infants With Breech Presentation?

    Patient Presentation
    A 1-week-old female came to clinic for her health supervision visit. Breastfeeding was going well and mild clinical jaundice had resolved. The past medical history showed a full-term female with no prenatal risk factors who had been born by Cesarean section for breech presentation. The family history was negative for orthopaedic issues.

    The pertinent physical exam showed an alert infant. Her weight was 3.26 kg (50%), length of 48% (50%) and head circumference of 35 cm (90%). Her examination was notable for erythema toxicum neonatorum on her cheeks and a normal hip examination. The diagnosis of a healthy female was made and routine parent education was given. The physician did schedule a screening hip ultrasound because of the breech delivery. The patient’s clinical course at 1 month found her to be in good health with growth parameters consistent with birth. The radiologic evaluation of a hip ultrasound showed developmental dysplasia of the left hip. The patient was sent to Orthopaedics who placed her in a Pavlik harness. At her 2 month check up she was doing well with only minimal intermittent skin irritation from the harness.

    Case Image

    Figure 115 – Coronal views from a hip ultrasound exam show a normal right hip (above) with the right femoral head well centered in the right acetabulum and a dysplastic left hip (below) with the left femoral head displaced laterally out of the shallow left acetabulum.

    Discussion
    Developmental dysplasia of the hip (DDH) includes several abnormalities where the femoral head and the acetabulum are not aligned normally or grow abnormally. This includes hips that are dislocatable, dislocated, dysplastic and subluxed. The natural history and pathophysiology are poorly understood.

    Screening can lead to earlier identification, but there are high rates of spontaneous resolution in the newborn period that require no intervention. Resolution rates are 60-80% if identified by physical examination and 90% resolve if identified by ultrasound examination in studies. Physical examination screening includes the Barlow and Ortolani examinations. Barlow examination is the adducting of a flexed hip with posterior force to identify a dislocatable hip. Ortolani examination is the abducting of a flexed hip with anterior force to relocate a dislocated hip. Some people remember Barlow is “back” (gentle force to push the femoral head backward) and Ortolani is “out” (the femoral head is out of place and is realigned with the gentle anterior force). These maneuvers can be difficult to perform in a manner that provides consistent accuracy. A review of other physical examination signs can be found here.

    Ultrasound examination is another screening and diagnostic technique. In some studies ultrasound has a high false-positive rates which could lead to unnecessary treatment and followup. It is felt that this is due to operator dependence. In other studies ultrasound has high rates of intraobserver and inter-observer reliability. Screening recommendations differ by different professional groups and can be found at the National Guideline Clearinghouse link in the To Learn More section below.

    DDH treatment includes abduction devices such as the most commonly used Pavlik harness or less commonly a hip spica cast. Surgical procedures which are even less common involve reduction of the femoral head into the acetabulum and potentially other procedures on the acetabulum, femur or hip adductor tendons. If DDH is left untreated problems such as pain, osteoarthritis, leg length discrepancies, and gait abnormalities may occur. Even if treated there still exists the possibility of hip deformity and osteoarthritis in later life.

    Learning Point
    DDH incidence is between 1.5-20 per 1000 births. Of patients identified with DDH only 10-27% have risk factors for DDH other than female gender. Risk factors include:

    • *Breech delivery
    • *Family history of DDH
    • *Female gender
    • Congenital anomalies
    • Interuterine postural deformities
    • Oligohydramnios
    • Primiparity
    • High birth weight

    *These are the most consistent risk factors for DDH.

    Risks for clinical hip instability or DDH are:

    • Breech females – 84 per 1000
    • Family history positive females – 24 per 1000
    • Breech males – 18 per 1000
    • Females without risk factors – 14 per 1000
    • Males without risk factors – 3 per 1000

    Questions for Further Discussion
    1. What is the Graf classification?
    2. What are indications for surgical intervention for DDH?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Hips Injuries and Disorders
    and at Pediatric Common Questions, Quick Answers for this topic: Developmental Dysplasia of the Hips

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Lehmann HP, Hinton R, Morello P, Santoli J. Developmental dysplasia of the hip practice guideline: technical report. Committee on Quality Improvement, and Subcommittee on Developmental Dysplasia of the Hip. Pediatrics. 2000 Apr;105(4):E57.

    Shipman SA, Helfand M, Moyer VA, Yawn BP. Screening for Developmental Dysplasia of the Hip: A Systematic Literature Review for the US Preventive Services Task Force. Pediatrics 2006;117;e557

    US Preventive Services Task Force. Screening for Developmental Dysplasia of the Hip: Recommendation Statement. Pediatrics. 2006:117(3); 898 -902.

    Mahan ST, Kasser JR. Does Swaddling Influence Developmental Dysplasia of the Hip? Pediatrics. 2008;121(1);177-178.

    Fox AE, Paton RW. The relationship between mode of delivery and developmental dysplasia of the hip in breech infants: a four-year prospective cohort study. J Bone Joint Surg Br. 2010 Dec;92(12):1695-9.

    American Academy of Orthopaedic Surgeons. Developmental Dislocation (Dysplasia) of the Hip (DDH). Developmental Dislocation (Dysplasia) of the Hip (DDH)
    Available from the Internet at http://orthoinfo.aaos.org/topic.cfm?topic=a00347 (rev. 10/13, cited 6/17/14).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Causes Proteinuria?

    Patient Presentation
    A 16-year-old female came to clinic because of 2 days of dysuria. She was having some increased frequency and also pain with urination. She wasn’t sure if the pain began with the bladder contracting or when her urine stream touched her genital area. She denied fever, chills, nausea, emesis, constipation or pain with defecation. She also denied previous bladder infections or sexual activity. The family history was negative for renal disease or hearing problems. The social history showed her to be a cross-country runner who had increased her mileage the past week by almost 50%. The review of systems was negative.

    The pertinent physical exam showed a healthy female with no distress. Her blood pressure was 106/62, pulse of 68 and respiratory rate of 16. She was afebrile and her growth parameters showed a weight of 25%, and height of 75%, consistent with previous measurements. Her abdomen examination was negative including no suprapubic or costovertebral angle tenderness. Genitourinary examination revealed diffuse erythema of the vaginal area and perineum.

    The diagnosis of skin irritation due to contact with sweat and clothing friction was made. The patient was advised to change into clean clothing often, not tuck her shirt into her pants to help keep moisture away from the genital area and to use sports lubrication products to decrease the friction from her clothing. Because a bladder infection could not be fully ruled-out a laboratory evaluation of a urine dip was done and showed a specific gravity of 1.015, 2+ protein and negative leukocyte esterase and blood. Because of the protein, the physician reviewed her chart more closely and saw normal blood pressure readings and also a BUN and creatinine that were normal during an emergency room visit for head trauma The physician thought that the proteinuria was most likely due to the increase in exercise. The patient’s clinical course over the next few weeks found none to 1+ protein in the urine, and which resolved after the cross-country season finished.

    Discussion
    Proteinuria occurs relatively often in pediatric practice with 5-15% of school children having transient proteinuria, the most common cause. However, proteinuria can be a sign of kidney disease. Therefore, it is important to evaluate the proteinuria in light of the clinical situation. A good history and physical examination along with a full urinalysis and/or BUN and creatinine, or urine protein/creatinine ratio may be all that is necessary. Another patient with edema, hypertension or hematuria needs a fuller evaluation and treatment. Proteinuria is usually categorized into three groups to assist with evaluation and treatment and they include: transient, orthostatic or persistent.

    Transient means just that. It occurs only during the inciting problem and remits afterwards. It generally is < 2+ on a dipstick. Proteinuria due to fevers usually resolves in 10-14 days, and exercise induced proteinuria remits within 48 hours of the exercise.

    Orthostatic (postural) proteinuria is proteinuria that occurs in the upright position only. It can be intermittent or persistent. It is the most common cause of asymptomatic proteinuria in children especially adolescents. Protein excretion in the recumbent position is < 4 mg/m2/hr and in the upright or ambulatory position is 2-4 times this amount.

    Persistent asymptomatic isolated proteinuria occurs in children and laboratory and clinical testing is otherwise normal. The protein is monitored every 6-12 months and if protein is rising then renal biopsy may be indicated. Glomerular diseases all have proteinuria. One of the most common in children is nephrotic syndrome due to minimal change disease. Nephrotic syndrome has the following characteristics: proteinuria, hypoalbuminemia, hypercholesterolemia and edema.

    An urine dipstick is often used to interpret proteinuria. The amounts of protein are shown here:

    Trace = 10-20 mg/dL
    1+ = 30 mg/dL
    2+ = 100 mg/dL
    3+ = 300 mg/dL
    4+ = 1000-2000 mg/dL

    “A urine sample is positive for protein if the dipstick is [> or =] 1+ on a urine sample with a specific gravity of [ 1.015, the dipstick must be [> or =] 2+ to be considered positive.”

    Learning Point
    The differential diagnosis of proteinuria includes:

    • Transient proteinuria
      • Cold exposure
      • Congestive heart failure
      • Epinephrine administration
      • Exercise
      • Fever
      • Seizures
      • Serum sickness
    • Orthostatic
    • Persistent asymptomatic isolated proteinuria
      • Glomerular disease
        • Nephrotic syndrome, minimal change
        • Alport syndrome
        • Glomerulonephritis
          • Membranoproliferative
          • Post-infectious
        • Henoch-Schonlein purpura
        • HIV-associated nephropathy
        • IgA nephropathy
        • Sickle cell anemia
        • Systemic lupus erythematosus, nephritis
        • Vasculitis
      • Tubulointerstitial disease
        • Fanconi anemia
          • Dent’s disease
        • Interstitial nephritis
        • Ischemia
        • Reflux nephropathy
        • Renal dys- or hypoplasia
        • Medications
          • Aminoglycosides
          • Lithium
          • Penicillin

    Questions for Further Discussion
    1. What are indications for renal biopsy with proteinuria?
    2. What are causes of falsely-positive proteinuria on dipstick?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Urine and Urination and Kidney Diseases.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Ariceta G. Clinical practice: Proteinuria. Eur J Pediatr. 2011 Jan;170(1):15-20.

    Hladunewich MA, Schaefer F. Proteinuria in special populations: pregnant women and children. Adv Chronic Kidney Dis. 2011 Jul;18(4):267-72.

    Kaplan BS, Pradhan M. Urinalysis interpretation for pediatricians. Pediatr Ann. 2013 Mar;42(3):45-51.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

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