Hello,
Thanks for asking your question. Although I am an internal medicine
physician, please see your primary care physician for specific
questions regarding any individual cases – please do not use Google
Answers as a substitute for medical advice. I will be happy to answer
factual medical questions.
You asked the following:
"I have this pain in the scrotum that no one seems to be able to
diagnose, what could cause it?"
First of all, let me state clearly that scrotal pain is an indication
to see a physician. I will give factual information about the causes
and evaluation of scrotal pain to better inform you as a patient.
The spectrum of conditions that affect the scrotum and its contents
ranges from incidental findings that merely require explanation and
reassurance to the patient to acute pathologic events that require
expeditious diagnosis and treatment.
The differential diagnosis of acute scrotal pain primarily includes
testicular torsion, appendiceal torsion, and epididymitis, although a
few other problems also may result in acute scrotal pathology.
Evaluation of acute scrotal pathology should begin with a thorough
history, followed by a detailed examination of the abdomen, testes,
epididymes, cord, scrotal skin, and inguinal region. A urinalysis also
should be performed since pyuria and/or bacteriuria suggest an
infectious etiology such as epididymitis. An experienced clinician can
often render an accurate diagnosis based upon the history and physical
examination alone, although advances in color Doppler imaging of the
scrotum have made this a useful adjunct to the physical examination in
equivocal cases.
1) Testicular torsion
Testicular torsion is the most dramatic and potentially the most
serious of the acute processes affecting the scrotal contents. It is
predominantly seen in neonates and postpubertal boys, although it can
occur at any age. The onset of pain is usually sudden, and often
occurs several hours after vigorous physical activity or minor
testicular trauma. There may be associated nausea and vomiting. A
history of trauma also suggests that testicular rupture be considered
in the differential diagnosis. Another typical presentation,
particularly in children, is awakening with scrotal pain in the middle
of the night or in the morning, likely related to cremasteric
contraction with nocturnal sexual stimulation during the rapid eye
movement (REM) sleep cycle. The patient should be asked about prior
similar episodes that might suggest intermittent testicular torsion.
Surgical intervention should occur emergently when the diagnosis of
testicular torsion can be made clinically based upon the history and
physical examination, since the duration of testicular ischemia
determines the clinical outcome. If the etiology of an acute scrotal
process is equivocal, color Doppler ultrasonography is the diagnostic
test of choice to differentiate testicular torsion from torsion of the
appendix testis or epididymitis.
2) Torsion of the appendix testis
The appendix testis is a small vestigial structure on the
anterosuperior aspect of the testis (an embryologic remnant of the
Müllerian duct system). It measures about 0.3 cm and its pedunculated
shape predisposes it to torsion, which can then produce testicular
pain that ranges from mild to severe. Its onset is usually more
gradual than with testicular torsion; it is not uncommon for patients
to have several days of scrotal discomfort from appendiceal torsion
before they present for evaluation. Testicular ultrasound will show
the torsed appendage as a lesion of low echogenicity with a central
hypoechogenic area.
Management of acute torsion of the appendix testis may be operative or
non-operative.
Conservative treatment includes rest, ice, and antiinflammatory
medications; recovery is generally slow with this approach and pain
may last for several weeks to months. The infarcted tissue is usually
reabsorbed; however, it is not uncommon to palpate a calcific nodule
on the tunica albuginea on the anterosuperior testicular surface in a
patient who has had a torsed appendix testis.
Surgical excision of the appendix testis, while not necessary, is safe
and quick, and patients can usually resume normal activity without
pain in a few days.
3) Epididymitis
The epididymis is a tightly coiled tubular structure located on the
posterior aspect of the testis from its superior to inferior poles.
Epididymitis is a common inflammatory/infectious condition that can be
categorized as acute, subacute, or chronic. It is characterized by
severe swelling and exquisite pain in the involved side, often
accompanied by high fever, rigors, and irritative voiding symptoms
(frequency, urgency, dysuria) secondary to a urinary tract infection.
It is commonly seen in conjunction with acute prostatitis,
particularly in older men who may have underlying prostatic
obstruction as a risk factor. Recent instrumentation is also a risk
factor. A more typical presentation is an otherwise healthy male
complaining of scrotal pain. Several factors may predispose
post-pubertal boys and men to develop subacute epididymitis, including
sexual activity, heavy physical exertion, and bicycle or motorcycle
riding.
Treatment varies according to the severity of the case at
presentation. Acutely febrile, septic patients often require
hospitalization for intravenous hydration and parenteral antibiotics.
Ice, scrotal elevation, and nonsteroidal antiinflammatory drugs
(NSAIDs) are helpful adjuncts. Less severe cases can be treated with
oral antibiotics, ice, and scrotal support. Treatment of nonbacterial
epididymitis is conservative, including scrotal support, rest, NSAIDs,
and possibly antibiotics.
4) Trauma
It is not uncommon for boys and men to suffer minor episodes of
scrotal trauma; only rarely does a severe testicular injury result,
usually due to compression of the testis against the pubic bones from
a direct blow or straddle injury.
5) Mumps
Epididymo-orchitis is the most common complication of mumps infection
in the adult male. It is frequently characterized by the abrupt onset
of fever from 39 to 41ºC and severe testicular pain, accompanied by
swelling and erythema of the scrotum; bilateral involvement is noted
in up to 30 percent of cases. (1)
I stress that this answer is not inteneded as and does not substitute
for medical advice - please see your primary care physician for
further evaluation of your individual case.
Please use any answer clarification before rating this answer. I will
be happy to explain or expand on any issue you may have.
Thanks,
Kevin, M.D.
Internet search strategy:
No internet search engine was used in this research. All sources were
from objective physician-written and peer reviewed sources.
Bibliography:
Eyre, R. Evaluation of scrotal pathology. UptoDate, 2002.
Links:
Cigna.com
http://www.cigna.webmd.com/question_and_answer/article/1685.52038
EMR Textbook
http://www.thrombosis-consult.com/articles/Textbook/148_scrotal.htm
GMO Manual
http://forum.nomi.med.navy.mil/cd/CD013/DATA/operationalmed/Manuals/GMO%20Manual/clinical/Acute%20Scrotal%20Pain.html |
