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the most common cause of scrotal pain

epididymitis (posterior and inferior)


Hx of epididymitis

1. Gradually increasing pain and swelling (over days)
2. Dysuria/Fever


MC ways an epididymitis get's infected


BUT not always infectious can be
Trauma”, Autoimmune dz, Vasculitis


Prehn’s Sign

Elevation of the scrotum relieves pain

This is unreliable to differentiate Testicular Torsion but is supposed to help you differentiate


Cremasteric Reflex

1. Stroking the thigh on the affected side causes the ipsilateral testis to pull upwards
a. Can use for testicular torsion


predominant method of choice for dx testicular complaints

what would epididymitis look like


Inflammation increases blood flow which shows up on the doppler

if blood is not getting to the testicle you might suspect something like torsion

also STD testing, ULS (hydrocele), urine culture (E.coli, pseudomonas)


Tx for epididymitis

UA, STD Testing, ?ULS (reactive Hydrocele Vs.)

Possible Urine culture (E.coli, Pseudomonas,)

Presumptive Therapy:

F/U instructions/expectations


Presumptive Therapy for epididymitis

Ceftriaxone 250 mg IM and Doxycycline or azithromyocin 100mg PO BID X days
(can't tell if gonorrhea or chlamydia)

If over age 35, consider Levofloxacin 500 mg qd X 10 days

Analgesics, SITZ baths, Scrotal Support (jock strap so that the testicles don’t bounce)


hydrocele is a collection of fluid where

painful or nah?

Collection of fluid between the Parietal and Visceral layers of the Tunica Vaginalis.

arise over a longer period of time
usually asymptomatic BUT increasing pain w/ increasing size


hydrocele dx

Dx: Transillumination

on ULS you see tis as


tx for a hrydocele

iv. Treatment rarely needed, Aspiration doesn’t work, Surgery will.

Most large hydroceles need to go to the urologist who will decide on surgery but it’s not preferred b/c it causes recurrent hydroceles



dilation of the Pampiniform plexus of spermatic veins. Left hemiscrotum.

ii. 20% of men; more common on the L
iii. Occas. Dull, achy pain.


DX test for ULS

Put your hands on the scrotum and ask them to grunt or bear down (valsalva) and it should dilate the vessels or can use ULS and have them bear down


how would you treat varicocele

Scrotal Support, NSAID, Surgery for infertility.


Epididymal cysts and Spermatoceles

are found where

Arise on the head of the epididymis, when larger than 2cm called Spermatoceles


Epididymal cysts and Spermatoceles vs cancer presentation

Generally asymptomatic, found on ULS
if they do get too large they can cause discomfort

Testicular Cancer

Usually painless, unless it causes hemorrhage or infarction


Testicular cancer ULS

less homogenous on ULS
can look abnormal

want to get a CT to look for METS most commonly to the lungs


Orchitis is defined as ___

what sxs do we see associated

Extension of epididymal infection into the testes, or complication of Mumps.

More systemic symptoms:

Fever, myalgias, malaise, parotid swelling


inguinal hernia is the result of

Failure of adequate embryonic closure of the Processus vaginalis in the inguinal canal, allowing intestines to force downwards into the scrotal sac.


inguinal hernia sx

Uncomfortable but not acutely painful, usually reducible by a push or lying supine. Often gradually enlarge.


Inguinal Hernia on PE

supine, and if not palpable, standing.
1. If acutely painful, think:
a. Obstructed vs. Incarcerated vs. Strangulated

"i think it is an inguinal hernia that is likely reducible. I have not reduced one before but could i practice"


dx tests for inguinal hernia

ULS/CT --> look with ULS but can’t tell where bowel gets narrow and pinched on the side so CT is very useful for this


can you push an inguinal hernia back in

Let the surgeon decide to push -->if you push dead bowel back inside, then the dead bowel gets dead-er


tx of inguinal hernia

Scrotal Support, Analgesics, Stool softeners, Surgical Referral.


CAT scan with air

necrotizing fasciitis seen as dark black hyperecohoic air


blue dot sign for



Torsion of the Appendix Testis

Caused by the infarction/necrosis of the appendix testis. Rare in adults.


Most common scrotal pathology in children

Torsion of the Appendix Testis


Torsion of the Appendix Testis sxs

7-14 y.o.

Pain usually more gradual than testicular torsion.

Tenderness localized to the anterosuperior testis and no swelling to the testis or epididymis.


tx of torsion of the appendix

Pain Control