Differentials
Testicular appendix torsion
SIGNS / SYMPTOMS
Pain located superiorly on testicle; onset is more gradual than in testicular torsion.
Not associated with symptoms such as nausea and vomiting.
Blue spot can be observed through the scrotal skin: the 'blue dot sign'.
On physical examination, there may be a normal cremasteric reflex.
INVESTIGATIONS
Colour Doppler ultrasound will demonstrate increased blood flow.
Urinalysis usually normal.
Epididymitis or epididymo-orchitis
SIGNS / SYMPTOMS
Pain located inferiorly and posterior to testicle.
Pain and swelling typically develops over the course of a few days, unlike testicular torsion, which is usually of sudden onset.
The epididymis can be felt as a tubular structure that lies posterior to the testis and runs in a sagittal plane.
Diffuse enlargement of the testis will be present in epididymo-orchitis.
Frequent and painful micturition are common features of lower urinary tract infection that can be associated with epididymitis.
INVESTIGATIONS
Colour Doppler ultrasound confirms the diagnosis: epididymis is enlarged and hyperaemic.[32]
Diagnosis by urethral swab and culture can detect associated sexually transmitted infections (e.g., positive culture of Neisseria gonorrhoeae or Chlamydia trachomatis).
May have an abnormal urinalysis.
Hydrocele
SIGNS / SYMPTOMS
On physical examination the scrotum will trans-illuminate with light.
The scrotal swelling is likely to be soft if the communication is large, or tense if it is small. It may be restricted to the scrotum or it may extend into the inguinal canal.
There may be enlargement of the scrotal swelling following activity and is typically at its worst at the end of the day.
INVESTIGATIONS
Scrotal ultrasound examination can confirm the presence of a hydrocele.
Trans-illumination when a focused beam of light is shone on the scrotum.
Varicocele
SIGNS / SYMPTOMS
Painless scrotal swelling which has been described to feel like “a bag of worms”. Palpation of enlarged veins during Valsalva manoeuvre is diagnostic on physical examination.
INVESTIGATIONS
Physical examination is diagnostic, but colour Doppler ultrasonography can be used for confirmation.
Scrotal ultrasound with colour flow Doppler imaging will show presence of varicocele or identification of subclinical varicocele.
Testicular cancer
SIGNS / SYMPTOMS
There may be no pain.
Mass has a gradual onset and may be an incidental finding on examination.
Not usually associated with sudden-onset testicular pain unless possibly associated with epididymo-orchitis or intra-tumoural haemorrhage.[19]
Neonatal scrotal haematoma
SIGNS / SYMPTOMS
On physical examination, there may be a normal lie of the affected scrotum and a normal cremasteric reflex on the affected side.
INVESTIGATIONS
Ultrasound may show an intra-testicular or extra-testicular mass.[4] Acute haemorrhage would appear hyper-echoic.[19] As haemorrhage ages, the ultrasound appearance would appear hypo-echoic or develop into a complex cyst.[19] Ultrasound should not show vascular flow because haematomas lack vascularity.
Isolated orchitis
SIGNS / SYMPTOMS
Signs of inflammation such as erythema, fever, and pain may be present.
Mostly caused by mumps or HIV.
If sexually active, suspect sexually transmitted infections.
Fournier's gangrene
SIGNS / SYMPTOMS
Clinically the patient will appear extremely unwell.
There may be an associated fever with frank necrotic tissue and crepitus.
INVESTIGATIONS
Ultrasound will show thickening of scrotal skin with a normal testicle.[19] The pathognomonic ultrasound finding is multiple hyper-echoic foci within the scrotal skin indicating gas within the scrotal wall.[19]
CT pelvis will show soft-tissue gas with possible fascial thickening and fat stranding. The aetiology of the gangrene may also be identified such as a peri-anal abscess or an incarcerated inguinal hernia.
Inguinal hernia
SIGNS / SYMPTOMS
May be a history of heavy lifting or previous surgery.
May detect a mass in the inguinal canal that may be non-reducible.[38]
Inguinoscrotal swelling with inability to palpate the spermatic cord superiorly.
On physical examination, there may be a normal lie and a normal cremasteric reflex.
INVESTIGATIONS
Ultrasound will show abnormal ballooning of the anteroposterior diameter of the inguinal canal and, occasionally, a pad of fat or segment of the bowel is seen.
CT of groin will show solid mass in the groin that follows the course of the spermatic cord.
Renal colic
SIGNS / SYMPTOMS
Flank pain.
On physical examination, there may be a normal testicular lie and a normal cremasteric reflex.
INVESTIGATIONS
Ultrasound may reveal hydronephrosis or hydro-ureter on the affected side.
Spiral CT of the abdomen/pelvis may show the location and size of the renal stone.
Urinalysis may show microscopic haematuria.
Henoch-Schonlein purpura
SIGNS / SYMPTOMS
Also known as IgA vasculitis.
Physical examination may reveal a palpable skin rash associated with colicky abdominal pain and arthralgia.
May also be scrotal tenderness and/or ecchymosis mimicking testicular torsion.[19] The incidence of scrotal manifestations (e.g., painful swelling and ecchymosis) ranges from 2% to 38% of cases of Henoch-Schonlein purpura, and about 3% of all cases of acute scrotum are caused by scrotal involvement of Henoch-Schonlein purpura.[19]
History of prior upper respiratory tract infection.
INVESTIGATIONS
Urinalysis may show red blood cells, proteinuria, or casts.
Abdominal ultrasound may show intussusception or perforation of the bowel, or testicular swelling.
Ultrasound of testicles may show testicular swelling.
Acute appendicitis
SIGNS / SYMPTOMS
Right lower quadrant abdominal pain, and possibly fever, nausea, and vomiting. Localised tenderness and guarding.
INVESTIGATIONS
Ultrasound or CT of the abdomen would reveal an inflamed appendix.
Spermatocele
Idiopathic testicular infarction
SIGNS / SYMPTOMS
Sudden-onset testicular pain.
May develop oedema and erythema.
INVESTIGATIONS
Rare entity with no definitive diagnostic test. Emergent surgical consult and early surgical exploration is advisable.[39]
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