For a 12 year old boy, there aren't even words he can use to
communicate to parents that he's having testicular pain. A huge problem
when testicular torsion causes the pain. Caused by what? “TESTICULAR
TORSION” While postage stamps advertise breast cancer, and the evening
news trumpets vaccinations to reduce cervical cancer, boys are left at
their own devises when facing this urological emergency. So before going
any further the first message of this article, designed so every male
understands the wording:
“IF YOUR NUT HURTS, GET HELP”
and the corollary
“SCAN IT OR LOSE IT”
Now that the initial message is out there, the gals can leave the room so
this talk can just be among us men. Testicular torsion occurs when the
testicle twists around its blood supply which cuts off the blood flow.
This results in severe pain (imagine foot vs. groin), can cause scrotal
swelling, and abdominal pain. It can hurt so bad you can puke your guts
out. The problem, without a blood supply, the testicle starts to die.
Within 6 to 8 hours the chance of saving the testicle starts to drop
rapidly and after 12 hours kiss it goodbye, it's dead.
Okay, can we all agree that this is a bad? But when was the last time you
heard of this? Example: in a particular month I encountered four patients
with this problem. Two came in too late to save the testicle, neither
fellow having a clue what might be going on. That's right, despite severe
pain and vomiting, they did not want to tell anyone or seek help until it
was too late. Another fellow came in time simply because the pain was too
much to bear. The fourth had the father in disbelief figuring it was just
a dodge to get out of school.
Soon after seeing these patients, I was asked to give some Cub Scouts
their health lecture for rank advancement....Going through the book: wrap
broken leg with twigs, yawn, wash your hands when you have a cold, duh,
call help if someone falls to the floor clutching their chest, you think?
Wait a minute. I realize that this is nuts; nothing about, well, nuts.
Even in a chapter geared for young men there is nothing in regards to
torsion. That's when I developed the above slogans. (Bumper stickers and
brown ribbons soon to be available)
There might be early warnings that this may occur. Some experience sudden
pain that may go away and then can come back. This is a warning sign. If
the pain hits and doesn't go away, then seek medical help immediately. The
twisting can occur with trauma, getting kicked without a protective cup
could cause the twisting. Trauma, exercise, over active sex, or nothing in
particular can cause the twist which requires repair. While the peak age
of this occurs at age 14, most cases occur in men under 30, it can happen
at any age.
The first step, and the largest problem, is recognizing that this is an
emergency and that your family jewels are at stake. However most young
boys don't want to tell anyone. Many boys will think they'll be accused of
doing something they shouldn't have been doing, or don't realize it could
have such drastic consequences. To reiterate: If one of your testicles
hurt, you need to be evaluated right now to make sure it lives long and
prospers.
Now that you've made this decision to get in route here's the process:
1.
Do not eat or drink anything and note the time the pain occurred.
Also try to remember if you've had pain on and off in the past. Don't go
to the bathroom until the hospital since they will probably want a urine
sample.
2.
The next step is to get to an emergency department. If this is a
younger child and there isn't a large distance to a children's hospital,
then that's where you should go.
3.
Once there, be direct and to the point: “Sudden onset of testicular
pain 2 hours ago.” Don't dance around the issue “I have a little problem
down below” or “I have the stomach flu and I'm vomiting.” Dancing around
the issue is not a good idea, it might make the difference between you
being seen right now or enjoying the magazines in the waiting room.
4.
Despite the tight time line with this process, there still might be
a delay in getting the patient back to a room. The key thing here is to
make sure that the triage nurse understands that this may be a torsion and
“time is testicle.” The vast majority of emergency nurses will already be
formulating a plan when they hear the words “sudden testicular pain.” The
key things in the triage area is to stay calm, be ready to systematically
answer questions as quickly and crisply as possible. (See below for
questions)
5.
This should get you back relatively quickly at which time and exam
will be performed and if the physician concurs the pain medication will be
ordered along with an ultrasound. Sometimes an attempt to untwist the
testicle may be tried at bedside.
6.
If the ultrasound is positive (Shows that there is no or reduced
blood flow to a testicle), then surgery would be the next step to
straighten the testicle and get the blood supply going..
7.
The surgery is relatively straight forward and would also include
fixing of the other testicle, since it is also prone to twist. Once
repaired, it is considered a permanent fix.
Here's some questions you should be ready to answer, but don't greatly
delay going to the hospital to find out the answers:
1.
When did this pain start? What were you doing when it started? Have
you been having this pain on and off for a while? How would you rate the
pain on a scale of 1 to 10 (despite the pain, 10 is still the maximum)
2.
Have you been having burning when you urinate? Any blood in the
urine? Been vomiting or diarrhea? Has there been any trauma to the area.
3.
Any past medical history of surgeries (especially hernia surgery or
any surgery involving the testicles), history of an undescended testicle,
any reaction to medications or surgical anesthesia? Any family history of
the above ?
4.
When was the last time you ate or had something by mouth? (and the
answer better not be a McDonald's happy meal while in the waiting room).
5.
Who is your family physician? Do you have a preference of a
urologist? Don't worry if you don't have a preference for a urologist, and
realize that there only may be one urologist on call at that hospital to
take emergency cases. A urologist is a surgeon who specializes in this
area.
There are other processes that can cause testicular pain, these will all
be addressed at the time of your visit, these include:
1.
Kidney stone
2.
Orchitis which is not a burning flower, but an inflammation of the
testicle caused by an infection including Mumps.
3.
Epididymitis – Which is an inflammation of some surrounding
structures.
4.
Trauma causing a contusion and swelling
5.
A hernia, which is some bowel content going into the scrotum or
pitching on one of the nerve.
The key factor in all the above however is rapid diagnosis and treatment,
none of this can occur if the problem isn't recognized early and treatment
sought early. While there is a 6 hour window, 2 to 3 of these hours can be
tied up in the emergency department running tests, having the test results
evaluated and then, if needed, getting a surgical team assembled to
correct the problem.
So as a friendly reminder, here's a poem for guys to live by:
When the pain makes you pout
It may be a case of Twist and Shout
Better come in to check things out
So the final diagnosis isn't in doubt
Pain increases, Scrotum will grow
Things are miserable down below
To the E.R. Now you must go
Or soon a duet will become a solo.
Fred Ginsburg, MD, MBA, FAAEM
Academy of Medicine of Toledo and Lucas County
