Examination

Examination should respect the patients’ privacy and assess the abdomen, scrotum and penis. Consent should be gained and a chaperone should be present.

The abdomen: Assess for tenderness, hernias and lymphadenopathy

The scrotum and penis

Inspection: Look for swelling, erythema, the lie of the testicle, penile rash/dishcharge. The “Blue Dot Sign” may be difficult to see but occurs in a torted testicular appendange.¹²

Palpation: Palpate the testicle and scrotum to assess any masses or tenderness. Localised oedema may develop rapidly in torsion making assessment difficult.

Is it within or surrounding the testis? Typically, in epididymitis the pain is localised there, as opposed to torsion where the pain is diffuse.

How does the testis lie? The normal testis rests vertically with the epididymis above the superior pole in a posterolateral position. A torted testis is often high riding with a horizontal lie.

Special Tests: The Cremasteric Reflex is elicted by stroking the inner thigh, and elevation of the ipsilateral testis should be observed if present. In testicular torsion this reflex is commonly absent with a high (but not absolute) negative predictive value.¹³ Prehn’s Sign is demonstrated by elevating the scrotum which in theory relieves the pain of epididymitis, but not torsion.

Learning Bite

History and Examination may make one diagnosis more likely than another, but no key feature can completely rule out torsion.

Differentials

Trauma	Testicular trauma may cause torsion, testicular rupture or haematoma which should be referred to a urologist or surgeon for a specialist opinion and possible intervention.
Inguinal Hernias	May have a history of fluctuant testicular swelling. These have the potential to become irreducible and incarcerated causing pain and discomfort.
Fournier’s Gangrene	This is necrotising fasciitis of the perineum and is a urological emergency. It is more common in diabetes and vasculopaths. Presents with severe pain and rapidly spreading necrotic cellulitis.
Malignancy	Testicular cancers typically present in men aged 15-40 years with a small hard lump within the testis with/without pain. If any concern an USS may be indicated.
Oedema	Peripheral oedema may progress up the legs to the testes causing diffuse swelling and pain; this will require diuretics and medical management.
Cysts/Hydroceles	Cyst and hydroceles should be relatively painless, but may cause a heavy or dragging sensation.
Referred Pain e.g. Renal Colic, AAA, Appendicitis	Abdominal pain may be referred into the groin and testes. It is important to complete a thorough abdominal examination and consider these differentials, particularly in older patients.