SCROTAL PAIN AND SWELLING
Scrotal pain may arise as a consequence of pathology within the scrotum itself (e.g., torsion of the testicles or its appendages, epididymo-orchitis) or it may be referred from disease elsewhere (e.g., the pain of ureteric colic may be referred to the testis).
The classic presentation of testicular torsion is one of sudden onset of acute pain in the hemiscrotum, sometimes waking the patient from sleep. It may radiate to the groin and/or the loin. There may be a history of mild trauma to the testis in the hours before the acute onset of pain. Similar episodes may have occurred in the past, with spontaneous resolution of the pain, suggesting torsion with spontaneous detorsion. Patients will be in considerable pain. They may have a slight fever. They do not like the testis being touched and will find it difficult to walk and to get up on the examination couch, as movement exacerbates the pain. The testis is usually swollen, very tender to touch, and may appear abnormally tense (if the patient lets you squeeze it!). It may be high-riding (lying at a higher than normal position in the scrotum) and may lie horizontally due to twisting of the cord. The testis may feel hard and there may be scrotal wall erythema.
6 H. HASHIM AND J.REYNARD
Epididymo-orchitis may present with similar symptoms. The localisation of tenderness in the epididymis and the absence of testicular tenderness may help to distinguish epididymo-orchitis from testicular torsion, but in many cases it is difficult to make a precise diagnosis on clinical grounds alone, and often testicular exploration is the only way of establishing the diagnosis with certainty.
Other scrotal pathology may present as acute scrotal swelling leading to emergency presentation. Rarely testicular tumours present as an emergency with rapid onset (days) of scrotal swelling. Very rarely they present with advanced metastatic disease (see Chapter 9).
Priapism is a painful persistent prolonged erection not related to sexual stimulation. Its causes are summarised in Chapter 6. Knowledge of these causes allows appropriate questions to be asked during history taking. The two broad categories of priap-sim are low flow (most common) and high flow. Low-flow pri-apism is essentially due to haematological disease, malignant infiltration of the corpora cavernosa with malignant disease, or drugs. High-flow priapism is due to perineal trauma, which creates an arteriovenous fistula. It is painless, unlike low priap-sim where ischaemia of the erectile tissue causes pain.