Problems of the penis and testicles

Painful testicle

If a male complains of a painful testicle, examine both testicles. Look for discoloration or swelling. If a testicle has been injured by a blow, provide support with an improvised jockstrap and apply cold packs. If a testicle suddenly becomes painful, particularly in an adolescent, and appears swollen and/or discolored, usually without a penile discharge, it might be twisted, or “torsed.” If a painful testicle appears to be resting in a higher position than the other testicle, particularly if it appears swollen and/or has a horizontal orientation, suspect testicular torsion. Since this usually happens if the testicle rotates inward (toward the midline) ( Fig. 143 ), gently see if you can rotate it outward (looking from above, like opening a book) within the scrotum. If this causes a dramatic relief of pain, you might have saved the testicle. If the testicle rotates easily but the severe pain is not reduced, be prepared to continue the outward rotation, because the testicle might have torsed itself by rotating completely, up to twice around. If the maneuver increases the pain and appears to shorten the “hang” of the testicle, you might be worsening the torsion and might attempt rotating the testicle in the opposite direction.

If you believe an unresolved torsion is present, this is an emergency, and the victim should be rushed to a physician. If a torsion is not resolved within the first 4 to 6 hours, the testicle might be lost. The pain is usually followed by swelling in the scrotum and groin region. Sometimes the affected testicle is seen to be slightly higher than the uninvolved testicle. The pain might be of a severity to cause the victim to become nauseated or vomit, and to feel faint.

If a testicle is swollen and the victim complains of pain or burning on urination, he may be suffering from infection or inflammation of the epididymis (called epididymitis), which is part of the sperm-collection pathway (see Fig. 143 ). Other symptoms include lower abdominal, flank, or groin pain. If the case is severe, the victim might suffer fever, chills, nausea, and muscle aches. This should be treated with doxycycline (100 mg twice a day), tetracycline (500 mg four times a day), levofloxacin (250 mg daily), norfloxacin (400 mg twice a day), or trimethoprim–sulfamethoxazole (one double-strength tablet twice a day) for 10 days. Another diagnosis to consider, particularly in an adolescent male, is a sexually transmitted disease (see Penile Discharge, below). If epididymitis is diagnosed, the victim will require decreased activity for a few days, and scrotal support using an athletic garment. (See fluoroquinolone antibacterial drugs precaution on page 498.)

One way to help distinguish epididymitis from testicular torsion is to gently elevate the scrotum—in general, with epididymitis the pain is diminished, whereas with torsion it is commonly increased, although this is not absolute.