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Endgames Picture quiz

Testicular pain

BMJ 2009; 338 doi: (Published 26 February 2009) Cite this as: BMJ 2009;338:b259
  1. Gordon G Kooiman, consultant urologist ,
  2. Paul S Sidhu, consultant radiologist
  1. 1King’s College Hospital, London SE5 9RS
  1. Correspondence to: P S Sidhu paul.sidhu{at}

    A 17 year old man presented to the accident and emergency department with a seven hour history of sudden onset of left testicular pain and nausea. He did not have dysuria, urethral discharge, urinary frequency, rigors, or a history of scrotal trauma. He was not sexually active. On examination, his left testis was swollen and tender, and he had swelling and erythema of the scrotum. The contents of the right scrotum were normal. He was afebrile and urinalysis was normal. The patient underwent an ultrasound examination (fig 1).

    Fig 1 A “spectacle” view of both testes with colour Doppler ultrasound


    • 1 What is the likely diagnosis?

    • 2 What are the differential diagnoses?

    • 3 How should acute testicular pain be investigated and does colour Doppler ultrasound have a role?

    • 4 What is the correct management?


    Short answers

    • 1 Given the patient’s age, the acute onset of symptoms, associated nausea, and clinical findings, the likely diagnosis is that of spermatic cord torsion affecting the left testis.

    • 2. Differential diagnoses include acute and chronic epididymo-orchitis, torsion of the appendix testis (hydatid of Morgagni), intermittent spermatic cord torsion, trauma, segmental testicular infarction, Henoch-Schönlein purpura, occasionally tumour, and rarely a patent processus vaginalis with intra-abdominal sepsis—for example, appendicitis.

    • 3 Urine analysis for white blood cells and a full blood count for leucocytosis are useful. If time allows, colour Doppler ultrasound is useful for distinguishing between epididymo-orchitis and torsion (fig 2). Colour Doppler ultrasound may confirm the diagnosis when arterial flow is …

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