Testicular Conditions in Athletes: Torsion, Tumors, and Epididymitis

ABDOMINAL CONDITIONS
Testicular Conditions in Athletes: Torsion,
Tumors, and Epididymitis
Bradley Sandella, DO; Brett Hartmann, MD; David Berkson, MD; and Eugene Hong, MD
in the third trimester of pregnancy
through the processus vaginalis, an out
pouching of the peritoneum. Following this descent, the processus vaginalis
closes, and the remaining portion around
the testes becomes the tunica vaginalis,
which covers the anterior two-thirds of
the testis. The left testis usually suspends
lower than the right (16). The epididymis
is situated on the posterior margin of the
testis and is composed of a head, body,
and tail. The sinus of the epididymis, which is a recess of the
tunica vaginalis, spans the lateral surface of the testis and the
body of the epididymis.
The testis and epididymis are supplied by the testicular
artery, and their veins drain into the pampiniform plexus,
which forms the majority of the spermatic cord. Lymphatics
accompany the testicular vessels and drain into the aortic
nodes (16). When blood flow to the testicle is compromised,
usually a result of torsion, within 6 to 12 h, infarction and
atrophy of the testicle can develop.
Abstract
Individuals involved in sports are at risk for sustaining various injuries.
In addition to musculoskeletal complaints, male athletes are at risk of
incurring testicular injuries. These issues can range from an acute emergency such as testicular torsion to indolent testicular tumors. In contrast,
epididymitis can present in stages. Presentation and management of testicular complaints can vary depending on the condition. Physicians who
provide medical care to athletes need to be competent in diagnosing and
managing testicular injuries.
Introduction
Testicular conditions can occur in active sports medicine patients of all ages and abilities. Some conditions are
common, and some are less so, and some have devastating
consequences. The differential diagnosis for testicular pain
includes testicular torsion, epididymitis, hernia, varicocele,
testicle fracture, scrotal edema, or appendix testis torsion.
Successful management of any testicular condition includes
accurate evaluation and appropriate treatment. Consequently,
this also requires prompt recognition of the anatomic structures. This article will discuss three testicular conditions that
may be encountered by sports medicine physicians: testicular torsion, epididymitis, and testicular tumors. The sports
medicine physician should be familiar with the evaluation
of these three testicular conditions.
Testicular Anatomy
The testicle is the male gonad in mammals. During embryonic development starting at about week 4, the process
of male gonad development begins (9). Between the third
month of pregnancy and delivery, the testes become transferred from the lumbar area into the future scrotum, secondary to a combination of growth processes and hormones
including insulin-like peptide hormone 3 and testosterone (14).
The testes pass through the abdomen and into the scrotum
Drexel University College of Medicine, Philadelphia, PA
Address for correspondence: David Berkson, MD, Drexel University
College of Medicine, Philadelphia, PA (E-mail: [email protected]).
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Testicular Torsion
Testicular torsion is the twisting of the spermatic cord
causing severe pain and ischemia of the testicle. This condition is a true urologic emergency and must be differentiated from other etiologies of testicular pain because a delay
in diagnosis and management can lead to loss of the testicle
(8). When blood flow to the testicle is compromised, infarction and atrophy can develop within 6 to 12 h.
Though testicular torsion can occur at any age, including the prenatal and perinatal periods, it most commonly
occurs in adolescent boys. About 65% of cases present
between 12 and 18 years with an overall incidence of 1 in
4,000 males per year before 25 years (2). Interestingly,
in regards to the active sports medicine patient, only 4%
to 8% of testicular torsion cases result from trauma V most
cases have no acute traumatic precipitating event.
There are two different groups of torsion: extravaginal
and intravaginal. Extravaginal torsion mostly is seen in neonates because of an undescended testicle and involves torsion
of the testes, spermatic cord, and processus vaginalis. Intravaginal torsion is caused by a congenital malformation of
the processus vaginalis, creating a ‘‘bell clapper deformity,’’
Testicular Injuries in the Athlete
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which is the failure of normal posterior anchoring of the
gubernaculum, epididymis, and testis, allowing the testis to
rotate freely within the tunica vaginalis. In this malformation,
the tunica vaginalis covers not only the testicle and the epididymis but also the spermatic cord. This type of torsion
accounts for about 90% of cases and typically presents in
adolescent boys (5). A larger testicle due to either normal
variation or a tumor increases the risk of torsion (3).
Signs and Symptoms
Testicular torsion usually presents with an acute onset of
diffuse unilateral testicular pain and tenderness of less than
6 h of duration. Many of the symptoms of testicular torsion
are similar to the infection epididymitis (13) as shown in
the Table. About half of patients with torsion complain of
nausea and vomiting, and about one in four complains of fever
(3). Typical presentation does not involve urinary symptoms
such as dysuria, hematuria, frequency, or discharge. Scrotal
edema develops rapidly, however, and often obscures the
physical examination findings. A ‘‘blue dot sign’’ may be visible, which is a blue discoloration upon transillumination;
this may be consistent with torsion of the appendix testis.
The Prehn sign, a decrease in pain with physical lifting of
the testicle, will relieve pain in epididymitis but not the pain
caused by testicular torsion. Although a classic physical examination finding, it has not been found to be reliable in distinguishing torsion from other causes of testicular pain (26).
The most reliable examination findings are absence of the
cremasteric reflex and the affected testis palpated in a horizontal lie (26).
Evaluation
Because of the risk of rapid progression to testicular
ischemia, acute testicular torsion should be evaluated immediately. It is a surgical emergency, and rapid surgical
exploration is required and the gold standard for diagnosis. Upon presentation, there should be a complete genitourinary examination, while also monitoring the patient’s
level of pain and ability to ambulate and communicate appropriately (25). Early in testicular torsion, the testicle is
firm, swollen, and tender. The cremasteric reflex is a vital
part of the evaluation of testicular pain and is performed by
stroking the superior medial thigh in a downward motion
while observing the scrotum. The normal response is a
contraction of the cremasteric muscle, which elevates the
scrotum and testis on the stroked side. This reflex is absent
in testicular torsion but present in torsion of the appendix
testis (11). Multiple studies have determined the loss of this
reflex in testicular torsion to be 99% sensitive (12,18).
Laboratory results do not provide much aid in the diagnosis of testicular torsion. A urinalysis is typically normal,
but up to half of patients may have an elevated white blood
cell count. If a diagnosis is not certain, high-frequency color
Doppler ultrasound is the preferred imaging modality when
looking for decreased or absent perfusion (8). Sensitivity is
between 86% and 100%, and specificity is 97% to 100%
(3). A more accurate study is a radionuclide testicular
scintigraphy with 99mTc with a sensitivity and specificity of
98% and 100%; however, it is more time-consuming and
not as readily available (3).
Treatment
With prompt diagnosis and treatment, the testicle can be
saved. Prompt surgical exploration and correction are the
treatment of choice (26). In some instances, the testicle can
untwist on its own, or it can be untwisted manually in a
process called ‘‘detorsion,’’ with success evaluated by the
degree of pain relief. Because, typically, the testis rotates
toward the midline, the examiner should attempt to rotate
the testis laterally toward the thigh (as if opening a book)
after cooling the scrotum and performing a cord block with
lidocaine if possible (25); 66% of torsions are rotated in the
medial direction. If relief is not achieved, an attempt to
rotate the testis in the opposite direction can be considered.
Manual detorsion is successful in 26% to 80% of patients
based upon a number of different studies (19).
Testicular torsion that cannot be reduced is a surgical
emergency that needs immediate intervention. If treated
within 6 h, there is about a 90% chance of saving the
testicle. Within 12 h, the rate decreases to 50%; within 24 h,
Table
Testicular torsion versus epididymitis.
Testicular Torsion
Age of onset
Presence of pain
Presence of swelling
Urinary symptoms (dysuria, hematuria)
Prehn sign
Epididymitis
12- to 18-yr-old males
18- to 50-yr-old males
Acute onset, severe pain
Gradual onset with varying levels of pain
Present
Present
Not present
Often present
Negative for pain relief
Positive for pain relief
Cremasteric reflex
Absent
Present
Urinalysis
Normal
Possible leukoesterase and white blood cells seen
Decreased perfusion
Increased perfusion
Appearance of scintigraphy
Appearance of ultrasound
Absence or decreased blood flow
Increased blood flow
Treatment of choice
Surgery
Antibiotics
Severity of condition
Medical emergency
Urgency
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the rate decreases to 10%; and after 24 h, the rate approaches zero (26). Once the testicle is dead, it must be
removed to prevent gangrenous infection. All torsions
require exploratory surgery of the contralateral testis, and
orchiopexy of both testes should be performed to prevent
recurrence. Return-to-play principles after testicular torsion
include healing of surgical wounds, if any, and resolution
of any testicular pain of symptoms. Current recommendations also include use of a protective cup for high-risk sports.
Epididymitis
Epididymitis is a condition in which the epididymis becomes inflamed. It can be classified into one of three
categories V acute, subacute, and chronic V depending on
the duration of symptoms (24). Acute epididymitis is the
most common cause of acute-onset scrotal pain when
symptoms of pain and swelling are present for less than
6 wk (24). Acute epididymitis is also the most common
cause of intrascrotal inflammation, typically caused by retrograde bacterial infection into the ejaculatory duct (24).
Chronic epididymitis is characterized by pain usually without swelling that persists for more than 3 months. Subacute
epididymitis usually consists of mild tenderness and no dysuria for greater than 6 wk and less than 3 months. Orchitis
is seen when the inflammation spreads to the adjacent testicle.
There are approximately 600,000 cases of epididymitis
per year in the United States, typically occurring in men
between 18 and 50 years (15). It is the fifth most common
urological condition in men of this age (23). The most common cause is sexually transmitted infections by Neisseria
gonorrhoeae or Chlamydia trachomatis. In the younger
and older age groups, epididymitis generally is caused by
common urinary pathogens such as Escherichia coli. Although less common, noninfectious etiologies include vasculitides, sarcoidosis, Behc¸et disease, and medications such
as amiodarone.
Signs and Symptoms
Epididymitis usually presents with gradual onset of pain
localized posterior to the testis with potential radiation
to the lower abdomen (24). The testicle may be warm
and/or red. Other symptoms of urinary tract infections
such as fever, tachycardia, frequency, urgency, hematuria,
and dysuria also may be present (24).
Evaluation
When evaluating a patient with acute testicular pain and
swelling, the diagnosis should be testicular torsion until
proven otherwise. Whereas testicular torsion usually presents as rapid-onset pain, epididymitis and orchitis have a
gradual onset of pain. The scrotum should be examined for
a tender or an indurated spermatic cord, which is common
in epididymitis, and for the lie of the testis, which is usually
in its normal anatomical position as opposed to torsion in
which it often lays transversely. The cremasteric reflex is
normal. Pain relieved by elevation of the testicle or the
Prehn sign is common in epididymitis but nonspecific and
should not be used in diagnosis. It is important to check for
costovertebral angle tenderness, a sign of pyelonephritis.
The inguinal area should be examined for hernias or lymphadenopathy.
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Diagnostic studies can help confirm epididymitis and rule
out other pathologies. Gram staining of urethral discharge
should be performed to detect bacterial urethritis. Urinalysis may be normal, but the presence of leukocyte esterase and white blood cells is suggestive of urethritis (24). In
all patients with suspected epididymitis, color Doppler
ultrasound is the preferred test. It can demonstrate increased blood flow, as opposed to testicular torsion with
decreased blood flow. Measuring C-reactive protein and
erythrocyte sedimentation rate levels also has been shown
to be a useful aid in the diagnosis of epididymitis, with a
sensitivity and specificity of up to 96% (7).
Treatment
If epididymitis is suspected, antibiotics should be initiated. The treatment of choice is a single dose of 250 mg
of intramuscular ceftriaxone and twice-daily 100 mg of
doxycycline for 10 d. If compliance is an issue, a single dose
of 1 g of per os azithromycin may be substituted for the
doxycycline. For cases caused by enteric organisms such as
E. coli, a fluoroquinolone is recommended (21). In children,
fluoroquinolones and doxycycline should be avoided, and
cephalexin is recommended (24). When treating athletes and
active patients, caution needs to be exercised with using fluoroquinolones because of the increased incidence of tendon
ruptures. If there is a sexually transmitted disease, the partner
also should be treated.
Pain control usually is necessary and aided by cold compresses and elevation of the scrotum, as well as narcotics or
anti-inflammatories. While an epididymitis patient typically
can be treated as an outpatient with close follow-up, hospitalization is indicated for severe cases, which include
intractable pain, vomiting, abscess formation, and signs of
sepsis. Surgery rarely is necessary, except, for example, in
rare instances of abscess formation.
Testicular Tumors
In American men aged 20 to 35 years, primary testicular
tumors represent the most common solid malignancy, and
for unknown reasons, the incidence has increased over the
last century (20). This alarming trend forces physicians to
be more vigilant in recognizing and treating this condition.
Roughly 1 in 300 males will develop a testicular tumor, but
because of its responsiveness to treatment, the mortality
rate is 1 in 5,000 with a 5-year survival rate of 90% to 95%
(20). The keys to the high survival rate are early detection
and an accurate treatment protocol.
Testicular neoplasms can be divided into two broad categories. Germ cell tumors (GCT) make up more than 90%,
while non-germ cell tumors (non-GCT) only account for
less than 10% of testicular cancers. The most common
GCT is the seminoma followed by the embryonal cell carcinoma and mixed testicular GCT. The incidence of these
tumors increases after the onset of puberty (1). In contrast,
non-GCT, including the yolk sac tumor and teratoma, are
rare in adults and usually occur in children (1). The two
most common risk factors for the development of a tumor in an adult are cryptorchidism or a prior history of a
GCT (1).
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Signs and Symptoms
Patients with a testicular tumor usually present with a
painless mass found either by the patient or by the physician
on routine examination. If there is discomfort, it often is
reported as a dull ache or sense of heaviness in the scrotum.
Sharp pain, which is an uncommon symptom, can be reported and is usually secondary to bleeding or a hematoma (10).
an appropriate evaluation including physical examination
and diagnostic testing, and develop an optimal course of
management.
The authors have no conflict of interest and do not have
any financial disclosures.
Evaluation
After completion of a detailed history, the physical examination usually reveals a small nontender palpable lesion
at the posterior aspect of the affected testicle. Once a lesion
is identified, the scrotum should be transilluminated. A
solid mass will not allow light to pass through or give a red
glow. A secondary examination of the chest should be performed to evaluate for gynecomastia, as well as evaluation
of the abdomen.
Follow-up testing includes diagnostic imaging and laboratory testing. Scrotal ultrasonography will help define suspect lesions (10) revealing a hypoechoic signal (6). Magnetic
resonance imaging also can be employed and will demonstrate a mass that is relatively isointense on T1 imaging and
enhancement with intravenous gadolinium on T2 imaging
(6). Obtaining tumor markers, > fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase also is useful
for monitoring progression but cannot be used to screen or to
make an initial diagnosis.
References
Treatment
Radical orchiectomy is the treatment of choice for testicular tumors. An inguinal approach through the spermatic
cord is the preferred method to help reduce the incidence of
scrotal recurrence, lymph node metastases (10), or nerve
injury. Adjunct treatment with radiation and chemotherapy
also is used. Consideration for lymph node dissection also is
necessary because tumor cells can spread along lymph
channels to the retroperitoneal cavity. Finally, follow-up
serum markers can be obtained to check for elimination or
recurrence.
Preventive measures also can be taken. To decrease the
risk of cancer, undescended testicles should be treated
before puberty with orchiopexy (17). In addition, identification of bilateral undescended testis places the patient at
even a greater risk for cancer, so careful examination and
treatment of the entire scrotum need to be performed (22).
Athletes who suffer from testicular cancer and undergo
treatment may return to sport participation after treatment
without limitation. Once surgical wounds have healed and
pain is resolved, full return is possible with the recommendations to use a protective cup for high-risk sports (4).
Considering that the athlete is playing with a solitary organ,
risk counseling should occur. In addition, information on
sperm banking should be made available to the patient.
12. Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics.
1998; 102(Pt 1):73Y6.
Conclusions
Testicular conditions can occur to males in all levels of sport.
Three not uncommon and potentially serious conditions are
testicular torsion, epididymitis, and testicular tumors. To achieve the best possible outcome in these testicular conditions, it
is critical to form a thorough differential diagnoses, perform
24. Trojian TH, Lishnak TS, Heiman D. Epididymitis and orchitis: an overview.
Am. Fam. Physician. 2009; 79:583Y7.
www.acsm-csmr.org
1. Bahrami A, Ro JY, Ayala AG. An overview of testicular germ cell tumors.
Arch. Pathol. Lab. Med. 2007; 131:1267Y80.
2. Barada JH, Weingarten JL, Cromie WJ. Testicular salvage and age-related
delay in the presentation of testicular torsion. J. Urol. 1989; 142:746Y8.
3. Black TL. Testicular torsion. In: Bracker MD, Rice EL, Yassini P, editors.
The 5-Minute Sports Medicine Consult. Baltimore (MD): Lippincott Williams
& Wilkins; 2001. p. 1058Y9.
4. Boyajian-O’Neill L, Cardone D, Dexter W, et al. Preparticipation Physical
Evaluation. 3rd ed. Minneapolis: McGraw-Hill; 2004. p. 100.
5. Candocia FJ, Sack-Solomon K. An infant with testicular torsion in the
inguinal canal. Pediatr. Radiol. 2003; 33:722Y4.
6. Coakley FV, Hricak H, Presti JC. Imaging and management of atypical testicular masses. Urol. Clin. North Am. 1998; 25:375Y88.
7. Doehn C, Fornara P, Kausch I, et al. Value of acute-phase proteins in the
differential diagnosis or acute scrotum. Eur. Urol. 2001; 39:215Y21.
8. Dogra V, Bhatt S. Acute painful scrotum. Radiol. Clin. North Am. 2004;
42:349Y63.
9. Gilbert S. Developmental Biology. 6th ed. Sunderland (MA): Sinauer Associates, Inc.; 2000. Chapter 17.
10. Junnila J, Lassen P. Testicular masses. Am. Fam. Physician. 1998; 57:685Y92.
11. Kadish H. Pediatric surgical emergencies: the tender scrotum. Clin. Pediatr.
Emerg. Med. 2002; 3:55Y61.
13. Karmazyn B, Steinberg R, Kornreich L, et al. Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys. Pediatr.
Radiol. 2005; 35:302Y10.
14. Kubota Y, Temelcos C, Bathgate RA, et al. The role of insulin 3, testosterone,
Mu¨llerian inhibiting substance and relaxin in rat gubernacular growth.
Mol. Hum. Reprod. 2002; 8:900Y5.
15. National Center for Health Statistics. National Ambulatory Medical Care
Survey. 2001. Hyattsville (MD): Centers of Disease Control and Prevention,
National Health Services; 2002. Available from: http://www.cdc.gov/nchs/
data/ad/ad337.pdf.
16. O’Rahilly R, Muller F, In: Carpenter S, Catlin B, Fabricant A, Lyons
McDaniel M, editors. Basic Human Anatomy. Philadelphia: W.B. Saunders
Co.; 1982: Chapter 34.
17. Pettersson A, Richiardi L, Nordenskjold A, et al. Age at surgery for undescended testis and risk of testicular cancer. N. Engl. J. Med. 2007; 356:
1835Y41.
18. Rabinowitz R. The importance of the cremasteric reflex in acute scrotal
swelling in children. J. Urol. 1984; 132:89Y90.
19. Rupp TJ, Zwanger M. Testicular torsion in emergency medicine. Available
from: http://emedicine.medscape.com/.
20. Sachdeva K, Mansoor J, Isaam M, et al. Testicular cancer. Available from: http://
emedicine.medscape.com.
21. Smith DM. A really big pain: acute epididymitis. AIDS Read. 2008. 18:
453Y5.
22. Swerdlow AJ, Higgins CD, Pike MC. Risk of testicular cancer in cohort of
boys with cryptorchidism. BMJ. 1997; 314:1507Y11.
23. Tracy CR, Steers WD, Costabile R. Diagnosis and management of epididymitis. Urol. Clin. North Am. 2008; 35:101Y8.
25. Schneck FX, Bellinger MF. Acute scrotum. In: Walsh PC, Retik AB, Vaughan
ED, Wein ED, editors. Campbell’s Urology. 8th ed. Philadelphia (PA):
Elsevier Science; 2002. p. 2379Y84.
26. Wampler SM, Llanes M. Common scrotal and testicular problems. Prim.
Care. 2010; 37:613Y26.
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