A 21-year-old previously healthy man comes to the emergency department with acute onset of severe left scrotal pain and nausea. The pain started after he returned home from the gym following an intense workout. He denies any trauma, fever, or dysuria. Examination shows a swollen and tender left testis that lies higher than the right testis. Doppler ultrasound shows decreased arterial blood flow in the left spermatic cord entering the testis. Which of the following is the likely origin of the artery involved in this patient's condition?

Question

A 21-year-old previously healthy man comes to the emergency department with acute onset of severe left scrotal pain and nausea.  The pain started after he returned home from the gym following an intense workout.  He denies any trauma, fever, or dysuria.  Examination shows a swollen and tender left testis that lies higher than the right testis.  Doppler ultrasound shows decreased arterial blood flow in the left spermatic cord entering the testis.  Which of the following is the likely origin of the artery involved in this patient's condition?

Quizplus · Accepted Answer

11ec160b_3590_8dd7_9249_0bb279e9b232_MD0001_00 The gonadal arteries arise from the abdominal aorta slightly below the renal arteries. Each gonadal artery courses obliquely downward and laterally within the retroperitoneal space near the psoas major muscle. After crossing anteriorly over the ureter, the gonadal arteries run parallel to the external iliac vessels and eventually traverse the inguinal canal to supply the testes via the spermatic cord in males. This patient most likely has testicular torsion, which is usually due to inadequate fixation of the lower pole of the testis to the tunica vaginalis. Testicular torsion is caused by twisting of the spermatic cord, resulting in compression of the pampiniform plexus of the testicular vein and reduced venous outflow. Arterial blood flow in the testicular arteries is initially preserved or slightly decreased, leading to engorgement and eventual hemorrhagic infarction. Torsion is characterized by acute, severe pain with nausea/vomiting, an asymmetrically high-riding testis, and absent cremasteric reflex (elevation of testis while pinching the skin in upper thigh). (Choices B and C) The external and internal iliac arteries arise from the common iliac artery. The external iliac artery travels underneath the inguinal ligament and becomes the femoral artery, which supplies the lower extremity. The internal iliac artery provides blood supply to the pelvic wall/viscera, buttock, female reproductive organs, bladder, and medial thigh. (Choice D) The internal pudendal artery is a branch of the internal iliac artery and provides blood supply to the anal canal, scrotum, and penis. However, it does not provide blood supply to the testis. (Choice E) The obturator artery arises from the internal iliac artery and provides blood supply to the pelvis, bladder, and parts of the femoral head and medial thigh muscles. (Choice F) The renal artery provides blood supply to the kidney. Branches of the renal artery supply the ureter but do not travel to the testis. Unlike the gonadal arteries, the gonadal veins arise from different structures. The right gonadal vein drains directly into the inferior vena cava while the left gonadal vein drains into the left renal vein. Educational objective: Testicular torsion is due to twisting of the testis around the spermatic cord (containing the gonadal artery), which can eventually lead to ischemia. The gonadal arteries arise from the abdominal aorta. The right gonadal vein drains directly into the inferior vena cava while the left gonadal vein drains into the left renal vein. __________ References: Testicular torsion: diagnosis, evaluation, and management. (http://www.ncbi.nlm.nih.gov/pubmed/24364548)

A 21-Year-Old Previously Healthy Man Comes to the Emergency Department