A 30-year-old man comes to the emergency department due to scrotal pain. The patient initially felt a sharp pain along his right groin yesterday morning after lifting weights. He tried resting and taking a warm bath, which initially improved his symptoms, but as the day progressed, the pain returned and was accompanied by nausea. The patient took a few doses of ibuprofen, but it did not help. The pain progressively worsened overnight; when the patient woke up this morning, he had difficulty walking and has vomited twice. Medical history includes an umbilical hernia that was surgically repaired at age 2. The patient takes no daily medications. Temperature is 37.7 C (99.9 F), blood pressure is 142/90 mm Hg, pulse is 110/min, and respirations are 20/min. Physical examination shows marked swelling, induration, and erythema of the right hemiscrotum. Ultrasound reveals that the right testicle is twice as large as the left. The right testicle is heterogeneous in echotexture and has a small hydrocele. Which of the following is the most likely cause of this patient's presentation?

Question

A 30-year-old man comes to the emergency department due to scrotal pain.  The patient initially felt a sharp pain along his right groin yesterday morning after lifting weights.  He tried resting and taking a warm bath, which initially improved his symptoms, but as the day progressed, the pain returned and was accompanied by nausea.  The patient took a few doses of ibuprofen, but it did not help.  The pain progressively worsened overnight; when the patient woke up this morning, he had difficulty walking and has vomited twice.  Medical history includes an umbilical hernia that was surgically repaired at age 2.  The patient takes no daily medications.  Temperature is 37.7 C (99.9 F), blood pressure is 142/90 mm Hg, pulse is 110/min, and respirations are 20/min.  Physical examination shows marked swelling, induration, and erythema of the right hemiscrotum.  Ultrasound reveals that the right testicle is twice as large as the left.  The right testicle is heterogeneous in echotexture and has a small hydrocele.  Which of the following is the most likely cause of this patient's presentation?

Quizplus · Accepted Answer

11ec25c8_d92c_c703_bc81_2d91fa9167a0_MD0003_00 This patient's abrupt-onset scrotal pain, testicular swelling (enlarged right testicle), and heterogeneous testicular echotexture with a small hydrocele are concerning for testicular torsion. This condition occurs due to insufficient fixation of the testis to the tunica vaginalis, which can lead to testicular hypermobility, twisting of the spermatic cord, ischemia, and necrosis. spermatic cord Although testicular torsion occurs most commonly in adolescent boys (due to rapid testicular growth during puberty), it can present in any age group. Patients typically develop acute-onset, severe scrotal pain, often after physical activity or mild testicular trauma; associated nausea and vomiting are common. Boys classically awaken at night due to pain, and some patients report prior episodes that resolved without intervention (intermittent torsion). Physical examination classically reveals a profoundly tender, enlarged, high-riding testicle associated with marked scrotal swelling and erythema. The cremasteric reflex (elevation of the ipsilateral testicle when the inner thigh is stroked) is absent. The diagnosis is often made clinically. However, Doppler ultrasound of the scrotum can be used for confirmation or in case of equivocal findings. It may demonstrate twisting of the spermatic cord or reduced blood flow, and a reactive hydrocele may be present. Heterogeneous echotexture, as seen in this patient, is a late finding indicating testicular necrosis, which develops after >12 hours of ischemia and can result in nonviability. Therefore, if testicular torsion is suspected, urgent urologic evaluation is indicated. (Choice A) Although inguinal hernias can cause a scrotal mass and present after elevated intraabdominal pressure (eg, weight lifting), pain is typically localized to the groin or abdomen rather than the scrotum, the testicles remain normal sized, and ultrasound demonstrates loops of bowel within the scrotum. (Choice B) Varicocele is characterized by dilation of the pampiniform plexus within the spermatic cord. Examination findings are often described as a "bag of worms" in the scrotum. Varicocele is often asymptomatic but may cause a dull pain that worsens with standing. (Choice C) Testicular neoplasms typically present subacutely as a painless, slow-growing testicular mass. Acute pain and swelling are more consistent with testicular torsion. (Choice D) Hydrocele is a collection of peritoneal fluid within the scrotum that forms due to a patent processus vaginalis; reactive hydrocele can occur in the setting of testicular trauma. While hydroceles cause scrotal swelling, they do not cause testicular enlargement and typically cause mild, dull pain rather than the acute, severe pain noted in this patient. Hydrocele Educational objective: Testicular torsion is caused by twisting of the spermatic cord and may result in testicular necrosis and nonviability. Patients have severe scrotal pain and swelling and may report prior episodes that resolved without intervention. A reactive hydrocele may be visible on ultrasound; heterogeneous echotexture indicates testicular necrosis.

A 30-Year-Old Man Comes to the Emergency Department Due to Scrotal