News & Events: Member Articles

“It Hurts Down There”
By Fred Ginsburg, MD

For a 12 year old boy, there aren't even words he can use to communicate to parents that he's having testicular pain. A huge problem when testicular torsion causes the pain. Caused by what? “TESTICULAR TORSION” While postage stamps advertise breast cancer, and the evening news trumpets vaccinations to reduce cervical cancer, boys are left at their own devises when facing this urological emergency. So before going any further the first message of this article, designed so every male understands the wording:

“IF YOUR NUT HURTS, GET HELP” and the corollary “SCAN IT OR LOSE IT”

Now that the initial message is out there, the gals can leave the room so this talk can just be among us men. Testicular torsion occurs when the testicle twists around its blood supply which cuts off the blood flow. This results in severe pain (imagine foot vs. groin), can cause scrotal swelling, and abdominal pain. It can hurt so bad you can puke your guts out. The problem, without a blood supply, the testicle starts to die. Within 6 to 8 hours the chance of saving the testicle starts to drop rapidly and after 12 hours kiss it goodbye, it's dead.

Okay, can we all agree that this is a bad? But when was the last time you heard of this? Example: in a particular month I encountered four patients with this problem. Two came in too late to save the testicle, neither fellow having a clue what might be going on. That's right, despite severe pain and vomiting, they did not want to tell anyone or seek help until it was too late. Another fellow came in time simply because the pain was too much to bear. The fourth had the father in disbelief figuring it was just a dodge to get out of school.

Soon after seeing these patients, I was asked to give some Cub Scouts their health lecture for rank advancement....Going through the book: wrap broken leg with twigs, yawn, wash your hands when you have a cold, duh, call help if someone falls to the floor clutching their chest, you think? Wait a minute. I realize that this is nuts; nothing about, well, nuts. Even in a chapter geared for young men there is nothing in regards to torsion. That's when I developed the above slogans. (Bumper stickers and brown ribbons soon to be available)

There might be early warnings that this may occur. Some experience sudden pain that may go away and then can come back. This is a warning sign. If the pain hits and doesn't go away then seek medical help immediately. The twisting can occur with trauma, getting kicked without a protective cup could cause the twisting. Trauma, exercise, over active sex, or nothing in particular can cause the twist which requires repair. While the peak age of this occurs at age 14, most cases occur in men under 30, it can happen at any age.

The first step, and the largest problem, is recognizing that this is an emergency and that your family jewels are at stake. However, most young boys don't want to tell anyone. Many boys will think they'll be accused of doing something they shouldn't have been doing, or don't realize it could have such drastic consequences. To reiterate: If one of your testicles hurt, you need to be evaluated right now to make sure it lives long and prospers.

Now that you've made this decision to get in route here's the process:

  1. Do not eat or drink anything and note the time the pain occurred. Also try to remember if you've had pain on and off in the past. Don't go to the bathroom until the hospital since they will probably want a urine sample.
  2. The next step is to get to an emergency department. If this is a younger child and there isn't a large distance to a children's hospital, then that's where you should go.
  3. Once there, be direct and to the point: “Sudden onset of testicular pain 2 hours ago.” Don't dance around the issue “I have a little problem down below” or “I have the stomach flu and I'm vomiting.” Dancing around the issue is not a good idea; it might make the difference between you being seen right now or enjoying the magazines in the waiting room.
  4. Despite the tight time line with this process, there still might be a delay in getting the patient back to a room. The key thing here is to make sure that the triage nurse understands that this may be torsion and “time is testicle.” The vast majority of emergency nurses will already be formulating a plan when they hear the words “sudden testicular pain.” The key things in the triage area are to stay calm, be ready to systematically answer questions as quickly and crisply as possible. (See below for questions)
  5. This should get you back relatively quickly at which time and exam will be performed and if the physician concurs the pain medication will be ordered along with an ultrasound. Sometimes an attempt to untwist the testicle may be tried at bedside.
  6. If the ultrasound is positive (Shows that there is no or reduced blood flow to a testicle), then surgery would be the next step to straighten the testicle and get the blood supply going..
  7. The surgery is relatively straight forward and would also include fixing of the other testicle, since it is also prone to twist. Once repaired, it is considered a permanent fix.

Here are some questions you should be ready to answer, but don't greatly delay going to the hospital to find out the answers:

  1. When did this pain start? What were you doing when it started? Have you been having this pain on and off for a while? How would you rate the pain on a scale of 1 to 10 (despite the pain, 10 is still the maximum)
  2. Have you been having burning when you urinate? Any blood in the urine? Been vomiting or diarrhea? Has there been any trauma to the area.
  3. Any past medical history of surgeries (especially hernia surgery or any surgery involving the testicles), history of an undescended testicle, any reaction to medications or surgical anesthesia? Any family history of the above?
  4. When was the last time you ate or had something by mouth? (The answer better not be a McDonald's happy meal while in the waiting room).
  5. Who is your family physician? Do you have a preference of a urologist? Don't worry if you don't have a preference for a urologist, and realize that there only may be one urologist on call at that hospital to take emergency cases. A urologist is a surgeon who specializes in this area.

There are other processes that can cause testicular pain, these will all be addressed at the time of your visit, and these include:

  1. Kidney stone
  2. Orchitis which is not a burning flower, but an inflammation of the testicle caused by an infection including Mumps.
  3. Epididymitis which is an inflammation of some surrounding structures.
  4. Trauma causing a contusion and swelling
  5. A hernia, which is some bowel content going into the scrotum or pitching on one of the nerve.

The key factor in all the above however is rapid diagnosis and treatment, none of this can occur if the problem isn't recognized early and treatment sought early. While there is a 6 hour window, 2 to 3 of these hours can be tied up in the emergency department running tests, having the test results evaluated and then, if needed, getting a surgical team assembled to correct the problem.

So as a friendly reminder, here's a poem for guys to live by:

“When the pain makes you pout
It may be a case of Twist and Shout
Better come in to check things out
So the final diagnosis isn't in doubt

Pain increases, Scrotum will grow
Things are miserable down below
To the E.R. now you must go
Or soon a duet will become a solo.”

Fred Ginsburg, MD, MBA, FAAEM
Academy of Medicine of Toledo and Lucas County