© The Canadian Journal of Urology™; 21(Supplement 2); June 2014
will show that there is good blood flow to the testicle,
witha small defect inflowat theupper pole of the testicle.
Testicular torsion
A patient—usually a young man—will typically
present in the middle of the night with an exquisitely
tender total testicle. There can be significant scrotal
swelling (edema) and often swelling in the scrotal skin
as well. This will often suggest a testicular torsion,
which is an acute emergency. The testicle will usually
twist on the spermatic chord. Initially, venous return
will be lost, causing pain and more swelling. Once
the venous blockage reaches a certain level, it will
cause secondary decreased arterial inflow leading to
an infarcted or dead testicle.
One usually has about 6 hours from the time of pain
onset until the emergency repair to salvage the testicle.
Because of the twisting on the chord, the testicle will
normally be higher in the scrotum and not hanging in
the normal vertical axis.
Epididymitis/orchitis
In this case, a man, usually older than 30, will present
with a very tender epididymis or tender testicle or
both. The scrotal skin will not be edematous and the
testicle will be lower in the scrotum and hanging in the
normal position. The patient will usually have a fever
and signs of a UTI. The theory is that there is a sudden
increase in abdominal pressure at the same time that
a few drops of urine leak into the prostatic fossa. It
can be secondary to heavy lifting, a bowel movement,
or even sexual activity. The result is that some urine
will reflux either through the vas deferens or some
of the pelvic veins, usually first into the epididymis
and later into the testicle causing inflammation or a
significant infection.
The following maneuver may sometimes help
distinguish between testicular torsion and acute
epididymal-orchitis. With the patient lying down,
if one elevates the scrotum, there will be an impact
on the perceived pain. If the patient has an infection,
the elevated scrotum encourages the testicle to drain,
which reduces some of the swelling and results in
reduced pain. If the pain is secondary to torsion, then
elevation of the scrotum does not allow fluid to drain
away, because the drainage is blocked, and the pain
may be exacerbated.
Some men report that they had some swelling in
their testicles and then later developed severe pain.
This could represent bleeding into a testicular tumor.
Men should do a testicular self-examination every
month. If they detect a hard, non-tender lump, they
should seek prompt medical attention.
The best way to assess a patient with acute scrotal pain is
with an emergency color ultrasound Doppler (USD). This
will tell you if there is decreased or increased blood flow to
the testicle (torsion versus infection/inflammation) or if there
is fluid around the testicle or a hernia. It will also suggest
if there is a mass within the testicle.
Urinary tract infections
In a female patient, a sudden onset of urinary frequency,
urgency, and dysuria with or without hematuria, and
without fever usually signifies a bout of simple cystitis.
Sometimes this is related to sexual intercourse or
prolonged retention of urine.
For women who present with a UTI for the first
time, a 3 day course of antibiotics is usually sufficient.
If urine-culture-provenUTIs recur more than two times
a year, then a 10 day course of antibiotics and awork up
with renal and pelvic ultrasound (KUB) is appropriate.
If any abnormality is found (such as an elevated post
void residual urine volume, hydronephrosis, or a renal
or ureteric stone) or if awoman hasmore than twoUTIs
in a year, then she should be referred to a urologist.
Simple lifestyle changes such as wearing cotton
underpants, wiping in the right direction, not holding
the urine, double voiding, and voiding after intercourse
may help prevent the recurrence of simple cystitis.
If a woman has confirmed fever or an elevated
white blood cell count with the UTI, then she should be
referred to a urologist after antibiotic treatment. Any
man with a documented, urine-culture-proven UTI
should be referred to a urologist after the first attack.
For a complete review of UTIs see Mazzulli et al.
16
Renal colic
Renal stones have been described as far back as the
time of the Pharaohs, where they were depicted in
Egyptian hieroglyphics.
It was previously believed that bladder stones
were more common than renal stones. But as we have
become more aware of the sequelae of untreated BPH
and urinary retention, the incidence of bladder stones
has decreased, in parallel with an increasing incidence
of kidney and ureteral stones.
Renal colic is said to be themost uncomfortable pain
that a man can have. Women who have experienced
childbirth often say that the pain from renal colic is
worse than the pain from childbirth.
Presentation
The patient usually presents with excruciating, waxing
and waning, lateralizing pain. The location of the
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A guide to the management of urologic dilemmas for the primary care physician (PCP)
