Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

10. Groin Pain Etiology: Spermatic Cord and Testicular Causes
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Testicular Torsion Testicular torsion must be suspected in a man
presenting with sudden onset unilateral pain without a history of trauma,
often accompanied by nausea and vomiting. This may be seen after an
open inguinal hernia repair, especially if the hernia had scrotal extension
of its contents. During the operative manipulation, the testicle may be
raised into the operative field, i.e., the groin incision, and returning the
testicle back down into the scrotum may initiate the torsion. The window
of time to save the testis is 4–8 h [ 16 ]. Physical exam findings include
scrotal edema, erythema, and exquisite diffuse tenderness over the testis.
Pain localized over the epididymis may be due to epididymitis or torsion
of the appendix testis. Although the cremasteric reflex is often absent in
testicular torsion, the presence of the reflex does not rule out torsion
[ 17 ]. Ultrasound is helpful in the diagnosis of testicular torsion, with
specificity approaching 100 % [ 18 , 19 ]. If suspicion for torsion is high,
surgical exploration should proceed without need for ultrasonic
verification [ 20 ]. Surgery involves either orchiopexy or orchiectomy of
the affected testis and orchiopexy of the contralateral testis if it was a
spontaneous torsion.
Fournier’s Gangrene Fournier’s gangrene is an infected, necrotizing
fasciitis of the perineal, genital, or perianal regions [ 21 ]. Patients present
with local discomfort associated with erythema, swelling, and crepitus.
Abnormal vital signs and metabolic derangements predict worse
prognosis and higher mortality risk [ 22 ]. Fournier’s gangrene is a clinical
diagnosis, requiring emergent surgical intervention if suspicion is high
[ 23 ]. CT scan may demonstrate subcutaneous emphysema along fascial
planes in the scrotum, perineum, and inguinal regions [ 24 ]. Treatment
includes aggressive fluid resuscitation, broad- spectrum antibiotics, and
early extensive debridement of the involved fascial planes [ 25 ]. The
mortality of Fournier’s gangrene even with appropriate treatment is high,
approaching 15–40 % [ 23 , 26 , 27 ].
Torsion of the Appendix Testis One of the most common causes of
acute scrotal pain in the pediatric population is torsion of the appendix
testis. Torsion of the appendix testis is a far more common cause of acute
scrotal pain in boys than testicular torsion; one series showed that only
16 % of children presenting with testicular pain had torsion of the testicle
as opposed to 46 % diagnosed with torsion of the appendix testis [ 20 ].
The appendix testis is a remnant of the Müllerian duct located on
the upper pole of the testis. Differentiating torsion of the appendix
testis from true testicular torsion can be challenging. Patients with torsion