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

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J. Jamnagerwalla and H.H. Kim
of the appendix testis may have a more insidious onset of pain over
several days, with waxing and waning of pain levels. The “blue dot sign”
of a palpable, infarcted appendix testis can be seen on exam in
up to 21 % of patients [ 28 ]. Ultrasound can reliably identify torsion of
the appendix testis and differentiate it from testicular torsion [ 29 ].
Treatment consists of rest and nonsteroidal anti-inflammatory drugs
(NSAIDs).
Acute Epididymitis Acute epididymitis is an inflammation of the
epi didymis presenting acutely with pain and swelling. Objective findings
of acute epididymitis include fever, scrotal erythema, leukocytosis on
urinalysis, and positive urine culture. The pathophysiology is unclear but
is thought to be secondary to retrograde flow of infection into the
ejaculatory ducts [ 30 ]. In men under age 35 years, the most common
etiology of acute epididymitis is sexually acquired Chlamydia trachomatis
and Neisseria gonorrhoeae , while in men aged 35 years and over,
the organisms that cause urinary tract infections (e.g., Gram-negative
rods) are the predominant isolates [ 31 , 32 ]. Men presenting with possible
acute epididymitis should have a midstream urine collection along with
Gram stain of a urethral smear, although empiric treatment should begin
at the time of initial evaluation. Treatment involves bed rest, scrotal
support, NSAIDs, and antibiotics.
Orchitis Isolated acute orchitis is relatively rare, as it usually occurs
by local spread of infection from the epididymis. Isolated orchitis often
has a viral cause, with mumps being the most common etiology. Mumps
orchitis is characterized by painful testicular swelling 4–8 days after the
appearance of parotitis [ 33 ]. Orchitis develops in 15–30 % of men with
mumps. Mumps orchitis is not common before puberty [ 34 ]. Mumps
orchitis is associated with reduced testicular size in up to half of patients
and with semen analysis abnormalities in about 25 % [ 35 ]. Treatment is
largely supportive.
Nephrolithiasis Nephrolithiasis is a common urological problem,
with lifetime prevalence of approximately 10 % in men [ 36 ]. Although
the classic presentation includes flank pain and hematuria, a stone
impacted in the distal third of the ureter can cause referred pain to the
groin. A stone should be considered in a patient who has groin pain
associated hematuria, flank pain, or a history of nephrolithiasis. A noncontrast
helical computed tomography (CT) scan is the preferred imaging