Scrotal Pain for Canadian Medical Students

Introduction

Scrotal pain is a common presentation in Canadian emergency departments and primary care settings. As a future Canadian physician preparing for the MCCQE1, understanding the diagnosis and management of scrotal pain is crucial. This guide will help you navigate the key concepts, with a focus on Canadian guidelines and practices.

Etiology of Scrotal Pain

Understanding the causes of scrotal pain is essential for MCCQE1 success. Here are the main etiologies:

1. Acute causes:

   • Testicular torsion
   • Epididymitis
   • Orchitis
   • Trauma

2. Chronic causes:

   • Varicocele
   • Hydrocele
   • Chronic epididymitis
   • Testicular cancer

3. Other causes:

   • Referred pain (e.g., from kidney stones)
   • Inguinal hernia

Clinical Presentation and Diagnosis

When approaching a patient with scrotal pain in a Canadian healthcare setting, consider the following steps:

Key Differential Diagnoses

For MCCQE1 preparation, focus on distinguishing between these critical conditions:

Management

The management of scrotal pain in Canada follows these general principles:

1. Testicular Torsion:

   • Surgical emergency
   • Immediate urological consultation
   • Manual detorsion may be attempted while awaiting surgery

2. Epididymitis:

   • Antibiotics (e.g., ceftriaxone plus doxycycline for <35 years, ciprofloxacin for >35 years)
   • Pain management
   • Scrotal support and ice packs

3. Orchitis:

   • Supportive care (rest, scrotal support, analgesics)
   • Antibiotics if bacterial cause suspected

Canadian Guidelines for Scrotal Pain Management

The Canadian Urological Association (CUA) provides guidelines for managing acute scrotal pain:

1. Immediate urological consultation for suspected testicular torsion
2. Ultrasound with color Doppler as the first-line imaging modality
3. Antibiotic selection based on local resistance patterns for epididymitis
4. Follow-up within 24-48 hours for patients managed conservatively

Key Points to Remember for MCCQE1

• 🇨🇦 Testicular torsion is a surgical emergency in Canada, requiring immediate exploration
• 🏥 Scrotal ultrasound with color Doppler is the gold standard for diagnosis in Canadian healthcare
• 🦠 Consider sexually transmitted infections in young adults with epididymitis
• 🩺 The absence of the cremasteric reflex is highly suggestive of testicular torsion
• 🚑 In Canada, if torsion cannot be ruled out, surgical exploration is mandatory

Sample MCCQE1-Style Question

# Sample Question

A 16-year-old male presents to a Canadian emergency department with sudden onset of left scrotal pain that began 3 hours ago. He denies fever, dysuria, or recent trauma. On examination, the left testis is high-riding and exquisitely tender. The cremasteric reflex is absent on the left side. Which of the following is the most appropriate next step in management?

- [ ] A. Administer oral antibiotics and schedule follow-up in 48 hours
- [ ] B. Perform manual detorsion and observe for symptom improvement
- [ ] C. Order a scrotal ultrasound with color Doppler
- [ ] D. Consult urology for immediate surgical exploration
- [ ] E. Prescribe analgesics and recommend scrotal support

Explanation

The correct answer is:

• D. Consult urology for immediate surgical exploration

This case presents a classic picture of testicular torsion in a Canadian healthcare setting. The sudden onset of pain, high-riding testis, and absent cremasteric reflex are highly suggestive of torsion. In Canada, when testicular torsion is suspected, immediate surgical exploration is warranted, even before obtaining imaging studies. While ultrasound can be helpful, it should not delay surgical intervention if clinical suspicion is high. The other options would be inappropriate and potentially harmful by delaying definitive treatment.

References

1. Canadian Urological Association. (2017). Guideline: Diagnosis and Management of Testicular Cancer. Retrieved from https://www.cua.org/guidelines (opens in a new tab)

2. Eyre RC. Evaluation of acute scrotal pain in adults. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2021.

3. Kapoor S. (2008). Testicular torsion: a race against time. International Journal of Clinical Practice, 62(5), 821-827.

4. Mellick LB. (2012). Torsion of the testicle: it is time to stop tossing the dice. Pediatric Emergency Care, 28(1), 80-86.

5. Sharp VJ, Kieran K, Arlen AM. (2013). Testicular torsion: diagnosis, evaluation, and management. American Family Physician, 88(12), 835-840.