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Distinguishing features of acute scrotal pain in adults

Distinguishing features of acute scrotal pain in adults
  Necrotizing fasciitis (Fournier's gangrene) Testicular torsion Acute epididymitis Torsion of appendix testis
Historical features
Onset of pain Usually sudden Usually sudden Usually gradual Usually sudden
Duration of pain Usually <12 hours Usually <12 hours Usually >24 hours Usually >12 hours
Previous pain episodes No Common Occasional Unusual
Nausea and vomiting Unusual Common Unusual Occasional
Fever Common Unusual Common Unusual
History of trauma Unusual Occasional Unusual Unusual
Dysuria or discharge Rare Unusual Common Unusual
Physical findings
Distinguishing features on examination Tense edema of the skin, blisters/bullae, crepitus, subcutaneous gas Horizontal lie, high-riding testis, bell clapper deformity, profound testicular swelling None Palpable nodule or "blue dot sign"
Tenderness Diffuse, rapidly progressive Testicular initially, then diffuse Epididymis initially, then diffuse Anterosuperior pole of the testis initially, then diffuse
Scrotal erythema or edema Common, rapidly progressive Common >12 hours Common >12 hours Common >12 hours
Cremasteric reflex Usually present Usually absent Usually present Usually present
Laboratory tests
Pyuria No Unusual Common Unusual
Positive smear, culture, rapid molecular testing, or NAAT for STI No No Common No
Leukocytosis Common Uncommon Common Uncommon
This table reviews the distinguishing features of etiologies of acute scrotal pain in adults. In practice, acute epididymitis is the most common cause. Necrotizing fasciitis (Fournier's gangrene) and testicular torsion are surgical emergencies that require prompt recognition and escalation of care. Torsion of the appendix testis, though rare, has highly suggestive features that facilitate prompt diagnosis and exclusion of other causes. Unlike in testicular torsion, torsion of the appendix testis is managed conservatively and is not a surgical emergency.
NAAT: nucleic acid amplification testing; STI: sexually transmitted infection.
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