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Three Part Question

In [male patients presenting with acute testicular pain] is [clinical examination enough] to [differentiate torsion, rupture and epididymo-orchitis]

Clinical Scenario

A 20 year old gentleman presents to the Emergency department with a one hour history of an acute onset of severe testicular pain. On examintion the left testicle was found to be rather swollen and tender.

Search Strategy

Ovid MEDLINE 1966 to June Week 4 2006
EMBASE 1980 to 2006 Week 27
PUBMED
CINAHL - Cumulative Index to Nursing & Allied Health Literature 1982 to June Week 5 2006
The Cochrane Library
[exp Physical Examination/ or clinical examination.mp. or exp Clinical Competence/
] AND [exp Testicular Diseases/pa, di, pp, pc, th [Pathology, Diagnosis, Physiopathology, Prevention & Control, Therapy]] OR [exp Physical Examination/ or clinical examination.mp. or exp Clinical Competence/] AND [testicular torsion.mp. or exp Spermatic Cord Torsion/] OR [exp Physical Examination/ or clinical examination.mp. or exp Clinical Competence/] AND [*Rupture/ or *Testis/ or testicular rupture.mp.] OR [exp Physical Examination/ or clinical examination.mp. or exp Clinical Competence/] AND [Spermatic Cord Torsion/ or Epididymis/ or Epididymitis/ or Orchitis/ or epididymo-orchitis.mp. or Testis/] AND [limit 11 to (humans and english language and "all adult (19 plus years)")]

Search Outcome

MEDLINE 468
EMBASE 316
CINAHL 50
PUBMED 211
The Cochrane Library Issue 2 2006
testicular torsion, ti.ab.kw OR spermatic cord torsion -[MeSH] 3 articles none relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Abul, Fawzi. Al-Sayer, Hilal. Arun, Narayanaswamy. May-June 2005 Kuwait	40 patients hospitalised January 2002 and December 2002 with acute scrotal pain.	Retrospective cohort study	They were studied with respect to history, physical examination, blood tests, urine analysis including culture, and scrotal ultrasonography with color Doppler study.	Epididymitis was found to be the commonest cause of the acute scrotum, followed by testicular torsion. Patients with testicular torsion presented earlier than those with Epididymitis (19.1 h vs 4.5 days). The testis was salvaged in 81.8% of patients with testicular torsion. The accuracy of ultrasonography was only 72.7% in testicular torsion.	The actual sample size used was quite small which would have introduced some bias. There was no statement that they gained ethical approval for the study they carried out.

Comment(s)

There is limited evidence available but it is a topic that is side-lined in many studies. However, its importance in the managment of the acute scrotum, is still paramount.

Clinical Bottom Line

Clinical examination is an extremely important adjunct to other tests and investigations in the management of the testicular pain.

References

1. Abul, Fawzi. Al-Sayer, Hilal. Arun, Narayanaswamy. The acute scrotum: a review of 40 cases. Medical Principles & Practice. May-June 2005; 14(3):177-81