Scrotal Pain: MCCQE1 Preparation Guide

Introduction

Acute scrotal pain (often referred to as “Acute Scrotum”) is a urological emergency until proven otherwise. For MCCQE1 preparation, candidates must demonstrate the ability to rapidly distinguish between surgical emergencies (specifically testicular torsion) and medical conditions (such as epididymitis).

This guide focuses on the Canadian medical context, aligning with the CanMEDS roles of Medical Expert and Health Advocate, ensuring timely diagnosis to preserve fertility and testicular function.

MCCQE1 Objectives: Acute Scrotum

According to the Medical Council of Canada, the candidate should be able to:

1. Identify urgent conditions requiring immediate surgical intervention.
2. Differentiate between torsion, infection, and trauma.
3. Manage sexually transmitted infections (STIs) according to Canadian guidelines.
4. Counsel patients on fertility implications and partner notification (Public Health).

Differential Diagnosis

The differential diagnosis for scrotal pain is broad, but for the MCCQE1, you must master the “Big Three.”

Other Important Etiologies

• Incarcerated Inguinal Hernia: Bowel sounds in scrotum, non-reducible.
• Fournier’s Gangrene: Necrotizing fasciitis of the perineum (Surgical Emergency).
• Testicular Trauma: Hematocele, rupture.
• Referred Pain: Ureteral colic (T10-L2 distribution).
• Henoch-Schönlein Purpura (HSP): Vasculitis causing scrotal swelling/pain.

Clinical Evaluation

History Taking (Key Questions)

When taking a history for an MCCQE1 OSCE or written case, focus on these discriminators:

• Onset: Sudden (Torsion) vs. Gradual (Epididymitis).
• Duration: <6 hours implies salvageability for torsion.
• Associated Symptoms: Nausea/Vomiting (common in torsion due to vagal stimulation), fever/dysuria (infection).
• Sexual History: New partners, unprotected sex (STI risk).
• Past Medical History: Previous transient pain (intermittent torsion), recent instrumentation.

Physical Examination

Perform a focused urological exam. Always examine the patient in both standing and supine positions if possible.

Note: Prehn’s sign is not sensitive or specific enough to rule out torsion definitively but is a classic exam concept.

Diagnostic Approach

Management Guidelines (Canadian Focus)

1. Testicular Torsion

• Immediate: NPO, IV fluids, Analgesia.
• Surgical: Scrotal exploration, Detorsion, and Bilateral Orchiopexy (fixation of both testes to prevent recurrence).
• Manual Detorsion: “Open the book” maneuver (rotate outward). Only a temporizing measure while awaiting surgery.

2. Epididymitis

Management depends on the likely organism, guided by Public Health Agency of Canada (PHAC) guidelines.

Category A: Suspected STI (Age <35 years)

• Pathogens: N. gonorrhoeae, C. trachomatis.
• Treatment:
  • Ceftriaxone 500 mg IM (single dose) PLUS
  • Doxycycline 100 mg PO BID for 10-14 days.
• Health Advocacy: Partner notification and treatment.

Category B: Suspected Enteric Organism (Age >35 years or insertive anal sex)

• Pathogens: E. coli, Pseudomonas.
• Treatment:
  • Levofloxacin 500 mg PO daily for 10 days OR
  • Ciprofloxacin 500 mg PO BID for 10-14 days.

3. Torsion of Appendix Testis

• Management: Supportive care.
• Drugs: NSAIDs (Ibuprofen/Naproxen).
• Prognosis: Resolves in 3-10 days.

Key Points to Remember for MCCQE1

• Task List for Study:

  • Memorize the bimodal age distribution of torsion.
  • Understand the “Bell-clapper deformity” (anatomical defect predisoposing to torsion).
  • Review the PHAC STI treatment guidelines for Epididymitis.
  • Recognize Fournier’s Gangrene: Pain out of proportion, crepitus, diabetic patient -> Surgical Debridement.

• Mnemonic: “TORSIO” (Risk factors/Features)

  • Trauma (minor)
  • Onset (sudden)
  • Reflex absent (Cremasteric)
  • Swelling/High riding
  • Ischemia (<6 hours window)
  • Orchiopexy (treatment)

Sample Question

A 14-year-old male presents to the Emergency Department with sudden onset of severe left hemiscrotal pain that woke him from sleep 2 hours ago. He reports one episode of vomiting. On physical examination, the left hemiscrotum is swollen and tender. The left testis is high-riding and lies transversely. The cremasteric reflex is absent on the left side but present on the right. Urinalysis is negative for leukocytes and nitrites.

Which one of the following is the most appropriate next step in management?

• A. Administer IM Ceftriaxone and prescribe Doxycycline
• B. Order a scrotal Doppler ultrasound
• C. Attempt manual detorsion and discharge if pain resolves
• D. Urgent urological consultation for surgical exploration
• E. Reassure and prescribe NSAIDs for torsion of the appendix testis

Explanation

The correct answer is:

• D. Urgent urological consultation for surgical exploration

Explanation: This clinical presentation is classic for testicular torsion: adolescent age, sudden onset (often during sleep), nausea/vomiting, high-riding/transverse testis, and an absent cremasteric reflex.

• Option D is correct: Testicular torsion is a surgical emergency. The window for salvage is approximately 4-6 hours. When the clinical picture is highly suggestive (as in this case), surgical exploration should not be delayed by imaging. “Time is testicle.”
• Option B is incorrect: While Doppler ultrasound is the diagnostic gold standard, obtaining it in a patient with a classic presentation causes unnecessary delay and risks testicular infarction. Ultrasound is reserved for equivocal cases.
• Option A is incorrect: This treats epididymitis. The patient has no urinary symptoms, a negative urinalysis, and a presentation more consistent with torsion.
• Option C is incorrect: Manual detorsion (“opening the book”) may be attempted to relieve ischemia temporarily, but it is not definitive treatment. The patient requires surgical fixation (orchiopexy) to prevent recurrence, and discharge is inappropriate.
• Option E is incorrect: Torsion of the appendix testis usually presents with more gradual pain, the “blue dot” sign, and a preserved cremasteric reflex.

References

1. Public Health Agency of Canada. (2024). Canadian Guidelines on Sexually Transmitted Infections.
2. Canadian Urological Association (CUA). Guidelines on the management of acute scrotum.
3. Toronto Notes 2024. Urology Chapter: Acute Scrotum.
4. Medical Council of Canada. Objectives for the Qualifying Examination (Acute Scrotum).
5. Bickley, L. S. Bates’ Guide to Physical Examination and History Taking. (Relevant sections on Genitourinary exam).