# Testicle Pain



## Yurong (Dec 16, 2009)

Dispatched for a 78 year old male with abdominal pain. On arrival the 78 year old walks to your ambulance and states that his left testicle feels like "its on fire and is trying to tear itself in two). Pt states he has never been ill, and hasnt seen a doctor since 1972. No medications, prior medical Hx, allergies. Pt denies doing anything that he doesn't do every day - walk one mile, milk the cow (seriously) and listen to the radio on the couch. Pain began thirty minutes prior. denies any other pain except for the testicle. Abdomen is soft, non-tender.

First vitals:

HR: 84 reg, Respirations: 24 increased clear bilat, Skin: WPD, BP: 146/76, ECG: Sinus

Begin transport, patient cannot hold still and is obvious severe pain. 7 minutes later, pt stops yelling, become diaphoretic and pale and becomes unresponsive. one minute left to the hospital vitals:

ECG: Sinus Brady, Respirations 8 Shallow, Skin: pale, clammy, HR: 30, BP: 60/palp.

So what happened? Answer will be in the next post - just highlight it to read. This actually happened to me about 2 months after I first got my medic.


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## Yurong (Dec 16, 2009)

Patient is offloaded at the hospital and moved into the first trauma bay. New ER doc (first job out of residency, three weeks post boards) is dumbfounded and begins to treat the hypotension and bradycardia when our agency OMD walks in. He asks what is going on and then grabs the portable ultrasound machine. He promptly curses and calls to have an OR table prepped for the AAA that this guy just had. This hospital is only a level 4 and they don't usually handle this kind of thing, but the guy wouldn't have made it the 25 minutes ground or 15 air to the local level 2. They rolled him upstairs, literally kicked someone out of an OR room who was being prepped for some elective surgery and they opened him up right there. Best thing is, I was able to watch the whole thing. 

Now someone please find my a paramedic book anywhere that has referred testicle pain as a possible sign for a ruptured AAA, especially lacking the other signs. Best the read up on http://www.sciencedirect.com/scienc...21&_version=1&_urlVersion=0&_userid=10&md5=8cf9e54e871991f9e47555ed68b8f841 just in case it ever happens to you.[/COLOR]


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## JPINFV (Dec 16, 2009)

> Now someone please find my a paramedic book anywhere that has referred testicle pain as a possible sign for a ruptured AAA, especially lacking the other signs.



Actually, if you know where the gonads originate from and where their blood supply and nerves originate from, it makes complete sense. Although to be fair, I probably wouldn't have thought of AAA. Testicular torsion? Sure. STDs? Maybe. AAA? Most likely not.


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## Yurong (Dec 16, 2009)

Sure it makes sense now, but tell me thats what you were thinking when you first read it


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## JPINFV (Dec 16, 2009)

See edited post... I was adding things as you replied.


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## Yurong (Dec 16, 2009)

Yeah, torsion was my first thought (actually, my first thought was he pissed his wife off).


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## Aidey (Dec 16, 2009)

Torsion was my first thought too, then a cyst/infection and then cancer (he hasn't seen a doctor in 30 years, who knows what undiagnosed problems he may be having). But neither of those really correlate to his rapid deterioration. At that point I did think AAA, mostly because any severe abdominal area pain followed by an onset of very bad vital signs is a AAA until proven otherwise.


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## rescue99 (Dec 16, 2009)

Yurong said:


> Dispatched for a 78 year old male with abdominal pain. On arrival the 78 year old walks to your ambulance and states that his left testicle feels like "its on fire and is trying to tear itself in two). Pt states he has never been ill, and hasnt seen a doctor since 1972. No medications, prior medical Hx, allergies. Pt denies doing anything that he doesn't do every day - walk one mile, milk the cow (seriously) and listen to the radio on the couch. Pain began thirty minutes prior. denies any other pain except for the testicle. Abdomen is soft, non-tender.
> 
> First vitals:
> 
> ...



Had a cardiac patient like this once. Everything about him looked like every cardiac patient I had ever seen so, I went with cardiac. Tortion or epididimitis look like pain. My guy looked like approaching death. Yep, testicular pain vs. cardiac. Triple bypass that night.


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## Dominion (Dec 16, 2009)

Before I read your post, my first thought was testicular torsion or epididymitis.  Then I got to the part where he started going south.  Once I finished reading your scenario I thought about it for a moment and thought about his primary complaint:  "it feels like my testicles are being torn in two".  Now I was always taught and have had this backed up but 99% of the time when a patient complains of a tearing sensation in the abdomen, think AAA.  

My intial reaction was AAA with deferred pain from the area.  Just because the patient says their pain is in one area, doesn't always mean that the injury is in that area.  Think about what they are saying and do a differential on what that could be.  When someone says tearing, my first thought is always AAA. This applied here, as I read I kept thinking testicle issue, till I read the 'tearing' part.


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## DV_EMT (Dec 16, 2009)

ive had epididimytis.... it sucks... period. but the pain isnt what the op described...

i would have asked his if both testicles were "in the sack" to make sure that maybe it wasn't actually up in the pelvic region. 

had that been ok... i would have been with everyone and gone with the torsion. but i would also have liked to have seen is there was any swelling or bleeding to the scrotal area.

If that had been negative... i woulda been scratching my head!


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## daedalus (Dec 16, 2009)

Cool scenario. My thinking was torsion.


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## Seaglass (Dec 17, 2009)

daedalus said:


> Cool scenario. My thinking was torsion.



+1. Never heard of a triple A going that way before--thanks for sharing!


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## reaper (Dec 17, 2009)

daedalus said:


> Cool scenario. My thinking was torsion.



Geez, I was thing BB's from to much fun!


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## MrBrown (Dec 17, 2009)

I've had torsion oh wow did that hurt, they gave me two tylenol (cheap buggers) and said wait to see the surgical registrar (who was, guess where, in surgery!)

My A&P book (Marieb) says the inferior hypogastric plexus serves the testes and that it is intercepted by the the inferior portion of the aortic plexus and runs back to L2.  

See, now that makes sense.  

Kind of like referred pain eh?

.... Anatomy Brown away h34r:


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## Simusid (Dec 21, 2009)

This may be as close as I ever get to an AAA.   I know we were told "tearing pain" is a sign of AAA in class but I must admit I missed it here on my first read through.

We were also told that a sign of AAA is a pulsating mass.   I was amazed to read that the artery can expand to 5 cm diameter.   That is pretty big and I'm not surprised that it would be pulsating.   My question is, when it ruptures and the patient begins to crash, would it still be pulsating?   It seems to me that it would deflate like a balloon.   So if you missed it in the focused physical you might not have a second chance to catch it.


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## rescue99 (Dec 22, 2009)

Simusid said:


> This may be as close as I ever get to an AAA.   I know we were told "tearing pain" is a sign of AAA in class but I must admit I missed it here on my first read through.
> 
> We were also told that a sign of AAA is a pulsating mass.   I was amazed to read that the artery can expand to 5 cm diameter.   That is pretty big and I'm not surprised that it would be pulsating.   My question is, when it ruptures and the patient begins to crash, would it still be pulsating?   It seems to me that it would deflate like a balloon.   So if you missed it in the focused physical you might not have a second chance to catch it.



The of the patient's blood would dump rapidly so, expect an arrest.


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## Jeffrey_169 (Jan 9, 2010)

Interesting post. I must admit you stumped me. You learn something new every day.


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## medic417 (Jan 9, 2010)

*Why has no one palpated the testicles?*

Why has no one palpated the testicles?  Do your job and do it right.  You have to be willing to look, listen, and feel in EMS.  Guess what that means touching peoples genitals as well.  It is time to realize you are in a medical field not diesel bolus tech.


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## JPINFV (Jan 9, 2010)

medic417 said:


> Why has no one palpated the testicles?  Do your job and do it right.  You have to be willing to look, listen, and feel in EMS.  Guess what that means touching peoples genitals as well.  It is time to realize you are in a medical field not diesel bolus tech.



So... you give all of your multisystem trauma patients a digital rectal exam to test for sphincter tone, correct?


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## CAOX3 (Jan 9, 2010)

medic417 said:


> *Why has no one palpated the testicles?*  Do your job and do it right.  You have to be willing to look, listen, and feel in EMS.  Guess what that means touching peoples genitals as well.  It is time to realize you are in a medical field not diesel bolus tech.



Explain to me how this will benefit either one of us?


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## medic417 (Jan 10, 2010)

Palpation allows you to determine more fully what is going on with your patient.  Even if it does not change your care it allows you to give a better description which in turn hopefully gets the doctor to take it seriously and check it out more quickly.  Sorry just "because it does not change care in the ambulance" is a lazy medics way of not doing patient care properly.  

And JP it really is not a bad idea to look at adding to the proper exam techniques in the ambulance.  Perhaps I can get it added into the next national curriculum.  Thanks for the idea.


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## redcrossemt (Jan 10, 2010)

JPINFV said:


> So... you give all of your multisystem trauma patients a digital rectal exam to test for sphincter tone, correct?



Honestly, we probably should be. No reason for the hospital to take a patient off the backboard if it's indicated, and we've done a good exam of the patient's posterior - including rectal tone.


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## blevinsjosh (Jan 11, 2010)

Tearing pain anwhere with abdominal pain. and rapid decrease in patient condition and hypotension.... always consider a AAA


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## matt.anderson (Apr 21, 2010)

I had this same scenario yesterday afternoon.  68 y.o. male with R testicle pain x1 day.  Pt stated it was like someone was "ripping" his testicle in two.  He said pain also radiated around side to kidney area, so at first I thought kidney stone, but no hematuria or hx of kidney stones.  I also considered the torsion and epididimytis, and also hernia since he stated he had a hernia repair in the past.  No abdominal pain with palpation, and no pulsating mass.  His pressure stayed elevated during t/p. 170/96 ish.  HR around 100.  No change in LOC or skin during t/p. I jokingly told the doc at the ER he was having a AAA, referring to this thread, and we both laughed about it.  And then when I came in on a later run, that doc pulled me aside and told me that the pt had gone to surgery for a AAA.  So I just wanted to say thanks for posting this thread, because it helped me out yesterday.


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## MMiz (Apr 21, 2010)

That's awesome, thanks for sharing.  Stick around and contribute, we're glad to have you.


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## JMFL (May 28, 2010)

*Aaa?*

Whats AAA?  The car service?


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## JPINFV (May 28, 2010)

abdominal aortic aneurysm


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## blevinsjosh (May 28, 2010)

*aaa*

Aaa is a abdominal aortic anryrisim


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## Eydawn (Jun 1, 2010)

Why do a manual exam of the testicles? Because you are the first line of information-gathering, and if you miss something significant you extend the time in which it takes for that significant sign to be noticed by someone else. Digital rectal tone may also provide useful information, but as it is part of a doctor's trauma exam, it doesn't necessarily need to be done twice... it indicates one specific thing, rather than allowing you to rule out or rule in several possibilities. 

Manual palpation of testes: Are they hot to the touch? Possible infection. Do they not feel equal in size? Possible rupture. Is one no longer "in the sack" as someone else said? Good to know, to get a doc onto it quicker. If you don't expose and palpate the area, how do you know that there isn't something really nasty and potentially systemically significant going on like an infection of the scrotum that has perforated? 

Just my take on it. I get it- none of us wants to be handling grampa jewels. Trust me. Working in an assisted living, I know who was a "freeballer" and who wore tighty-whities from giving showers and doing topical treatments... and yeah, it's nasty, but if there was a major complaint of pain you bet I'd be looking and feeling so I could give a much better picture to the next higher person in the medical chain. 

Wendy
CO EMT-B


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## phideux (Jun 3, 2010)

A body part is a body part. If somebody complains that their upper arm hurts, at a minimum you are gonna cut off their shirt, look and probably have a feel.
Like Eydawn said, "none of us wants to be handling grampa jewels." But if the chief compliant is a tearing pain in their testicles, you are at least gonna have to look, if not touch. Parts is parts.


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## Yurong (Jun 4, 2010)

matt.anderson said:


> I had this same scenario yesterday afternoon.  68 y.o. male with R testicle pain x1 day.  Pt stated it was like someone was "ripping" his testicle in two.  He said pain also radiated around side to kidney area, so at first I thought kidney stone, but no hematuria or hx of kidney stones.  I also considered the torsion and epididimytis, and also hernia since he stated he had a hernia repair in the past.  No abdominal pain with palpation, and no pulsating mass.  His pressure stayed elevated during t/p. 170/96 ish.  HR around 100.  No change in LOC or skin during t/p. I jokingly told the doc at the ER he was having a AAA, referring to this thread, and we both laughed about it.  And then when I came in on a later run, that doc pulled me aside and told me that the pt had gone to surgery for a AAA.  So I just wanted to say thanks for posting this thread, because it helped me out yesterday.



Hey no problem! Glad I could help a brother out.


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