Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

Margaret Fitzgerald: A 14-year-old presents with a 4-hour history of sudden onset left lower quadrant, abdominal, and scrotal pain described as a pulling, burning sensation. He denies vomiting, diarrhea or constipation and reports mild nausea, but is taking fluids without difficulty. HPI is negative for recent trauma to the region, dysuria, penile discharge, genital lesions, or fever. He reports milder similar episodes during the past 3 months that "just went away.” 

Physical exam reveals loss of the cremasteric reflex on the affected side, negative Blumberg sign, and a high riding left testicle. The most likely diagnosis is: 

A: Testicular neoplasia. 

B: Acute epididymitis.  

C: Incarcerated inguinal hernia.  

D: Testicular torsion.  

The correct answer is D: Testicular torsion. And where do we start with this question? First, what kind of a question it is? 

Well, clearly, since we're being asked what this represents, this is a differential diagnosis question. Let's start off with some background information. Testicular torsion occurs when a testicle rotates, therefore, twisting the spermatic cord and cutting off the testicles’ blood supply. In experimental modeling of the event, it reveals that a 720-degree twist is needed to occlude the artery and venous blood flow that is needed to cause the true torsion that can result in testicular swelling and if unattended testicular tissue death. 

Interestingly, the left testicle is most often affected. The cremasteric reflex is a normal finding on the physical exam, and its absence is considered to be highly sensitive for testicular torsion to a 99% certainty. This superficial reflex characterized by contraction of the cremaster muscle that pulls up the scrotum in the testes on the side in response to light stroking of the ipsilateral inner thigh, remains present in other abnormalities of the testes, including neoplasm, epididymitis, and hernia. In testicular torsion, you would not expect to find Blumberg sign being positive because there is no peritoneal inflammation involved in this condition.  

Testicular torsion is most often found in adolescent males and on rare occasions in middle aged males and neonates. Interestingly, as is reported in this patient, about 50% of individuals presenting with testicular torsion will report milder similar episodes in the past, probably representing partial torsion that then self resolves. 

An important part of this is that, since the left testicle is involved in this patient, oftentimes the pain radiates to the left lower quadrant of the abdomen. It drives home an important differential diagnosis point and an important point on the physical exam. And that is as follows: it's always helpful to examine, if you will, organ or the body part above and below, wherever pain is occurring or at least that body region above and below where the problem is, for example. 

Good deal of the time, in a person with knee pain, if you examine the ankle or the hip, you're going to find a problem in one of those joints that's causing the person to alter their gait and therefore the knee hurts. But there's really nothing wrong with the knee. I know it's a tremendous stretch to go from the leg to talking about the male GU exam, but that analogy works. 

So, you check the belly as well as checking the male GU system when you're evaluating a person who has testicular torsion. Testicular torsion is considered to be a medical emergency as the testicle is without blood supply. So, one more time, I'm going into another analogy here. We always hear when you're dealing with a patient who has acute coronary syndrome, time equals myocardium, right? The longer the myocardium goes without a blood supply, the more damage there will be.  

When we have a patient with presenting with a stroke, time equals brain. Longer the brain goes without blood supply, the more damage. The same analogy applies here: time equals testicle. There is a fairly short period of time, likely around 4 hours before the testicle can become so devoid of blood supply that it's permanently damaged or perhaps even lost. 

Therefore, prompt identification and evaluation, as well as de-torsion of the testicle, is what needs to happen. The de-torting procedure can be done sometimes manually under anesthesia or it's done surgically. But in other words, this young man needs to see urology pronto. And if you're in a location like primary care, which is the setting of most of the questions with the NP boards in family and adult-gero primary care, then what you're going to have to do is send this person off the emergency department. 

Something like this I always call the ED ahead of time. I also fax over or share my note electronically so that they know that this is not a kid who's got a little bit of a belly ache and maybe he can sit while they attend to some multiple trauma or some other folks like that. So, always make sure that you give the ER or whoever you're sending the patient to as much information as you possibly can. 

With this in mind, let's take a look at the question again, answer options, and the rationales. A 14-year-old presents with a 4-hour history of sudden onset left lower quadrant, abdominal, and scrotal pain described as a pulling, burning sensation. He denies vomiting, diarrhea or constipation, but does report mild nausea and is taking fluids without difficulty. His HPI is negative for recent trauma to the region, dysuria, penile discharge, genital lesions, or fever. 

He reports milder, similar episodes during the past 3 months that "just went away.” Physical exam reveals the loss of the cremasteric reflex on the problematic side, negative Blumberg sign, and a high riding left testicle. The likely diagnosis is: 

A: Testicular neoplasm, and this is incorrect. A testicular neoplasm, and unfortunately this probably would be testicular cancer, presents as a painless scrotal mass. Usually with a testicular neoplasm, the mass is unilateral and it's often an incidental finding more often by the patient than even the provider noted during showering or the like.  

Sometimes it is picked up by clinical exam and the patient will come in and say, ‘I found this lump and it doesn't hurt.’ Now, the cremasteric reflex would be intact and likely the testes would be held more or less the same level within the scrotum. 

Testicular cancer is often a very firm mass as well. B: Acute epididymitis. This is also incorrect. Acute epididymitis can present as a relatively sudden onset scrotal pain, but it's usually accompanied by fever, often with fairly severe GI upset. And given that acute epididymitis usually is the result of an STI, there probably would be a report of penile discharge. C: Incarcerated inguinal hernia. 

This is of course incorrect. An incarcerated inguinal hernia would present as a painful mass within the groin, firm, and non-reducible. We no doubt would have heard as well that the patient had a previous history of inguinal hernia. Keep in mind, when there is an incarceration of a hernia, there is a loop of bowel that is trapped and can no longer be reduced or pulled back, pushed back into the abdomen. 

No mention of inguinal hernia in this case. And trust me, if there needed to be a notation of this to make the exam question valid, the certifying body certainly would have given that too. B: Testicular torsion. Of course, this is the correct answer. This young man presents with a classic presentation of testicular torsion, and once again he's a member of the highest risk group for the development of this condition. 

Also, as I had mentioned, he is 50% of the people presenting with testicular torsion. When you ask, will have had milder episodes earlier and he's telling you that as well. Next step would be ordering appropriate diagnostic studies and prompt referral to urology usually via the emergency department. I'm going to cover issues on the diagnostic studies with testicular torsion in another podcast. 

Key takeaway: the differential diagnosis of lower abdominal pain, particularly also involving scrotal discomfort, can be quite broad. However, as it is in countless clinical situations, knowing how a disease will present, knowing what the risk groups are, this will be key in coming up with the right answer. 

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