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young male, nausea+vomiting, abdo & scrotal pain O/E swollen tender…

- - - - Referred pain
        
        Testicular pain
        
        Via sympathetic fibres
        
        To T10-11 spinal segments
        
        Referred → lumbar & groin regions
      - Sympathetic
        
        Sensory fibres from T10-11 spinal segments
        
        Via testicular plexus
      - Parasympathetic
        
        Pelvic splanchnic nerves, hypogastric plexus (S2-4)
        
        Vagus & renal plexus
    - - Why is the testis vulnerable?
        
        Torsion
        
        Bell-clapper deformity
        
        Predipose to TT
        
        MC abnormality assoc. TT
        
        Inadequate fixation of testis-TV
        
        Via gubernaculum testis
        
        Increased mobility, transverse lie testis
        
        Intravaginal torsion, spermatic cord torsion
        
        TV extends over spermatic cord
        
        Testes suspended by cord
        
        Management
        
        Surgical exploration of contralateral testis
        
        Typically bilateral deformities
        
        Ischaemia
        
        Sole neurovascular supply via spermatic cord
        
        No collateral
        
        Ischaemia/ infarction within 12 h
        
        Surgical emergency
    - - Begin
        
        Access
        
        Descent
        
        Close
        
        Urogenital ridge, retroperitoneal T10, attached to mesonephros via mesorchium
        
        Coelomic cavity evaginates into scrotal swelling, form processus vaginalis
        
        Descent through inguinal canal guided via gubernaculum
        
        Processus vaginalis obliterate spontaneously (shortly after birth) leaving tunica vaginalis
  - - - 3 arteries
        3 veins
        
        testicular a. & v. (pampiniform plexus)
        
        artery & vein to/fro vas
        
        cremasteric vessels
        
        testicular vein
        
        left to left renal vein
        
        right to IVC
        
        cremasteric vessels
        
        from inferior epigastric
        
        testicular a.
        
        AA (L1-2)
      - 3 nerves
        
        genitial branch of GF n.
        
        ilioinguinal n.
        
        sympathetic pain fibres
        
        GF n. (L2)
        
        Sympathetic pain fibres
        
        In GVA
        
        To T9-10 dermatomes
        
        Referred pain
      - 3 others
        
        vas deferens
        
        lymphatics
        
        processus vaginalis
        
        Lymphatics
        → para-aortic nodes L1-2
    - - 3 coverings
        
        Inner → Outer
        
        Internal
        
        Cremasteric
        
        External
        
        Internal spermatic fascia ← transversalis fascia
        
        Cremasteric muscle/fascia ← internal oblique f. + transversus abdominis m.
        
        External spermatic fascia ← external oblique f.
- - - - Cremasteric reflex
        
        High NPV: if reflex present unlikely TT