Testicular torsion: Difference between revisions
| Line 33: | Line 33: | ||
**Abrupt onset testicular pain associated with nausea or [[vomiting]] | **Abrupt onset testicular pain associated with nausea or [[vomiting]] | ||
**May have previous similar intermittent, self-resolving episodes | **May have previous similar intermittent, self-resolving episodes | ||
*May present after scrotal trauma with persistent pain | **May present after scrotal trauma with persistent pain | ||
*Physical exam: | |||
**Swollen, high-riding testis | **Swollen, high-riding testis | ||
**Transverse testicular lie | **Transverse testicular lie | ||
Revision as of 20:19, 4 June 2020
Background
- Half occur during sleep
- Bimodal incidence
- First peak in first year of life
- Second peak at puberty
Risk factors
- Undescended testicle
- Bell-clapper deformity
Salvage Rates for Detorsion Times
| Time | Rate |
| <6 hrs | 90-100% |
| 6-12 hrs | 20-50% |
| >24 hrs | 0-10% |
Clinical Features
- History:
- Abrupt onset testicular pain associated with nausea or vomiting
- May have previous similar intermittent, self-resolving episodes
- May present after scrotal trauma with persistent pain
- Physical exam:
- Swollen, high-riding testis
- Transverse testicular lie
- Absent cremasteric reflex on affected side (99% sensitivity)
Differential Diagnosis
Testicular Diagnoses
- Scrotal cellulitis
- Epididymitis
- Fournier gangrene
- Hematocele
- Hydrocele
- Indirect inguinal hernia
- Inguinal lymph node (Lymphadenitis)
- Orchitis
- Scrotal abscess
- Spermatocele
- Tinea cruris
- Testicular rupture
- Testicular torsion
- Testicular trauma
- Testicular tumor
- Torsion of testicular appendage
- Varicocele
- Pyocele
- Testicular malignancy
- Scrotal wall hematoma
Evaluation
Work-Up
- Do not delay urologic consultation for work-up
- Consult urology immediately if strongly suspicious for torsion
- Urinalysis
- Ultrasound for equivocal cases
- Bedside U/S has a SN 0.95 and SP 0.94 compared to a gold standard of radiology U/S[1]
- Lab workup for surgery
TWIST Score
- Proposed score for assessing testicular torsion in children
| Finding | Points |
|---|---|
| Testicular swelling | 2 |
| Hard testicle | 2 |
| Absent cremasteric reflex | 1 |
| Nausea or vomiting | 1 |
| High-riding testicle | 1 |
- PPV 100% when >5 points (Suggesting stat urological consult)
- NPV 100% when <2 points (Suggesting clinical clearance)[2]
- Scores from 2-5 patients require U/S for further assessment
Diagnosis
- Ultrasound
- Only indicated for equivocal cases
- Unilateral absence of blood flow
Management
- Manual detorsion (temporizing measure)
- Urological consultation for detorsion and orchipexy
Manual Detorsion
- Not definitive treatment
- Temporizing measure if urologist not immediately available
- Provide parenteral analgesia or perform cord block (grasp cord at external ring and inject 10 mL lidocaine directly into cord)
- "Open the book" by twisting testicle outward and laterally
- Grasping testicle with thumb and forefinger, rotate 180 degrees in medial to lateral direction
- Repeat rotation 2 - 3 times until testicle is detorsed and pain decreases
- If pain is worse after rotation or if rotation is not successful, attempt to rotate testicle in opposite direction
Disposition
- To OR or urology
See Also
References
- ↑ Blaivas, M, et al. Emergency evaluation of patients presenting with acute scrotum using bedside ultrasonography. Academic Emergency Medicine. 2001; 8(1):90-93.
- ↑ Barbosa, JA, et al. Development of initial validation of a scoring system to diagnose testicular torsion in children. The Journal of Urology. 2013; 189:1853-8.