Testicular torsion: Difference between revisions
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[[File:Figure 28 01 03.jpg|thumb|Testicular anatomy]] | [[File:Figure 28 01 03.jpg|thumb|Testicular anatomy]] | ||
[[File:Illu testis surface.jpg|thumb|1. Epididymis 2. Head of epididymis 3. Lobules of epididymis 4. Body of epididymis 5. Tail of epididymis 6. Duct of epididymis 7. Deferent duct (ductus deferens or vas deferens)]] | [[File:Illu testis surface.jpg|thumb|1. Epididymis 2. Head of epididymis 3. Lobules of epididymis 4. Body of epididymis 5. Tail of epididymis 6. Duct of epididymis 7. Deferent duct (ductus deferens or vas deferens)]] | ||
* | *Must consider as a ddx in all acute scrotal pain | ||
**May lead to testicular ischemia and subsequent infertility | |||
*A clear precipitating factor is not necessary identified; half occur during sleep | |||
*Bimodal incidence | *Bimodal incidence | ||
**First peak in first year of life | **First peak in first year of life | ||
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===Risk factors=== | ===Risk factors=== | ||
*Mechanical: Exertional/exercise, trauma | |||
*Testicular masses | |||
*Undescended testicle | *Undescended testicle | ||
*Bell-clapper deformity | *Bell-clapper deformity | ||
'''Salvage Rates for Detorsion Times''' | '''Salvage Rates for Detorsion Times''' | ||
| Line 33: | Line 38: | ||
**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: | **May present as lower abd pain; thus, inquire specifically about scrotal pain in males with abd pain | ||
**Swollen, high-riding testis | *Physical exam: | ||
**Swollen, tender, high-riding testis | |||
**Transverse testicular lie | **Transverse testicular lie | ||
**Absent cremasteric reflex on affected side (99% sensitivity) | **Absent cremasteric reflex on affected side (99% sensitivity) | ||
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*NPV 100% when <2 points (Suggesting clinical clearance)<ref>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.</ref> | *NPV 100% when <2 points (Suggesting clinical clearance)<ref>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.</ref> | ||
*Scores from 2-5 patients require U/S for further assessment | *Scores from 2-5 patients require U/S for further assessment | ||
===Diagnosis=== | |||
*[[testicular ultrasound|Ultrasound]] | |||
**Only indicated for equivocal cases | |||
**Unilateral absence of blood flow | |||
==Management== | ==Management== | ||
*Manual detorsion (temporizing measure) | *Manual detorsion (temporizing measure) | ||
**Typically done if surgical management is not immediately available | |||
*Urological consultation for detorsion and orchipexy | *Urological consultation for detorsion and orchipexy | ||
**Surgical exploration is the gold standard; without surgery, difficult to determine if manual detorsion has worked | |||
===Manual Detorsion=== | ===Manual Detorsion=== | ||
*Not definitive treatment | *Not definitive treatment. Temporizing measure if urologist not immediately available | ||
*May require conscious sedation or parenteral [[analgesia]] if severe pain is anticipated | |||
#May perform cord block | |||
#*Grasp spermatic cord as it enters scrotum, track up to external ring, create skin wheal, and inject 10 mL [[lidocaine]] directly into the anterior, lateral, medial portions of cord <ref>Gordon J, Rifenburg RP. Spermatic Cord Anesthesia Block: An Old Technique Re-imaged. West J Emerg Med. 2016 Nov;17(6):811-813. doi: 10.5811/westjem.2016.8.31017. Epub 2016 Sep 13. PMID: 27833695; PMCID: PMC5102614.</ref> | |||
#"Open the book" by twisting testicle outward and laterally | #"Open the book" by twisting testicle outward and laterally | ||
#*Grasping testicle with thumb and forefinger, rotate 180 degrees in medial to lateral direction | #*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 | #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 | #If pain is worse after rotation or if rotation is not successful, attempt to rotate testicle in opposite direction | ||
#*In a small percentage of cases, testis is actually laterally rotated and thus, medial rotation is needed | |||
==Disposition== | ==Disposition== | ||
Latest revision as of 00:46, 21 November 2023
Background
- Must consider as a ddx in all acute scrotal pain
- May lead to testicular ischemia and subsequent infertility
- A clear precipitating factor is not necessary identified; half occur during sleep
- Bimodal incidence
- First peak in first year of life
- Second peak at puberty
Risk factors
- Mechanical: Exertional/exercise, trauma
- Testicular masses
- 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
- May present as lower abd pain; thus, inquire specifically about scrotal pain in males with abd pain
- Physical exam:
- Swollen, tender, 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)
- Typically done if surgical management is not immediately available
- Urological consultation for detorsion and orchipexy
- Surgical exploration is the gold standard; without surgery, difficult to determine if manual detorsion has worked
Manual Detorsion
- Not definitive treatment. Temporizing measure if urologist not immediately available
- May require conscious sedation or parenteral analgesia if severe pain is anticipated
- May perform cord block
- "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
- In a small percentage of cases, testis is actually laterally rotated and thus, medial rotation is needed
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.
- ↑ Gordon J, Rifenburg RP. Spermatic Cord Anesthesia Block: An Old Technique Re-imaged. West J Emerg Med. 2016 Nov;17(6):811-813. doi: 10.5811/westjem.2016.8.31017. Epub 2016 Sep 13. PMID: 27833695; PMCID: PMC5102614.