Testicular torsion: Difference between revisions
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== Background | ==Background== | ||
*Peak incidence in first year of life, 2nd peak incidence at puberty | *Peak incidence in first year of life, 2nd peak incidence at puberty | ||
*Increased risk: Undescended testicle or Bell-Clapper Deformity | |||
*Consider torsion in setting of scrotal trauma if pain persists >1hr | *Consider torsion in setting of scrotal trauma if pain persists >1hr | ||
*Half of all torsions occur during sleep | *Half of all torsions occur during sleep | ||
'''Salvage Rates for Detorsion Times''' | '''Salvage Rates for Detorsion Times''' | ||
{| | {| class="wikitable" | ||
|- | |- | ||
| ''' | | '''Time''' | ||
| ''' | | '''Rate''' | ||
|- | |- | ||
| 90-100% | | <6 hrs | ||
| 90-100% | |||
|- | |- | ||
| 20-50% | | 6-12 hrs | ||
| 20-50% | |||
|- | |- | ||
| 0-10% | | >24 hrs | ||
| 0-10% | |||
|} | |} | ||
== | ==Clinical Features== | ||
*History: | *History: | ||
**Abrupt onset testicular pain | **Abrupt onset testicular pain associated with nausea/[[vomiting]] | ||
**May have had intermittent episodes in the past | **May have had intermittent episodes in the past | ||
*Exam: | *Exam: | ||
**Swollen, high-riding testis | **Swollen, high-riding testis with transverse lie | ||
**Absent cremasteric reflex on affected side (99% Sn) | **Absent cremasteric reflex on affected side (99% Sn) | ||
**Blue dot sign: pathognomonic for torsion of the appendix testis or epididymis | |||
*Ultrasound | *Ultrasound | ||
**Only indicated for equivocal cases | **Only indicated for equivocal cases | ||
**Unilateral abscence of flow (specific) | **Unilateral abscence of flow (specific) | ||
== Work-Up | ==Differential Diagnosis== | ||
* | {{Template:Testicular DDX}} | ||
==Evaluation== | |||
===Work-Up=== | |||
*[[Urinalysis]] | |||
*US for equivocal cases | *US for equivocal cases | ||
**Bedside U/S has a SN 0.95 and SP 0.94 compared to a gold standard of radiology U/S<ref>Blaivas, M, et al. Emergency evaluation of patients presenting with acute scrotum using bedside ultrasonography. Academic Emergency Medicine. 2001; 8(1):90-93.</ref> | |||
*Lab workup for surgery | *Lab workup for surgery | ||
== | ===TWIST Score=== | ||
{ | *Proposed score for assessing testicular torsion in children | ||
{| class="wikitable" | |||
|- | |||
! 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)<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 | |||
== | ==Management== | ||
*Manual (ED) vs. surgical (urology) | *Manual (ED) vs. surgical (urology) | ||
=== Manual Detorsion | ===Manual Detorsion=== | ||
*Indicated if urologist is not immediately available | *Indicated if urologist is not immediately available | ||
*Not definitive | *Not definitive treatment | ||
** | **Patient still requires emergent urology consult even if successful | ||
*"Open the book" = twist outward and laterally | *"Open the book" = twist outward and laterally | ||
**Give parenteral analgesia or perform cord block | **Give parenteral analgesia or perform cord block | ||
| Line 55: | Line 81: | ||
***If difficult to detorse or pain is worse after rotation, try to rotate testicle in opposite direction and observe results. | ***If difficult to detorse or pain is worse after rotation, try to rotate testicle in opposite direction and observe results. | ||
== Disposition | ==Disposition== | ||
*To OR or urology | *To OR or urology | ||
== See Also | ==See Also== | ||
*[[Testicular | *[[Testicular diagnoses]] | ||
*[[Testicular ultrasound]] | |||
== | ==References== | ||
<references/> | |||
[[Category: | [[Category:Urology]] | ||
[[Category:Pediatrics]] | |||
Revision as of 20:44, 25 February 2018
Background
- Peak incidence in first year of life, 2nd peak incidence at puberty
- Increased risk: Undescended testicle or Bell-Clapper Deformity
- Consider torsion in setting of scrotal trauma if pain persists >1hr
- Half of all torsions occur during sleep
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/vomiting
- May have had intermittent episodes in the past
- Exam:
- Swollen, high-riding testis with transverse lie
- Absent cremasteric reflex on affected side (99% Sn)
- Blue dot sign: pathognomonic for torsion of the appendix testis or epididymis
- Ultrasound
- Only indicated for equivocal cases
- Unilateral abscence of flow (specific)
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
- Urinalysis
- US 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
Management
- Manual (ED) vs. surgical (urology)
Manual Detorsion
- Indicated if urologist is not immediately available
- Not definitive treatment
- Patient still requires emergent urology consult even if successful
- "Open the book" = twist outward and laterally
- Give parenteral analgesia or perform cord block
- Prep skin, palpate and grasp cord at external ring and inject 10mL lidocaine directly into cord
- Hold testicle with left thumb and forefinger
- Rotate testicle outward 180° in medial to lateral direction
- Counterclockwise for right testicle and clockwise for left testicle
- Rotation may need to be repeated 2-3x for complete detorsion/pain relief
- If difficult to detorse or pain is worse after rotation, try to rotate testicle in opposite direction and observe results.
- Rotate testicle outward 180° in medial to lateral direction
- Give parenteral analgesia or perform cord block
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.