Testicular torsion: Difference between revisions

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== Background ==
==Background==
*Bimodal incidence
**First peak in first year of life
**Second peak at puberty
*Risk factors
**Undescended testicle
**Bell-clapper deformity
*Half occur during sleep
*May present after scrotal trauma with persistent pain


'''Salvage Rates for Detorsion Times'''
'''Salvage Rates for Detorsion Times'''  


{| style="width: 500px" border="1" cellpadding="1" cellspacing="1"
{| class="wikitable"
|-
|-
| '''Rate<br/>'''
| '''Time'''
| '''Time<br/>'''
| '''Rate'''
|-
|-
| <6 hrs
| 90-100%
| 90-100%
| <6 hrs&nbsp;
|-
|-
| 6-12 hrs
| 20-50%
| 20-50%
| 6-12 hrs&nbsp;
|-
|-
| >24 hrs
| 0-10%
| 0-10%
| >24 hrs
|}
|}


<br/>-peak incidence in first year of life, 2nd peak incidence at puberty
==Clinical Features==
*History:
**Abrupt onset testicular pain associated with nausea or [[vomiting]]
**May have previous similar intermittent, self-resolving episodes
*Physical exam:
**Swollen, high-riding testis
**Transverse testicular lie
**Absent cremasteric reflex on affected side (99% sensitivity)
*Ultrasound
**Only indicated for equivocal cases
**Unilateral absence of blood flow


-scrotal trauma associated with torsion, consider if persistent scrotal pain > 1 hour
==Differential Diagnosis==
{{Template:Testicular DDX}}


==Diagnosis==
==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<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


===TWIST Score===
*Proposed score for assessing testicular torsion in children


* Absent cremasteric reflex on affected side (~100%)
{| class="wikitable"
* Ultrasound (Doppler) = unilateral abscence of flow (specific)
|-
! 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


Note:
==Management==
*Manual detorsion (temporizing measure)
*Urological consultation for detorsion and orchipexy


1)  UA = usually normal (~70%), but the WBC presence can not be relied upon to exclude the diagnosis (30%)
===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 detorted and pain decreases
#If pain is worse after rotation or if rotation is not successful, attempt to rotate testicle in opposite direction


2)  Ultrasound 88-100% sensitive, 90% specific
==Disposition==
 
*To OR or urology
==Work-Up==
 
 
* UA
* Ultrasound
==DDx==
 
 
-torsion of testicular appendage-epididymitis-tumor of testicle
 
==Treatment==
 
 
Emergent detorsion manual (ER) vs. surgical (urology) ===Manual Detorsion===
 
 
"Open the book" = twist outward and laterally26% success rate For Right Testicle:-stand in front of standing or supine patient-hold right testicle with left thumb and forefinger-rotate the right testicle outward 180° in a medial to lateral direction-rotation may need to be repeated 2-3 times for complete detorsion/pain relief For Left Testicle:-stand in front of standing or supine patient-hold left testicle with right thumb and forefinger-rotate the left testicle outward 180° in a medial to lateral direction-rotation may need to be repeated 2-3 times for complete detorsion/pain relief ==Disposition==
 
 
To OR or Urology
 


==See Also==
==See Also==
*[[Testicular diagnoses]]
*[[Testicular ultrasound]]


==References==
<references/>


Insert
[[Category:Urology]]
 
[[Category:Pediatrics]]
 
==Source==
 
 
KajiQuestions
 
Rosens
 
 
 
 
[[Category:GU]]

Revision as of 01:03, 14 May 2019

Background

  • Bimodal incidence
    • First peak in first year of life
    • Second peak at puberty
  • Risk factors
    • Undescended testicle
    • Bell-clapper deformity
  • Half occur during sleep
  • May present after scrotal trauma with persistent pain

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
  • Physical exam:
    • Swollen, high-riding testis
    • Transverse testicular lie
    • Absent cremasteric reflex on affected side (99% sensitivity)
  • Ultrasound
    • Only indicated for equivocal cases
    • Unilateral absence of blood flow

Differential Diagnosis

Testicular Diagnoses

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

Management

  • Manual detorsion (temporizing measure)
  • Urological consultation for detorsion and orchipexy

Manual Detorsion

  • Not definitive treatment
    • Temporizing measure if urologist not immediately available
  1. Provide parenteral analgesia or perform cord block (grasp cord at external ring and inject 10 mL lidocaine directly into cord)
  2. "Open the book" by twisting testicle outward and laterally
    • Grasping testicle with thumb and forefinger, rotate 180 degrees in medial to lateral direction
  3. Repeat rotation 2 - 3 times until testicle is detorted and pain decreases
  4. 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

  1. ↑ Blaivas, M, et al. Emergency evaluation of patients presenting with acute scrotum using bedside ultrasonography. Academic Emergency Medicine. 2001; 8(1):90-93.
  2. ↑ 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.
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