Testicular torsion: Difference between revisions

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==Background==
==Background==
*Peak incidence in first year of life, 2nd peak incidence at puberty
*Bimodal incidence
*Increased risk:  Undescended testicle or Bell-Clapper Deformity
**First peak in first year of life
*Consider torsion in setting of scrotal trauma if pain persists >1hr
**Second peak at puberty
*Half of all torsions occur during sleep
*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'''  


{| class="wikitable"
{| class="wikitable"
|-
|-
| '''Time'''
| '''Rate'''
| '''Rate'''
| '''Time'''
|-
|-
| 90-100%  
| <6 hrs
| <6 hrs
| 90-100%
|-
|-
| 20-50%
| 6-12 hrs
| 6-12 hrs
| 20-50%
|-
|-
| 0-10%
| >24 hrs
| >24 hrs
| 0-10%
|}
|}


==Clinical Features==
==Clinical Features==
*History:
*History:
**Abrupt onset testicular pain associated with nausea/[[vomiting]]  
**Abrupt onset testicular pain associated with nausea or [[vomiting]]  
**May have had intermittent episodes in the past
**May have previous similar intermittent, self-resolving episodes
*Exam:
*Physical exam:
**Swollen, high-riding testis with transverse lie  
**Swollen, high-riding testis
**Absent cremasteric reflex on affected side (99% Sn)
**Transverse testicular lie  
**Absent cremasteric reflex on affected side (99% sensitivity)
*Ultrasound  
*Ultrasound  
**Only indicated for equivocal cases  
**Only indicated for equivocal cases  
**Unilateral abscence of flow (specific)
**Unilateral absence of blood flow


==Differential Diagnosis==
==Differential Diagnosis==
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==Evaluation==
==Evaluation==
===Work-Up===
===Work-Up===
*Do not delay urologic consultation for work-up
**Consult urology immediately if strongly suspicious for torsion
*[[Urinalysis]]
*[[Urinalysis]]
*US for equivocal cases
*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>
**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
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*Scores from 2-5 patients require U/S for further assessment
*Scores from 2-5 patients require U/S for further assessment


==Treatment==
==Management==
*Manual (ED) vs. surgical (urology)
*Manual detorsion (temporizing measure)
*Urological consultation for detorsion and orchipexy


===Manual Detorsion===
===Manual Detorsion===
*Indicated if urologist is not immediately available
*Not definitive treatment
*Not definitive treatment  
**Temporizing measure if urologist not immediately available
**Patient still requires emergent urology consult even if successful
#Provide parenteral analgesia or perform cord block (grasp cord at external ring and inject 10 mL lidocaine directly into cord)
*"Open the book" = twist outward and laterally
#"Open the book" by twisting testicle outward and laterally
**Give parenteral analgesia or perform cord block
#*Grasping testicle with thumb and forefinger, rotate 180 degrees in medial to lateral direction
***Prep skin, palpate and grasp cord at external ring and inject 10mL lidocaine directly into cord
#Repeat rotation 2 - 3 times until testicle is detorted and pain decreases
**Hold testicle with left thumb and forefinger  
#If pain is worse after rotation or if rotation is not successful, attempt to rotate testicle in opposite direction
***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.


==Disposition==
==Disposition==
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<references/>
<references/>


[[Category:Urology]] [[Category:Pediatrics]]
[[Category:Urology]]
[[Category:Pediatrics]]

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.