Testicular torsion: Difference between revisions
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== Background | ==Background== | ||
* | *Bimodal incidence | ||
* | **First peak in first year of life | ||
*Half | **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''' | ||
{| | {| 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 or [[vomiting]] | ||
**May have | **May have previous similar intermittent, self-resolving episodes | ||
* | *Physical exam: | ||
**Swollen, high-riding testis | **Swollen, high-riding testis | ||
**Absent cremasteric reflex on affected side (99% | **Transverse testicular lie | ||
**Absent cremasteric reflex on affected side (99% sensitivity) | |||
*Ultrasound | *Ultrasound | ||
**Only indicated for equivocal cases | **Only indicated for equivocal cases | ||
**Unilateral | **Unilateral absence of blood flow | ||
==Differential Diagnosis== | |||
{{Template:Testicular DDX}} | |||
==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=== | ===TWIST Score=== | ||
Line 49: | Line 68: | ||
|} | |} | ||
*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 detorsion (temporizing measure) | |||
*Urological consultation for detorsion and orchipexy | |||
== | |||
* | |||
* | |||
=== Manual Detorsion | ===Manual Detorsion=== | ||
*Not definitive treatment | |||
*Not definitive | **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 | ||
== 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 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
- 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
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 detorted 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.