Testicular torsion: Difference between revisions

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==Background ==
==Background==
*Peak incidence in first year of life, 2nd peak incidence at puberty
[[File:Gray1144.png|thumb|Scrotal anatomy]]
*Increased risk: Undescended testicle or Bell-Clapper Deformity
[[File:Figure 28 01 03.jpg|thumb|Testicular anatomy]]
*Consider torsion in setting of scrotal trauma if pain persists >1hr
[[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)]]
*Half of all torsions occur during sleep
*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'''  
'''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 a/w N/V
**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:
**May present after scrotal trauma with persistent pain
**Swollen, high-riding testis w/ transverse lie  
**May present as lower abd pain; thus, inquire specifically about scrotal pain in males with abd pain
**Absent cremasteric reflex on affected side (99% Sn)
*Physical exam:
*Ultrasound
**Swollen, tender, high-riding testis
**Only indicated for equivocal cases
**Transverse testicular lie  
**Unilateral abscence of flow (specific)
**Absent cremasteric reflex on affected side (99% sensitivity)


==Differential Diagnosis==
==Differential Diagnosis==
{{Template:Testicular DDX}}
{{Testicular DDX}}


==Diagnosis==
==Evaluation==
===Work-Up ===
===Work-Up===
*UA
*Do not delay urologic consultation for work-up
*US for equivocal cases
**Consult urology immediately if strongly suspicious for torsion
*[[Urinalysis]]
*[[testicular ultrasound|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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|}
|}
   
   
*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


*PPV 100% when >5 patients (Suggesting clinical clearance)
===Diagnosis===
*NPV 100% when <2 patients (Suggesting stat urological consult)<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>
*[[testicular ultrasound|Ultrasound]]
*Scores from 2-5 patients require U/S for further assessment
**Only indicated for equivocal cases
**Unilateral absence of blood flow


==Treatment  ==
==Management==
*Manual (ED) vs. surgical (urology)
*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 ===
===Manual Detorsion===
*Indicated if urologist is not immediately available  
*Not definitive treatment. Temporizing measure if urologist not immediately available
*Not definitive tx
*May require conscious sedation or parenteral [[analgesia]] if severe pain is anticipated
**Patient still requires emergent urology consult even if successful
#May perform cord block
*"Open the book" = twist outward and laterally
#*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>
**Give parenteral analgesia or perform cord block
#"Open the book" by twisting testicle outward and laterally
***Prep skin, palpate and grasp cord at external ring and inject 10mL lidocaine directly into cord
#*Grasping testicle with thumb and forefinger, rotate 180 degrees in medial to lateral direction
**Hold testicle with left thumb and forefinger  
#Repeat rotation 2 - 3 times until testicle is detorsed and pain decreases
***Rotate testicle outward 180° in medial to lateral direction  
#If pain is worse after rotation or if rotation is not successful, attempt to rotate testicle in opposite direction
****Counterclockwise for right testicle and clockwise for left testicle
#*In a small percentage of cases, testis is actually laterally rotated and thus, medial rotation is needed
***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==
*To OR or urology  
*To OR or urology  


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


==References ==
==References==
<references/>
<references/>


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

Latest revision as of 00:46, 21 November 2023

Background

Scrotal anatomy
Testicular anatomy
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
    • 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

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
  1. 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 [3]
  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 detorsed and pain decreases
  4. 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

  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.
  3. ↑ 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.
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