Updated: 7/10/2020

Testicular Torsion

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Overview
 

 
Snapshot
  • A neonatal boy is brought to his pediatrician for concern of a blue mass in the scrotum. His parents noticed this an hour ago. On physical exam, the scrotum is blue and firm with some erythema. Transillumination test is negative. Doppler ultrasound shows absent blood flow. The neonate is immediately sent to hospital for surgery.
Introduction
  • Clinical definition
    • twisting of spermatic cord that results in compromised blood flow and ischemia
      • this is considered a surgical emergency
  • Epidemiology
    • demographics
      • neonatal
      • adolescent years
    • risk factors
      • prior history of testicular torsion
      • recent trauma to the testes
  • Pathogenesis
    • processus vaginalis (path as testes leaves abdomen with peritoneal lining) twists, causing decreased or absent blood flow to the testis and epididymis
  • Prognosis
    • prognostic variable
      • favorable
        • rapid time to surgery
Presentation
  • Symptoms
    • primary symptoms
      • in adolescents
        • acute onset and severe pain in unilateral scrotum
        • nausea
        • vomiting
      • in neonates
        • blue and firm unilateral scrotal mass
  • Physical exam
    • inspection
      • high riding testis with a horizontal lie 
      • erythema and swelling
    • tenderness to palpation
    • absent cremasteric reflex 
Imaging
  • Doppler ultrasound 
    • indications
      • if testicular torsion is suspected but not confirmed with physical exam and history
    • findings
      • decreased or absent blood flow
Studies
  • Urinalysis
    • to rule out epididymitis
  • Diagnostic criteria
    • diagnosed by history and physical exam
    • diagnosis confirmed only during surgery
Differential
  • Epididymitis
    • positive cremasteric reflex
  • Torsion of the appendix testis 
    • normal cremasteric reflex
    • normal testicular lie
    • positive blue dot sign
Treatment
  • Operative
    • orchiopexy (bilateral)    
      • indications
        • within 24 hours of disease onset
          • 4-8 hour window before there is permanent damage from ischemia
      • bilateral orchiopexy should be performed as contralateral testis is also at risk for future torsion
      • outcomes
        • 90-100% with viable testes if within 6 hours
        • 50% if within 12 hours
        • <10 % if after 24 hours
    • orchiectomy
      • indications
        • if testis is not viable
  • Non-operative
    • manual detorsion 
      • indications
        • if surgery is not available or delayed
Complications
  • Testicular ischemia
  • Infertility or subfertility

 

 

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(M3.RL.12.25) A 15-year-old boy presents to the emergency room with severe lower abdominal pain that awoke him from sleep about 3 hours ago. The pain is sharp and radiates to his left thigh. While in the emergency room, the patient experiences one episode of vomiting. His temperature is 99.3°F (37.4°C), blood pressure is 126/81 mmHg, pulse is 119/min, respirations are 14/min, and oxygen saturation is 99% on room air. Abdominal examination reveals no tenderness in all 4 quadrants. Scrotal examination reveals an elevated left testicle that is diffusely tender. Stroking of the patient's inner thigh on the left side does not result in elevation of the testicle. What is the next step in the management of this patient? Tested Concept

QID: 103048
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CT scan of abdomen and pelvis

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IV antibiotics

8%

(1/13)

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Observation and morphine

77%

(10/13)

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Surgical exploration

0%

(0/13)

5

Testicular doppler ultrasound

0%

(0/13)

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(M2.RL.12.4) A 16-year-old man presents to the emergency department with a 2-hour history of sudden-onset abdominal pain. He was playing football when his symptoms started. The patient’s past medical history is notable only for asthma. Social history is notable for unprotected sex with 4 women in the past month. His temperature is 99.3°F (37.4°C), blood pressure is 120/88 mmHg, pulse is 117/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is noted for a non-tender abdomen. Testicular exam reveals a right testicle which is elevated with a horizontal lie and the scrotum is neither swollen nor discolored. Which of the following is the most likely diagnosis? Tested Concept

QID: 103027
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Appendicitis

67%

(51/76)

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Epididymitis

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(11/76)

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Seminoma

1%

(1/76)

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Testicular torsion

14%

(11/76)

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Traumatic urethral injury

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