Review Question - QID 103027

This patient is presenting with sudden-onset abdominal pain, a benign abdominal exam, and an elevated testicle with a horizontal lie suggesting a diagnosis of testicular torsion.

Testicular torsion occurs when the testicle twists around its blood supply leading to ischemia. Acute testicular pain follows rapidly; however, other common presentations can include severe abdominal pain, nausea, and vomiting. The most common underlying cause is a congenital malformation known as a bell-clapper deformity in which the testis is inadequately affixed to the spermatic cord, allowing it to rotate freely on its axis and subsequently entangle. The diagnosis can be made clinically with a classic physical exam finding of a testicle with a horizontal lie in the setting of sudden testicular or abdominal pain. However, unclear cases can further be worked up with an ultrasound with Doppler to detect blood flow to the testicle. An ultrasound should never be performed to confirm the diagnosis if it in any way delays emergent surgical treatment. Other possible treatments can include manual detorsion which is particularly indicated when there is a delay to definitive surgical care (such as a patient in a rural hospital). Other useful findings that can clinically support a diagnosis of testicular torsion include an absent cremasteric reflex and a negative Prehn sign (improved pain with elevation of the testicle).

Incorrect Answers:
Answer 1: Appendicitis presents with abdominal pain that is typically periumbilical (associated with nausea/vomiting) followed by symptoms that migrate to the right lower quadrant. The diagnosis is confirmed with a CT scan and surgical removal is the typical treatment.

Answer 2: Epididymitis in a young patient is typically due to sexually transmitted organisms (such as Chlamydia trachomatis and Neisseria gonorrhea in contrast to E. coli which is seen in elderly patients). These patients could present with tenderness of the posterior testicle, a fever, pyuria, and symptoms that generally are not sudden in onset.

Answer 3: Seminoma is a malignant tumor that presents as a painless mass that does not transilluminate. Orchiectomy is the typical treatment.

Answer 5: Traumatic urethral injury is associated with pelvic trauma and is marked by symptoms such as blood at the urethral meatus. These patients require a retrograde urethrogram prior to any attempt to pass a Foley catheter.

Bullet Summary:
Testicular torsion presents with sudden-onset testicular/abdominal pain and presents with an elevated testicle with a horizontal lie.