Testicular torsion: Difference between revisions
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== Background | ==Background== | ||
* | [[File:Gray1144.png|thumb|Scrotal anatomy]] | ||
* | [[File:Figure 28 01 03.jpg|thumb|Testicular anatomy]] | ||
* | [[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 occur during sleep | |||
*Bimodal incidence | |||
**First peak in first year of life | |||
**Second peak at puberty | |||
===Risk factors=== | |||
*Undescended testicle | |||
*Bell-clapper deformity | |||
'''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 | ||
* | **May present after scrotal trauma with persistent pain | ||
**Swollen, high-riding testis | *Physical exam: | ||
**Absent cremasteric reflex on affected side (99% | **Swollen, high-riding testis | ||
**Transverse testicular lie | |||
**Absent cremasteric reflex on affected side (99% sensitivity) | |||
==Differential Diagnosis== | |||
{{Testicular DDX}} | |||
== Work-Up | ==Evaluation== | ||
* | ===Work-Up=== | ||
* | *Do not delay urologic consultation for work-up | ||
**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> | |||
*Lab workup for surgery | *Lab workup for surgery | ||
== | ===TWIST Score=== | ||
*Proposed score for assessing testicular torsion in children | |||
{| class="wikitable" | |||
|- | |||
! 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)<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 | |||
===Diagnosis=== | |||
*[[testicular ultrasound|Ultrasound]] | |||
**Only indicated for equivocal cases | |||
**Unilateral absence of blood flow | |||
== | ==Management== | ||
*Manual ( | *Manual detorsion (temporizing measure) | ||
*Urological consultation for detorsion and orchipexy | |||
=== Manual Detorsion | ===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 detorsed 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 diagnoses]] | ||
*[[Testicular ultrasound]] | |||
== | ==References== | ||
<references/> | |||
[[Category: | [[Category:Urology]] | ||
[[Category:Pediatrics]] |
Revision as of 20:19, 4 June 2020
Background
- Half occur during sleep
- Bimodal incidence
- First peak in first year of life
- Second peak at puberty
Risk factors
- 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
- Physical exam:
- Swollen, high-riding testis
- Transverse testicular lie
- Absent cremasteric reflex on affected side (99% sensitivity)
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
Diagnosis
- Ultrasound
- Only indicated for equivocal cases
- Unilateral absence of blood flow
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 detorsed 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.