Spaceflight testicular torsion
Background
- Testicular torsion is a true urologic emergency in the setting of acute scrotal pain, accounting for the most significant cause of testicular loss.[1]
- Testicular torsion accounts for 10-15% of acute scrotal illness in children within the United States.[2]
- Peak incidences of testicular torsion are during the neonatal period (first 30 days of life) and puberty (10-14 years). The majority of cases occur during the adolescent age range but can occur at any age.[3]
- No documented cases of testicular torsion have occurred during spaceflight, likely due to the demographic composition of current spaceflight crews.[4]
Clinical Features
- Subjective symptoms:
- Abrupt onset of severe testicular and/or lower abdominal pain
- Nausea and vomiting
- Physical exam findings:
- Swollen and tender testis with or without lower abdominal tenderness
- Non-tender spermatic cord
- Abnormal position of the testis:
- Scrotal elevation (high-riding testis)
- Abnormal transverse position
- Undescended testes (predisposes to testicular torsion)
- Absent cremasteric reflex
- Absent reflex: Light stroking of the inner thigh does not elicit testicular elevation on the ipsilateral side.
- Intact reflex: Light stroking of the inner thigh elicits testicular elevation on the ipsilateral side.
- Intact reflex suggests an alternative diagnosis but does not rule out testicular torsion.
- Negative Prehn sign
- Negative sign = elevation of scrotum does not relieve pain.
- Positive sign = elevation of scrotum relieves pain (suggestive of epididymitis).
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
Space medicine
- Anemia of spaceflight
- Bone loss of spaceflight
- Contact dermatitis of spaceflight
- Ocular foreign body (microgravity)
- Ebullism syndrome
- Interpersonal conflicts in spaceflight
- Nitrogen tetroxide toxicity
- Hydrazine toxicity
- Pulmonary disorders of spaceflight
- Sleep disorders of spaceflight
- Space adaptation syndrome
- Space dentistry
- Space motion sickness
- Spaceflight headache
- Spaceflight testicular torsion
- Spaceflight urinary retention
- Spaceflight urinary tract infection
Evaluation
- Conduct a focused history and physical examination, assessing the abdomen and testes for pain, swelling, abnormal positioning, or tenderness, while documenting the onset, severity, and progression of symptoms.
- Use the multi-study-validated TWIST scoring system, in which a higher score correlates with a greater probability of testicular torsion.[5]:
- Hard testis - 2
- Swelling - 2
- Nausea/vomiting - 1
- Absent cremasteric reflex - 1
- High riding testis - 1
100% positive predictive value if score >5.
100% negative predictive value if score <2.
Scores 2-5 require Ultrasound for further evaluation.
- Match the patient’s clinical presentation with the characteristic symptoms and peak incidence periods of testicular torsion in adolescents and young adults.
- Recognize that a strong clinical suspicion of torsion requires urgent action due to the narrow window for testicular salvage.
Workup
- Duplex ultrasound of the scrotum
- Urine dipstick (available in pre-packaged ISS and Space Shuttle medical kits)
Diagnosis
- Testicular torsion is primarily a clinical diagnosis, but point-of-care ultrasound serves as the key diagnostic modality beyond the physical examination.
- Characteristic findings on ultrasound:
- Leukocytes and erythrocytes in the urine suggest epididymitis, orchitis, or urinary tract infection but does not exclude torsion.
- Laboratory studies are not routinely indicated.
Management
- Testicular torsion ideally requires emergent exploratory surgery to salvage the testis. Clinical suspicion of testicular torsion likely necessitates the termination of spaceflight or deorbit to facilitate access to a location equipped with an operating room. However, the time required for space travelers to return to Earth—and subsequently reach an operating room—poses a significant challenge to timely intervention for testicular salvage.
- For those who present within the first 6 hours of symptoms, the salvage rate is nearly 100%, but this number quickly drops to less than 50% if the delay in seeking help is more than 12 to 24 hours.[11]
- Manual testicular detorsion may be attempted prior to surgery for immediate pain relief or if surgery is not available, but should not delay transferring the patient to the operating room.
- Procedure:
- Step 1 - Rotate the testis laterally toward the thigh
- Step 2 - If lateral rotation does not provide symptom relief, rotate the testis toward the midline[12]
- Procedure:
- Exploratory surgery involves untwisting the affected testis (reduction) and securing both the affected and unaffected testes in place with orchiopexy. Orchiectomy is recommended if the testis is grossly necrotic or nonviable.
Disposition
- Sudden, severe, unilateral scrotal pain in a patient with a tender, abnormally positioned testis on examination should be managed as testicular torsion until proven otherwise.
- Testicular torsion is a true urologic and spaceflight emergency requiring timely identification to prevent the need for amputation.
- Ultrasound is the gold standard imaging modality to evaluate scrotal contents for suspected torsion.
- Testicular torsion is an arising and significant concern as spaceflight becomes more accessible to younger individuals, including children and adolescents.
See Also
References
- ↑ Velasquez J, Boniface MP, Mohseni M. Acute Scrotum Pain. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; May 8, 2023.
- ↑ Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013;88(12):835-840.
- ↑ Huang WY, Chen YF, Chang HC, Yang TK, Hsieh JT, Huang KH. The incidence rate and characteristics in patients with testicular torsion: a nationwide, population-based study. Acta Paediatr. 2013;102(8):e363-e367. doi:10.1111/apa.12275
- ↑ Jones J, Pietrzyk RA, Cristea O, Whitson PA. Chapter 18: Renal and Genitourinary Concerns. In: Barratt MR, Baker E, Pool SL, eds. Priciples of Clinical Medicine for Spaceflight. Springer Nature; 2020.
- ↑ Sheth KR, Keays M, Grimsby GM, et al. Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score. J Urol. 2016;195(6):1870-1876. doi:10.1016/j.juro.2016.01.101
- ↑ Jones J, Pietrzyk RA, Cristea O, Whitson PA. Chapter 18: Renal and Genitourinary Concerns. In: Barratt MR, Baker E, Pool SL, eds. Priciples of Clinical Medicine for Spaceflight. Springer Nature; 2020.
- ↑ Jones J, Pietrzyk RA, Cristea O, Whitson PA. Chapter 18: Renal and Genitourinary Concerns. In: Barratt MR, Baker E, Pool SL, eds. Priciples of Clinical Medicine for Spaceflight. Springer Nature; 2020.
- ↑ McDowall J, Adam A, Gerber L, et al. The ultrasonographic "whirlpool sign" in testicular torsion: valuable tool or waste of valuable time? A systematic review and meta-analysis. Emerg Radiol. 2018;25(3):281-292. doi:10.1007/s10140-018-1579-x
- ↑ University of Arkansas for Medical Sciences. Testicular Torsion. UAMS Department of Radiology
- ↑ McDowall J, Adam A, Gerber L, et al. The ultrasonographic "whirlpool sign" in testicular torsion: valuable tool or waste of valuable time? A systematic review and meta-analysis. Emerg Radiol. 2018;25(3):281-292. doi:10.1007/s10140-018-1579-x
- ↑ Howe AS, Vasudevan V, Kongnyuy M, et al. Degree of twisting and duration of symptoms are prognostic factors of testis salvage during episodes of testicular torsion. Transl Androl Urol. 2017;6(6):1159-1166. doi:10.21037/tau.2017.09.10
- ↑ Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013;88(12):835-840.