Testicular torsion
(Redirected from Testicular Torsion)
Background
- 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
- 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)
- 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
- May perform cord block
- "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
- 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
- ↑ 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.
- ↑ 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.