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Basics ⬇

[Section Outline]

Author:

EdwardNewton

TakuTaira

Description!!navigator!!

Epidemiology!!navigator!!

Bimodal distribution of torsion:

Etiology!!navigator!!

Diagnosis ⬆ ⬇

[Section Outline]

Signs and Symptoms!!navigator!!

History

  • Sudden onset of unilateral testicular pain
  • Scrotal swelling and erythema
  • Less commonly, torsion may present with pain in the inguinal or lower abdominal area
  • Up to 40% of patients may describe previous similar episodes that remitted spontaneously:
    • Represents spontaneous torsion and detorsion
  • Nausea and vomiting occur in 50% of cases
  • Low-grade fever occurs in 25%
  • There is often a history of minor trauma to the testicle preceding the onset of pain
  • Symptoms of urinary infection (dysuria, frequency, and urgency) are absent

Physical Exam

  • In distinguishing torsion from epididymitis, localized tenderness is helpful early; however, once significant scrotal swelling occurs, the anatomy becomes indistinct
  • Torsion of the appendix testis is less painful and does not threaten the viability of the testicle
  • Characterized by the “blue-dot” sign
  • The affected torsed testicle may lie transversely as opposed to the normal vertical lie
  • Cremasteric reflex is frequently absent on the affected side with testicular torsion
  • Sensitivity 96%; specificity 66%
  • Prehn sign:
    • Relief of pain on elevation of the testicle in epididymitis
    • Worsening or no change in the pain with torsion
    • Considered unreliable

Essential Workup!!navigator!!

Diagnostic Tests & Interpretation!!navigator!!

Lab

  • Elevated WBC count with a left shift is present in 50% of cases
  • Urinalysis is usually normal, but up to 20% of cases of torsion include pyuria
  • There are no lab tests specific for testicular torsion

Imaging

ALERT
  • There are limitations of all flow studies:
    • Reflect only the current state of perfusion
    • Spontaneously detorsed testicle may show normal or even increased flow
    • Still at high risk for recurrent torsion
  • Traditional criterion stand ard has been technetium-99m radionuclide scans:
    • Decreased flow in the torsed testicle compared with the unaffected side
    • Frequent time delays in obtaining scans
  • Doppler US:
    • Assess testicular blood flow and visualize the torsed spermatic cord directly
    • Has replaced nuclear scanning:
      • Less invasive
      • More readily available test
      • Comparable results
    • Overall sensitivity and specificity of 76-98% and 100%, respectively for torsion but lower in distinguishing between testicular torsion and torsion of the appendix testis
    • Epididymitis will reveal increased flow due to inflammation
    • Torsion will reveal decreased or no blood flow
    • Color-flow Doppler is most commonly available
    • Use of Doppler contrast material may enhance the accuracy
    • High definition US (HDUS) is emerging as an accurate means of directly imaging the torsed spermatic cord (sensitivity 96%)

Pediatric Considerations
  • All imaging techniques have technical limitations in infants:
    • Testicular vessels are very small
    • Amount of blood flow to the testicle under normal conditions is minimal
  • Scrotal exploration may be required

Diagnostic Procedures/Surgery

  • Scrotal exploration can be done rapidly under local anesthesia to diagnose and treat torsion, although of those taken directly to surgery without imaging, only 51% prove to have torsion
  • The “bell-clapper” deformity of both testicles should be corrected by orchiopexy
  • Unsalvageable testes undergo orchiectomy

Differential Diagnosis!!navigator!!

Treatment ⬆ ⬇

[Section Outline]

Prehospital!!navigator!!

Initial Stabilization/Therapy!!navigator!!

IV fluid, analgesics as appropriate

ED Treatment/Procedures!!navigator!!

Medication!!navigator!!

Analgesia

Follow-Up ⬆ ⬇

Disposition

Admission Criteria

  • Patients with confirmed torsion must be admitted for scrotal exploration and bilateral orchiopexy
  • Flow studies that are inconclusive and technical failures mand ate further investigation by surgical exploration of the scrotum
  • Admission for urgent surgical exploration of an acute scrotum is mand atory if there is any potential delay in obtaining a flow study:
    • Patients in whom apparent spontaneous detorsion has occurred should undergo elective exploration for bilateral orchiopexy

Discharge Criteria

  • Patients with negative scrotal exploration and those with normal flow studies can be discharged with appropriate urologic follow-up
  • Parameters for return to ED must be discussed because of the possibility of recurrent torsion
  • Patients with an obvious diagnosis other than testicular torsion can be referred for care

Pearls and Pitfalls ⬆ ⬇

  • Testicular torsion can mimic acute appendicitis in children
  • Misdiagnosis is more common in younger children, those with developmental delay, and those who present with abdominal pain rather than scrotal pain
  • Remember that “time is testicle”; emergent work-up and consultation are required
  • Maintain a high index of suspicion for testicular torsion in all age groups even though peak incidence is in adolescents and neonates
  • If testicular torsion is diagnosed early, a near 100% salvage rate for the testicle is possible. Orchiopexy is not a guarantee against future torsion, although it does reduce the odds

Additional Reading ⬆ ⬇

See Also (Topic, Algorithm, Electronic Media Element)

Codes ⬆

ICD9

ICD10

SNOMED