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Testicular TorsionCenter for International Emergency

Disaster and Refugee Studies

Department of Emergency MedicineJohns Hopkins University

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Objectives

Discuss the epidemiology and prevention

of torsion

Review the pathophysiology of torsion

Discuss the means of diagnosing torsion

Discuss diagnostic and laboratory studies

relevant to torsionDiscuss the case management and

treatment of torsion

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Introduction

Urologic emergency

Important to differentiate testicular torsion from other

complaints of testicular pain.

Delay in diagnosis can lead to loss of the testicle. Magoha in the East African Medical Journal reported

the overall salvage rate was low at 21% with an

orchidectomy rate of 79

Prompt diagnosis of testicular torsion anddifferentiation of this condition from epididymitis

can be difficult

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Key points

Prompt diagnosis

Immediate surgical referral

Rapid definitive treatment salvage of the testicle

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Morbidity

Salvage rate of 80-100% possible in

patients who present within 6 hours of

pain.

Difficult in remote and underserviced areas

After 6-8 hours, the salvage rate markedly

decreases

Near 0% at 12 hours.

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Epidemiology

Young males < 30 years old

Typically: 12-18 years

Peak age: 14 years

Smaller peak during first year of life

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Pathophysiology

If high attachment of the tunica vaginalis,

testicle can rotate freely on the spermatic

cord

In neonates, testicle frequently has not

descended into the scrotum

Becomes attached within the tunica vaginalis

Mobility of the testicle predisposes it to torsion

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http://a248.e.akamai.net/7/248/430/20020531071028/www.merck.com/pubs/mmanual_home/illus/i229_1.gif

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Causes

Congenital anomaly

Undescended testicle

Sexual arousal and/or activityTrauma

Exercise

Active cremasteric reflex

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Presentation

History: sudden onset of severe unilateral

scrotal pain.

Scrotal swelling

Nausea and vomiting (20-30%)

Abdominal pain (20-30%)

Fever (16%)Urinary frequency (4%)

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Clinical Findings

Testicle painful to palpation

Frequently elevated in position when comparedto the other side

Horizontal lie of the testicle

Enlargement and edema of the testicle; Edema may involve the entire scrotum

Scrotal erythema

Ipsilateral loss of the cremasteric reflex

No relief of pain upon elevation of scrotum

Fever (uncommon)

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Differential Diagnosis

Epididymitis/orchitis

Hernia

HydroceleScrotal abscess

Fourniers gangrene

Appendicitis

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Diagnosis

Lab studies

Urinalysis

Usually normal

White blood cells in urine 30% of the time

CBC

Normal or elevated WBC count in as many as 60%

of patients who have torsion

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Diagnosis

Torsion is a CLINICAL diagnosis!

Imaging studies

Ultrasonography and color doppler

Demonstrate arterial blood flow to the testicle

Identify scrotal anatomy and other testicular

disorders

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Normal Testicle

Plain ultrasound

http://www.acuson.com/imagegallery/jpeg/10251.jpg

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Testicular Torsion Normal testicle

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Scrotal wall

Blood supply to testicle

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Treatment

Pain relief

Manual detorsion

Surgical/Urological consultation

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Treatment-Pain Relief

Essential to quality patient care

Mild analgesic after diagnosis or awaiting

further studies

Judicious and cautious adminstration

Morphine sulfate narcotic drug of choice

Starting dose: 0.1 mg/kg (iv/im/sc) Maintenance dose: 5-20 mg/70kg every 4 hrs

Reversible with naloxone

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Treatment-Manual Detorsion

Opening of a book"

Physician standing at the patient's feet

Relief of painsuccessful detorsion

Goal: reestablish or increase blood flow to

previously ischemic testicle

Never delay operative interventionSuccess in 30-70% of patients

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Treatment-Consultation

Earlysurgical consultation is mandatory

Definitive treatment is surgery

Detorsion

Orchiopexy.

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Disposition

Early diagnosis: 100% salvage rate

Transfer to another institution where

surgery can be performed if no surgeon is

available at your hospital.

Complications

Infarction of testicle

Loss of testicle

Infection

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Summary

Clinical diagnosis

Time is testicle

Emergent urological consultationTransfer to appropriate facility

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Case

11 year old boy complains of intermittent

pain in his right testicle for the past 2 days.

Now constant pain for the past 3 hours.

Denies trauma.

PE:

Tender right testicle, slightly elevated, red and

swollen

What would you do?

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Key Points

Diagnose suspected testicular torsion.

Immediate/prompt consult

Surgery/Urology

Pain medication

Image study

Attempt detorsionDefinitive: surgery

Detorsion and Orchiopexy