Testicular Torsion

Center for International Emergency Disaster and Refugee Studies Department of Emergency Medicine Johns Hopkins University

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 torsion Discuss 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 and differentiation 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

Testicular Torsion

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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.

Testicular Torsion

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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

Testicular Torsion

Center for International Emergency Disaster and Refugee Studies

Pathophysiology
Twisting of the spermatic cord upon itself

Obstruction of the blood vessels supplying the testis and epididymis

The typical testicle is covered by the tunica vaginalis,

Attaches to the posterolateral surface of the testicle Allows for little mobility
Center for International Emergency Disaster and Refugee Studies

Testicular Torsion

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

Testicular Torsion

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Testicular Torsion

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Testicular Torsion

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Causes
Congenital anomaly Undescended testicle Sexual arousal and/or activity Trauma Exercise Active cremasteric reflex

Testicular Torsion

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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 compared to 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 Hydrocele Scrotal abscess Fourniers gangrene Appendicitis

Testicular Torsion

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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

Testicular 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

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Testicular Torsion

Normal testicle

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Scrotal wall

Testicular Torsion

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supply to testicle

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Treatment
Pain relief Manual detorsion Surgical/Urological consultation

Testicular Torsion

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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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Testicular Torsion

Treatment-Manual Detorsion
Opening of a book"

Physician standing at the patient's feet

Relief of pain successful detorsion Goal: reestablish or increase blood flow to previously ischemic testicle Never delay operative intervention Success in 30-70% of patients
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Testicular Torsion

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Treatment-Consultation
Early surgical 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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Testicular Torsion

Summary
Clinical diagnosis Time is testicle Emergent urological consultation Transfer to appropriate facility

Testicular Torsion

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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 detorsion Definitive: surgery

Detorsion and Orchiopexy

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Testicular Torsion