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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
Testicular Torsion Center for International Emergency Disaster and Refugee Studies 2
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
Testicular Torsion Center for International Emergency Disaster and Refugee Studies 3
Key points
Prompt diagnosis Immediate surgical referral Rapid definitive treatment
Testicular Torsion
Morbidity
Salvage rate of 80-100% possible in patients who present within 6 hours of pain.
Near 0% at 12 hours.
Testicular Torsion
Epidemiology
Young males < 30 years old
Typically: 12-18 years Peak age: 14 years Smaller peak during first year of life
Testicular Torsion
Pathophysiology
Twisting of the spermatic cord upon itself
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
Testicular Torsion
Testicular Torsion
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Causes
Congenital anomaly Undescended testicle Sexual arousal and/or activity Trauma 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 compared to the other side Horizontal lie of the testicle Enlargement and edema of the testicle;
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
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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
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Testicular Torsion
Normal testicle
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Scrotal wall
Testicular Torsion
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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Testicular Torsion
Treatment-Manual Detorsion
Opening of a book"
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
Center for International Emergency Disaster and Refugee Studies
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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
Testicular Torsion
Summary
Clinical diagnosis Time is testicle Emergent urological consultation Transfer 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:
Key Points
Diagnose suspected testicular torsion. Immediate/prompt consult
Surgery/Urology
Testicular Torsion