MEDICAL

EMERGENCY!!

October 19, 2007

Marcia Spooner
PGY 1
Family Medicine
 Case Study
10 yr old male
CC: acute sudden onset of L testicular pain
waking him from sleep
Pain:
– constant
– no change with position
– No Hx of trauma
Other Sx:
– No dysuria
– No fever/No chills
– No nausea/vomiting
 Clinical Examination
Afebrile
moderate distress 2ndary to L scrotal
pain
L hemiscrotum edematous &
erythematous
L testicle = transverse lie + marked
tenderness to palpation
Absent cremasteric reflex on L
R hemiscrotum & testicle normal on
exam
circumcised penis = N + no urethral
discharge
 Investigations
CBC & urinalysis = N (this results in an unnecessary
delay of one hour)

Color Doppler ultrasound of scrotum =

– absence of blood flow to L testicle and
epididymis
– N blood flow to R testicle
– No testicular masses
 Treatment/Recovery
An emergent urological consult is obtained
IMMEDIATE SURGERY Scrotal exploration
– reveals a 720 degree torsion of the left spermatic cord,
– an ischemic testicle
– a "bell-clapper" deformity
DETORTION:
– L testicle's normal color returns
– L testicle : "fixed" to scrotal wall
(prevents retorsion)
– R testicle : also fixed to scrotal wall
Postoperatively,
– pain markedly relieved with detorsion
of L testicle
– remainder of recovery unremarkable
 Epidemiology/Risk Factors
1/4000 males <25 yrs annually
Congenital malformation of processus
vaginalis (90% of cases)
Covered testicle + epididymis + spermatic cord=
free rotation of testis in tunica vaginalis 
BELL CLAPPER DEFORMITY
Trauma (4-8% of cases)  especially with
significant swelling
Bell Clapper Deformity
Epidemiology/Risk Factors (cont…)
Other (2-6% of cases):
– Increase in testicular volume (puberty)
– testicular tumor
– testicles with horizontal lie
– spermatic cord with long intrascrotal portion
– Cryptorchidism (one or both testes)
– Strenuous exercise
Diagnosis is
CRITICAL!!
 Testicular Torsion
Initially obstructs
venous return

Equalization of venous and

arterial pressures
As soon as
4 hours!!
Compromised arterial flow

TESTICULAR ISCHEMIA
 ISCHEMIA vs Salvage Rate
ISCHEMIA: as soon as 4 hrs almost
CERTAIN in 24 hrs

Salvage Rate:
90% success if < 6 hrs
50% success if <12 hrs
<10% success if >24 hrs
 Testicular PAIN!

16-42% acute scrotal pain

TESTICULAR TORSION

NOT something you want to miss!!!

 Epididymitis/ Incarcerated
Orchitis Hernia

Differential
Diagnosis
Torsion of
Varicocele Idiopathic
Appendix Testis
Scrotal Edema
 NO DIFFERENCE in

PRESENTING SYMPTOMS
 Clinical Examination
Epididymitis: edematous , orange peel (late),
possible pyuria

Appendix Testis: hard, tender nodule (2-3mm)

on upper pole of testicle, BLUE DOT sign,
edema, epididymis remains posterior torsed
appendage

Scrotal Edema: develops rapidly obscuring

physical exam findings
Clinical Examination (cont…)
Testicular Torsion:
– PAIN in scrotum: often described as
“sharp and debilitating”
– No necessary precipitant event
– Scrotal erythema and edema
– Associated irritative voiding Sx, burning on
urination, urethral discharge  of note:
urinalysis and culture = Normal with early course
of testicular torsion
– Possible Nausea/Vomiting
– Lightheadedness
 Clinical Examination (cont…)
Testicular Torsion:
– Epididymis: medially, laterally or anteriorly
(depends on degree of torsion)  one side

– Spermatic cord shortens as it twists

higher appearing testis

STRONG EVIDENCE
OF TORSION
 Clinical Examination (cont…)
Testicular Torsion: NO Cremasteric
Reflex (most sensitive finding; 99%)  if testicle
moves ≥ 0.5 cm = +ve
Testicle:
– Hard
– Fixed to dartos & scrotal wall
– Larger than unaffected side
(due to congestion of blood)
Prehn’s sign negative
 Diagnostic Modalities
Imaging:
ONLY IF
SUSPICION FOR
TORSION =LOW

Doppler Ultrasound
Faster Radionuclide Testing
More available More sensitive

Surgical Exploration
Evaluation of Acute Scrotal Pain
 Treatment
Rapid restoration of blood flow: CRITICAL
Manual detorsion = quick, noninvasive treatment
rotate testicle away from midline 180 degrees (done with IV sedation)
document return of blood flow relieves problem acutely,
however elective orchipexy still recommended

open book

DON’T DELAY SURGICAL CONSULT!!! only

definitive resolution of torsion

DON’T MISS THE DIAGNOSIS

Most Significant Complication
Loss of testis may lead to infertility
Common Causes of loss of testis:
– 58%: DELAY in seeking medical attention
– 29%: INCORRECT initial DIAGNOSIS
– 13%: DELAY in TREATMENT at hospital!
 References
Testicular Torsion, AAFP, November 15, 2006.
Volume 74, Number 10, pg 1739-1743
General Medical Officer (GMO) Manual: Clinical
SectionSubmitted by CAPT M. Melanie Haluszka, MC,
USN, LCDR Brian K. Auge, MC, USN, and LT Timothy
F. Donahue, MC, USNR, National Naval Medical
Center, Bethesda (1999).
Family Practice Notebook: fpnotebook.com,
testicular torsion
Case Based Pediatrics For Medical Students and
Residents. Department of Pediatrics, University of
Hawaii John A. Burns School of Medicine. Chapter
XIII.10. Acute Scrotum. Robert G. Carlile, MD, May
2002
dictionary.com
cancerweb.ncl.ac.uk/cgi-bin/omd
Medline plus Encycopedia