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Testicular Torsion, Emergency Medicine

Basics

Description

- Congenital abnormality of the genitalia: - High insertion of the tunica vaginalis on the spermatic cord - Redundant mesorchium - Permits increased mobility and twisting of the testicle on its vascular pedicle

- 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

- Doppler ultrasound: - Assess testicular blood flow and visualize the torsed spermatic cord directly. - Has replaced nuclear scanning: - Less invasive - More readily available test - Comparable results

- Acute hydrocele - Epididymitis/orchitis - Henoch " Sch Άnlein purpura - Incarcerated inguinal hernia - Testicular neoplasm - Testicular trauma or rupture of the testicle - Torsion of the appendix testis (31 " 70% of acute scrotum cases) - Other intra-abdominal conditions: - Appendicitis - Pancreatitis - Renal colic

  • Rotation of the testicle around the spermatic cord and vascular pedicle
  • Rotation often occurs medially (two-thirds of cases):Ranges from incomplete (90 " 180 °) to complete (360 " 1,080 °) torsionDepending on the degree of torsion:Vascular occlusion occursInfarction of the testicle after more than 6 hr of warm ischemia
  • Testicular salvage:73 " 100% with <6 hr of ischemia50 " 70% at 6 " 12 hr<20% after 12 hrIt is still worthwhile to attempt to salvage the testicle up to 24 hr after the onset.
  • Testicular infarction leads to atrophy and may ultimately decrease fertility.

Epidemiology

Bimodal distribution of torsion:

  • Peak incidences in infancy and adolescence
  • 85% of cases occur between ages 12 and 18 yr, with a mean of 13 yr.
  • Torsion is rare after age 30 but still possible.

Etiology

  • Congenital abnormality of the genitalia:High insertion of the tunica vaginalis on the spermatic cordRedundant mesorchiumPermits increased mobility and twisting of the testicle on its vascular pedicle
  • The anatomic abnormality is bilateral in 12%, so both testicles are susceptible to torsion.

Diagnosis

Signs and Symptoms

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 epididymitisWorsening or no change in the pain with torsionConsidered unreliable

Essential Workup

  • The presentation of an "acute scrotum " in a child or adolescent requires rapid assessment and immediate consultation with a urologist.
  • These patients require noninvasive flow studies or surgical exploration to confirm torsion.
  • 3.3 (ED) " 30% (Urology service) of these patients ultimately prove to have testicular torsion.

Diagnosis Tests & Interpretation

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

  • There are limitations of all flow studies:Reflect only the current state of perfusionSpontaneously detorsed testicle may show normal or even increased flow.Still at high risk for recurrent torsion
  • Traditional criterion standard has been technetium-99m radionuclide scans:Decreased flow in the torsed testicle compared with the unaffected sideFrequent time delays in obtaining scans
  • Doppler ultrasound:Assess testicular blood flow and visualize the torsed spermatic cord directly.Has replaced nuclear scanning:Less invasiveMore readily available testComparable resultsOverall sensitivity and specificity of 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 ultrasound (HDUS) is emerging as an accurate means of directly imaging the torsed spermatic cord
  • 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.
  • The "bell-clapper " deformity of both testicles should be corrected by orchiopexy.

Differential Diagnosis

  • Acute hydrocele
  • Epididymitis/orchitis
  • Henoch " Sch Άnlein purpura
  • Incarcerated inguinal hernia
  • Testicular neoplasm
  • Testicular trauma or rupture of the testicle
  • Torsion of the appendix testis (31 " 70% of acute scrotum cases)
  • Other intra-abdominal conditions:AppendicitisPancreatitisRenal colic

Treatment

Pre-Hospital

  • There is no definitive treatment that can be rendered in the field.
  • Pre-hospital personnel must recognize the urgency of acute testicular pain in young patients.
  • These patients should be transported to the ED immediately.

Initial Stabilization/Therapy

IV fluid, analgesics as appropriate

Ed Treatment/Procedures

  • Rapid triage and assessment
  • Exam of testicle to exclude primary neoplasm
  • Establish the diagnosis and mobilize appropriate urologic care.
  • Applying an ice pack to the scrotum relieves pain:May prolong the viability of the ischemic testicle
  • If definitive care is likely to be delayed beyond 4 " 5 hr from the onset of torsion, manual detorsion may be attempted (26.5 " 80% successful).Externally rotate the affected testicle opposite the usual medial direction of torsion.Continue until pain is relieved, normal anatomy is restored, or Doppler US shows return of flow.All patients who undergo manual detorsion must be surgically explored.

Medication

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 mandate further investigation by surgical exploration of the scrotum.
  • Admission for urgent surgical exploration of an acute scrotum is mandatory 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.
  • Remember that "time is testicle " ; emergent workup 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

  • Baldisserotto M. Scrotal emergencies. Pediatr Radiol. 2009;39:516 " 521.
  • Beni-Israel T, Goldman M, Chaim S, et al. Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med. 2010;28:786 " 789.
  • Drl k M, Ko vara R. Torsion of spermatic cord in children: A review. J Pediatr Urol. 2013;9:259 " 266.
  • Gatti JM, Murphy JP. Acute testicular disorders. Pediatr Rev. 2008;29:235 " 241.
  • Schmitz D, Safranek S. Clinical inquiries. How useful is a physical exam in diagnosing testicular torsion? J Fam Pract. 2009;58:433 " 434.

See Also (Topic, Algorithm, Electronic Media Element)

  • Epididymitis/Orchitis
  • Hydrocele

Codes

ICD9

  • 608.20 Torsion of testis, unspecified
  • 608.21 Extravaginal torsion of spermatic cord
  • 608.22 Intravaginal torsion of spermatic cord
  • 608.23 Torsion of appendix testis
  • 608.24 Torsion of appendix epididymis
  • 608.2 Torsion of testis

ICD10

  • N44.00 Torsion of testis, unspecified
  • N44.01 Extravaginal torsion of spermatic cord
  • N44.02 Intravaginal torsion of spermatic cord
  • N44.03 Torsion of appendix testis
  • N44.04 Torsion of appendix epididymis
  • N44.0 Torsion of testis

SNOMED

  • 81996005 Torsion of testis (disorder)
  • 198047009 Torsion of appendix of testis (disorder)
  • 304544003 Intermittent torsion of testis (disorder)