Urology
A 19 year old man presents to the Emergency Department with a 2 hour history of atraumatic left testicular pain. He describes a sudden onset of pain whilst sitting. He tells you he has had one similar episode a year ago that resolved after 3 hours, he did not seek medical attention for this. He describes the pain as 10/10 and it is associated with vomiting. What is the most likely diagnosis?
Answer:
Testicular torsion:- Can occur at any age, but most commonly in the neonatal period or around puberty.
- Onset is usually sudden.
- Pain is usually severe, unilateral, and is associated with abdominal pain, or nausea and vomiting.
- There may be a history of previous episodes of severe, self-limiting pain.
- There is usually severe tenderness to palpation of the affected testicle.
- There is usually no relief of pain upon elevation of the scrotum.
- The testis is often elevated in the scrotum, and may have a transverse lie.
- The cremasteric reflex, obtained by stroking the inner thigh on the affected side with subsequent testicular rise, is almost always absent.
- A more delayed presentation may reveal worsening of the scrotal erythema and oedema, and a reactive hydrocele may develop.
Testicular Torsion
Urology
Last Updated: 12th February 2021
Testicular torsion is a urological emergency caused by the twisting of the testicle on the spermatic cord leading to constriction of the vascular supply and time-sensitive ischaemia and/or necrosis of testicular tissue.
Torsion of testicular or epididymal appendages (also known as torsion of the appendix testis, appendix epididymis, or testicular hydatids) can also occur.
Causes
Testicular torsion occurs in boys of any age, can occur in the first year of life, but most commonly occurs in those aged 12–18 years, with peak incidence between 13–16 years.
Classification:
- Intravaginal torsion (most common type):
- In older children and adults, testicular torsion is usually intravaginal (twisting of the cord within the tunica vaginalis). The 'bell clapper deformity' is the most common anatomical defect associated with the development of intravaginal testicular torsion, with around 4–8% caused by trauma. It is caused by an abnormal fixation of the tunica vaginalis to the testicle, which allows the testicle to rotate freely within the tunica vaginalis. Some boys and men give a history of previous episodes of severe, self-limiting scrotal pain and swelling, which is assumed to be spontaneous torsion and detorsion.
- Extravaginal torsion:
- Torsion may also occur in the womb or during the neonatal period. Extravaginal torsion predominates where there is twisting of the entire cord, including the processus vaginalis. The exact aetiology of extravaginal torsion is unknown, and an anatomical defect is not usually identified.
Predisposing factors include:
- Bell-clapper deformity
- Testicular tumour
- Testicles with horizontal lie
- History of undescended testis
- Testicular/scrotal trauma
- Spermatic cord with long intra-scrotal portion
Clinical features
A high index of suspicion is important to ensure timely diagnosis and management.
Testicular torsion
- Can occur at any age, but most commonly in the neonatal period or around puberty.
- Onset is usually sudden.
- Pain is usually severe, unilateral, and is associated with abdominal pain, or nausea and vomiting.
- There may be a history of previous episodes of severe, self-limiting pain.
- There is usually severe tenderness to palpation of the affected testicle.
- There is usually no relief of pain upon elevation of the scrotum.
- The testis is often elevated in the scrotum, and may have a transverse lie.
- The cremasteric reflex, obtained by stroking the inner thigh on the affected side with subsequent testicular rise, is almost always absent.
- A more delayed presentation may reveal worsening of the scrotal erythema and oedema, and a reactive hydrocele may develop.
- Neonatal cases of testicular torsion may present with scrotal swelling and discoloration (similar to scrotal haematoma).
Torsion of appendix testis or appendix epididymis:
- Onset is sudden, or gradual over a few days.
- Typically painful and tender over the head of the testis or epididymis, not associated with nausea and vomiting.
- Early on, a nodule can be palpated at the upper end of testis or epididymis. Later, there is more generalised scrotal oedema.
- May be indistinguishable from testicular torsion, but usually the testis is mobile and of normal size, and the cremasteric reflex is present.
- An infarcted appendage may be seen through the skin (the 'blue dot sign').
Management
- Torsion should be diagnosed clinically and a high index of suspicion maintained in order to identify and provide definitive treatment as quickly as possible.
- A careful history and physical examination that is suspicious for testicular torsion may warrant immediate surgical exploration for repair without further delay by diagnostic testing; acute testicular pain, often with abdominal pain and sometimes vomiting has a high predictive value for testicular torsion.
- However, a history and examination leading to an unclear diagnosis warrants the need for quick diagnostic studies to avoid unnecessary surgery for a diagnosis requiring conservative management but lead to timely surgical intervention if necessary; ultrasound examinations are non-invasive and quick, and can determine the presence of testicular torsion or identify other aetiologies for testicular pain.
- In the setting of acute testicular torsion, immediate urological consultation for operative repair is essential to optimise testicular salvageability. The decision for orchiectomy versus orchidopexy is based on the extent of damage to testicular tissue. During exploration, the contralateral testis is fixed to the posterior wall to prevent asynchronous bilateral testicular torsion.
Prognosis
Patients presenting with symptoms lasting less than 4 to 6 hours' duration have a greater likelihood of testicular viability. Testicular salvage rates decline as the duration of symptoms increases. Duration of symptoms beyond 48 hours leads to consistently poor testicular salvage results.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
