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Testicular torsion
From WikEM
Contents
Background
- Peak incidence in first year of life, 2nd peak incidence at puberty
- Increased risk: Undescended testicle or Bell-Clapper Deformity
- Consider torsion in setting of scrotal trauma if pain persists >1hr
- Half of all torsions occur during sleep
Salvage Rates for Detorsion Times
| Rate | Time |
| 90-100% | <6 hrs |
| 20-50% | 6-12 hrs |
| 0-10% | >24 hrs |
Clinical Features
- History:
- Abrupt onset testicular pain associated with nausea/vomiting
- May have had intermittent episodes in the past
- Exam:
- Swollen, high-riding testis with transverse lie
- Absent cremasteric reflex on affected side (99% Sn)
- Ultrasound
- Only indicated for equivocal cases
- Unilateral abscence of flow (specific)
Differential Diagnosis
Testicular Diagnoses
- Testicular torsion
- Epididymitis
- Orchitis
- Torsion of testicular appendage
- Scrotal abscess
- Fournier gangrene
- Hydrocele
- Indirect inguinal hernia
- Hematocele
- Spermatocele
- Testicular trauma
- Testicular rupture
- Varicocele
- Inguinal lymph node (Lymphadenitis)
- Testicular tumor
- Cellulitis
- Tinea cruris
Evaluation
Work-Up
- Urinalysis
- US for equivocal cases
- Bedside U/S has a SN 0.95 and SP 0.94 compared to a gold standard of radiology U/S[1]
- Lab workup for surgery
TWIST Score
- Proposed score for assessing testicular torsion in children
| Finding | Points |
|---|---|
| Testicular swelling | 2 |
| Hard testicle | 2 |
| Absent cremasteric reflex | 1 |
| Nausea or vomiting | 1 |
| High-riding testicle | 1 |
- PPV 100% when >5 patients (Suggesting clinical clearance)
- NPV 100% when <2 patients (Suggesting stat urological consult)[2]
- Scores from 2-5 patients require U/S for further assessment
Treatment
- Manual (ED) vs. surgical (urology)
Manual Detorsion
- Indicated if urologist is not immediately available
- Not definitive treatment
- Patient still requires emergent urology consult even if successful
- "Open the book" = twist outward and laterally
- Give parenteral analgesia or perform cord block
- Prep skin, palpate and grasp cord at external ring and inject 10mL lidocaine directly into cord
- Hold testicle with left thumb and forefinger
- Rotate testicle outward 180° in medial to lateral direction
- Counterclockwise for right testicle and clockwise for left testicle
- Rotation may need to be repeated 2-3x for complete detorsion/pain relief
- If difficult to detorse or pain is worse after rotation, try to rotate testicle in opposite direction and observe results.
- Rotate testicle outward 180° in medial to lateral direction
- Give parenteral analgesia or perform cord block
Disposition
- To OR or urology
See Also
References
- ↑ Blaivas, M, et al. Emergency evaluation of patients presenting with acute scrotum using bedside ultrasonography. Academic Emergency Medicine. 2001; 8(1):90-93.
- ↑ Barbosa, JA, et al. Development of initial validation of a scoring system to diagnose testicular torsion in children. The Journal of Urology. 2013; 189:1853-8.
