Patient will present as → a 15-year-old boy with severe lower abdominal pain that awoke him from sleep about 3 hours ago. The pain is sharp and radiates to the left thigh. While in the emergency room, the patient experiences one episode of vomiting. He denies any fever, dysuria or chills. The mom reports a childhood history of cryptorchidism. Physical examination reveals normal vitals with blood pressure 100/60 and temperature of 98.6F. Abdominal examination is relatively benign. Scrotal examination reveals an elevated left testis that is diffusely tender. Lifting of the left testicle does not relieve pain and there is a loss of cremasteric reflex. Transillumination test is negative. Doppler ultrasound shows absent blood flow.
Twisting of spermatic cord that results in compromised blood flow and ischemia - this is considered a surgical emergency
- Often after vigorous activity or minor trauma
- Usually in postpubertal boys: 65% occur in boys ages 10-20 years old
- Asymmetric high riding testicle “bell clapper deformity”
- Negative prehn's sign (lifting of testicle will not relieve pain)
- Loss of cremasteric reflex (elevation of the testes in response to stroking of the inner thigh)
- Blue dot sign: Tender nodule 2 to 3 mm in diameter on the upper pole of the testicle
- More common in patients with a history of cryptorchidism
Testicular doppler for diagnosis = best initial test
- Radionuclide scan demonstrates decreased uptake in the affected testes = gold standard
- This is a surgical emergency - 6 hour time frame for repair with the best outcomes
- Emergent surgical intervention on the affected testis must be followed by elective surgery on the contralateral testes, which is also at risk for torsion.
Elevation of the scrotum and ice therapy
Ultrasound evaluation with Doppler color flow
Computed tomography (CT) scan of the pelvis
Doppler stethoscope evaluation
Oral doxycycline is the treatment of choice for epididymitis. While epididymitis and testicular torsion present similarly, the Doppler ultrasound in epididymitis would show increased blood flow, not decreased.
incision and drainage
Incision and drainage is indicated for treatment of abscesses, not testicular torsion.Incision and drainage is indicated for treatment of abscesses, not testicular torsion.
scrotal elevation and ice packs
Scrotal elevation and ice packs are indicated for adjunct treatment of epididymitis, not testicular torsion.
Nodular mass within the testis
Testicular cancer is characterized by a painless nodular enlargement of the testis typically discovered by the patient.
Transilluminated fluid mass
A hydrocele is a collection of fluid within the scrotum which can be transilluminated on exam.
Palpation of a soft bag of worms
A varicocele refers to varicose veins of the spermatic cord. It feels like a soft bag of worms in the scrotum separate from the testis.