Lecture
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 a 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 a cremasteric reflex. Transillumination test is negative. Doppler ultrasound shows absent blood flow.
To watch this and all of Joe Gilboy PA-C's video lessons you must be a member. Members can log in here or join now.
Twisting of the 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 post pubertal 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
The doppler ultrasound shows no blood flow in the left testicle
Orchiopexy
- 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.
Testicular torsion occurs when the spermatic cord twists, cutting off the testicle’s blood supply, leading to ischemia. The principal symptom is a rapid onset of testicular pain. The most common underlying cause in adolescents and neonates is a congenital malformation known as a “bell-clapper deformity” wherein the testis is inadequately affixed to the scrotum allowing it to move freely on its axis and susceptible to induced twisting of the cord and its vessels. Testicular malignancy is the most common etiology in adults. Diagnosis is clinical, with surgical detorsion urgently performed to prevent necrosis of the testicle and possible subfertility.
Play Video + QuizQuestion 1 |
Elevation of the scrotum and ice therapy | |
Ultrasound evaluation with Doppler color flow | |
Continued observation | |
Computed tomography (CT) scan of the pelvis | |
Doppler stethoscope evaluation |
Question 2 |
True | |
False |
Question 3 |
oral doxycycline Hint: 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. | |
emergent surgery | |
incision and drainage Hint: 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 Hint: Scrotal elevation and ice packs are indicated for adjunct treatment of epididymitis, not testicular torsion. |
Question 4 |
Nodular mass within the testis Hint: Testicular cancer is characterized by a painless nodular enlargement of the testis typically discovered by the patient. | |
High-lying testis | |
Transilluminated fluid mass Hint: A hydrocele is a collection of fluid within the scrotum which can be transilluminated on exam. | |
Palpation of a soft bag of worms Hint: 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. |
|
List |
References: Merck Manual · UpToDate
