PANCE Blueprint Genitourinary (5%)

Testicular torsion (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 right thigh. While in the emergency room, the patient experienced 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 a blood pressure of 100/60 and a temperature of 98.6F. Abdominal examination is relatively benign. Scrotal examination reveals an elevated right testis that is diffusely tender. Lifting of the right testicle DOES NOT relieve pain, and there is a loss of a cremasteric reflex. The transillumination test is negative. Doppler ultrasound shows absent blood flow in the right testis.

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What is a “bell clapper” deformity?
Bilateral nonattachment of the testicles by the gubernaculum to the scrotum (free like the clappers of a bell)
How much time is available from the onset of symptoms to detorse the testicle?
< 6 hours will bring about the best results (> 90% salvage rate). There is a < 10% chance of salvaging the testicle after 24 hours. 

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 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 in testicular torsion)
    • Compare this to the (+) Prehn's sign = relief with elevation of the testicle, which is a classic sign of epididymitis
  • Loss of cremasteric reflex (elevation of the testes in response to stroking of the inner thigh)
"The cremasteric reflex is elicited by stroking or pinching the medial thigh, causing contraction of the cremaster muscle, which elevates the testis. The cremasteric reflex is considered positive if the testicle moves at least 0.5 cm"
  • Blue dot sign: Tender nodule 2 to 3 mm in diameter on the upper pole of the testicle - is indicative of the torsion of a testicular appendage, which is a vestigial remnant present in 80% of people designated male at birth
  • 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

Acute testicular torsion in a 23-year-old man who presented with sudden right scrotal pain for 1 hour:a: Transverse ultrasound shows enlarged, hypoechoic right testis (RT) with thickened scrotal skin (asterisk). b: Color Doppler ultrasound shows no vascularity in the right testis. Image: 'Acute testicular torsion' by Thinyu S, Muttarak M. License: CC BY 2.5

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.

Picmonic
Testicular 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 + Quiz

Question 1
A 5-year-old presents to your office complaining of scrotal pain and you note swelling of the left testis. What is the appropriate next step?
A
Elevation of the scrotum and ice therapy
B
Ultrasound evaluation with Doppler color flow
C
Continued observation
D
Computed tomography (CT) scan of the pelvis
E
Doppler stethoscope evaluation
Question 1 Explanation: 
Testicular torsion should be suspected in patients who complain of acute scrotal pain and swelling. Testicular viability is in jeopardy with delay in diagnosis, ultimately impacting the patient fertility. Associated conditions that may resemble testicular torsion not warranting surgery are torsion of a testicular appendage, epididymitis/ orchitis, trauma, incarcerated hernia, varicocele, and idiopathic scrotal edema. Testicular torsion is most common in men younger than 25 years old, although it can occur in men of any age. A prepubertal or young male adult with acute scrotal pain should be diagnosed as testicular torsion until proven otherwise. Physical exam finding of higher testicular lie and absent cremasteric reflex are supportive evidence for this condition. Scrotal imaging with Doppler color flow ultrasound is necessary when the diagnosis remains unclear. Once the correct diagnosis is established, prompt surgical evaluation should be performed. It is reasonable to perform manual detorsion for immediate noninvasive treatment followed by elective orchiopexy.
Question 2
True or False: A patient presenting with testicular torsion will have a negative prehn’s sign
A
True
B
False
Question 2 Explanation: 
A patient presenting with testicular torsion will have a negative prehn’s sign (lifting of testicle will not relieve pain). A positive prehn's sign is seen in patients with epididymitis, they will have relief of pain with lifting of the testicle.
Question 3
A 16 year-old male presents with increasing pain and swelling of his right scrotum. The right testicle is extremely tender to palpation on examination. A Doppler ultrasound demonstrates decreased blood flow. Which of the following is the most appropriate intervention?
A
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.
B
emergent surgery
C
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.
D
scrotal elevation and ice packs
Hint:
Scrotal elevation and ice packs are indicated for adjunct treatment of epididymitis, not testicular torsion.
Question 3 Explanation: 
Once a diagnosis of testicular torsion is suspected, emergent surgery is indicated to have the best possible chance of salvaging the testicle (85-97% chance if less than 6 hours). Any other treatment measures delay the definitive treatment and increase the risk of testicular ischemia and infarction.
Question 4
A 15-year-old man comes to the office with acute onset of nausea, severe pain and swelling within the right testis. He has no fever or irritative voiding symptoms. Which of the following scrotal physical examination findings would you expect in this patient?
A
Nodular mass within the testis
Hint:
Testicular cancer is characterized by a painless nodular enlargement of the testis typically discovered by the patient.
B
High-lying testis
C
Transilluminated fluid mass
Hint:
A hydrocele is a collection of fluid within the scrotum which can be transilluminated on exam.
D
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.
Question 4 Explanation: 
Testicular torsion occurs in the 10-20 year age group, and is characterized by acute onset of severe pain and swelling of the testis. Physical examination will reveal a tender high-riding testis.
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References: Merck Manual · UpToDate

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