PANCE Blueprint Genitourinary (4%)

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 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 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, consistent with testicular torsion. Management includes emergency surgical detorsion and bilateral orchiopexy to prevent recurrence. The patient’s prognosis depends on prompt surgical intervention, ideally within 6 hours of symptom onset.

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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.