Wednesday, February 1, 2017

Testicular Torsion

 A young male , age 16 years presents to the emergency with the complain of the sudden onset of pain in one testicle, followed by swelling of the affected testicle, reddening of the overlying scrotal skin, lower abdominal pain, nausea, and vomiting.
An examination reveals a swollen, tender, retracted testicle that often lies in the horizontal plane (bell-clapper deformity).

A diagnosis of Testicular torsion was made and the patient was prepared for immediate surgery.

Case Discussion:

Testicular torsion is one of the urologic emergencies and is very painful on presentation.

Testicular torsion occurs when a testicle rotates, twisting the spermatic cord that brings blood to the scrotum. The reduced blood flow causes sudden and often severe pain and swelling.

Testicular torsion is most common between ages 12 and 16, but it can occur at any age, even before birth.

Testicular torsion usually requires emergency surgery. If treated quickly, the testicle can usually be saved. But when blood flow has been cut off for too long, a testicle might become so badly damaged that it has to be removed.

Etiology: The most common underlying cause 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.

Clinical Features: Signs and symptoms of testicular torsion include:
  • Sudden, severe pain in the scrotum
  • Swelling of the scrotum
  • Abdominal pain
  • Nausea and vomiting
  • A testicle that's positioned higher than normal or at an unusual angle
  • Painful urination
  • Fever
Young boys who have testicular torsion typically wake up due to scrotal pain in the middle of the night or in the morning.
The spermatic cord is frequently swollen on the affected side. In delayed presentations, the entire hemiscrotum may be swollen, tender, and firm.

Diagnosis: The diagnosis should usually be made on the presenting signs and symptoms and an urgent ultrasound should only be done when the diagnosis is unclear. 
The urine is usually clear with a normal urinalysis. In one-third of cases, there is a peripheral leukocytosis.
Irreversible ischemia begins around six hours after onset and emergency diagnosis and treatment is required within this time to minimize the risk of testicle loss.

Treatment: With prompt diagnosis and treatment the testicle can often be saved. Typically, when a torsion takes place, the surface of the testicle has rotated towards the midline of the body. 
Non-surgical correction can sometimes be accomplished by manually rotating the testicle in the opposite direction (i.e., outward, towards the thigh); if this is initially unsuccessful, a forced manual rotation in the other direction may correct the problem. The success rate of manual detorsion is not known with confidence.

Testicular torsion is a surgical emergency that requires immediate intervention to restore the flow of blood. If treated either manually or surgically within six hours, there is a high chance (approx. 90%) of saving the testicle.

Common treatment for children is surgically sewing the testicle to the scrotum to prevent future recurrence (orchiopexy).

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