by Sujata Kirtikant Sheth
A 16-year-old male was sleeping when he suddenly started to feel left sided lower abdominal pain. He continued to bear through the pain for another 30 minutes until he started to vomit. At this time he decided to go to the nearest hospital, which is about 15 minutes away. When he reached the hospital his vital signs were as follows: BP: 120/60 mmHg, HR: 120 bpm, RR: 20 bpm, Temp 36.5C, Pain 10/10 and SpO2 was 100% on room air. Physical shows a swollen right scrotum with significant tenderness. What is the next step?
Critical Bedside Actions and General Approach
- Perform full physical examination including a genital examination
- Induce cremasteric reflex- stoke the inner thigh to see if the cremasteric muscle contracts and the testicle elevates
- Perform ultrasound but do not delay care
- Detorse the testis from medial to lateral
- Consult urology
History and Physical Exam Hints
Key questions to establish an accurate diagnosis are:
- What time did this occur?
- What was the patient doing at the time?
- Have they had pain on the same side before?
- Was there any trauma involved?
- What are the other associated symptoms?
- Are you sexually active?
- Are all your immunizations up to date?
Signs and Symptoms
The diagnosis of testicular torsion is based on signs and symptoms. The most classic presentation is a severe testicular pain within 6 hours. However, some patients have milder, less acute pain or no scrotal pain. Alternatively, abdominal pain or inguinal pain may be present. The pain may start at rest, while asleep, or with physical activity. Testicular torsion rarely may be bilateral.
The most common physical findings are testicular tenderness and absence of the cremasteric reflex. Note that 10% of proven testicular torsion cases have a cremasteric reflex. A negative Prehn’s test (relief of pain with elevation of the testes) is another sign to look for, but it is not 100% reliable. All patients with testicular torsion have one or more of the following: Nausea or vomiting, pain duration of less than 24 hours, high position of the testis or abnormal cremasteric reflex.
- Epididymal appendage torsion
- Epididymitis or orchitis
- Idiopathic scrotal edema
- Idiopathic testicular infarction
- Testicular torsion
- Testis tumor
- Traumatic hematoma
Acute scrotum warrants the exclusion of the testicular torsion. The emergency physician should bear a high index of suspicion because the clinical signs and symptoms vary widely between patients. No single details in the history, physical or imaging confirm or exclude the diagnosis with 100% certainty.
Two main types of testicular torsion are intravaginal and extravaginal. The extravaginal torsion occurs in the perinatal period before the fixation of the tunica vaginalis. Intravaginal torsion refers to when the testis twists inside the tunica vaginalis. Bell Clapper deformity refers to a partial or complete fusion of the tunica vaginalis along the epididymis. It causes an excessive testicular movement and about 12% of the testicular torsions.
Emergency Diagnostic Tests and Interpretation
- Scrotal ultrasound is the method of choice. The ultrasound shows a hypoechoic and enlarged testis in patients with testicular torsion. Reduced blood flow and parenchymal heterogeneity are the other signs of testicular torsion.
The testicular ultrasound shows bilateral normal blood supply in doppler investigation (below).
Which testicle has no “blood flow” on the below ultrasound image?
- Urine analysis may prove other diagnoses. However, the presence of infection in urine does not exclude the testicular torsion.
- Pre-operation labs if required by the surgical team
Emergency Treatment Options
There are a few steps to perform in the ED. The emergency physician may try to detorse the testicle manually at the bedside if the diagnosis is likely. Most testicular torsions are from lateral to medial, so the physician should move the testicle from a medial to a lateral position to detorse the testicle. The patient’s pain should relieve if the detorsion is successful. Rarely, if the patient’s torsion is from medial to lateral, the physician should detorse in the opposite direction. Turning the testicle in the wrong direction increases the pain.
Torsion of the appendix is more common than torsion of the spermatic cord. Torsion of the appendix is managed conservatively unlike the torsion of the spermatic cord. Torsion of the spermatic cord requires early surgical exploration because this will result in ischemia, damage or loss.
Testicular torsion is a painful condition. Please do not ignore and treat the patient’s pain with proper pain medication, paracetamol, ibuprofen or with stronger alternatives. In a pediatric patient, the physician may consider options such as intranasal fentanyl. Ideally, oral medications are not preferable as the operation is likely.
If the emergency physician suspects testicular torsion, an emergent urological consult is indicated. The urologist determines the need for ultrasound or emergency surgery. Ultrasound or any other diagnostic tests should not delay the intervention in patients with high clinical suspicion. The emergency physician may attempt a bedside ultrasound while waiting for the urologist. Consider drawing blood for operation.
Patient with testicular torsion present within 6 hours should undergo an emergent surgery. Patients with testicular torsion for more than 48 hours should be admitted to the urology ward unless the patient is hemodynamically unstable.
Patients with testicular torsion should not be discharged from the emergency department. In a patient with intermittent symptoms and a negative ultrasound, if the urologist does not admit the patients for observation, it is safer to observe the patient in the ED for repeating symptoms. If the symptoms occur again, repeating the ultrasound and urology consultation is sensible.
If you have deemed the patient as not having a testicular torsion you can refer them to urology a week later to see if their symptoms have resolved. Please provide patients with strict information on when to return to the emergency department. If they start having pain again, increased vomiting, inability to urinate, fever, any other worrisome symptoms they need to return.
References and Further Reading
- Wein Alan J., Kavoussi Louis R., Partin Alan W., and Peters Craig A. “Acute Scrotum.” Campbell-Walsh Urology. Elsevier, 2016. 3389.
- Schick MA, Sternard BT. Testicle, Torsion. [Updated 2017 Oct 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448199/
- Testicular Torsion Clinical Presentation: History …. https://emedicine.medscape.com/article/2036003-clinical