A 14 y/o M presents to the ED complaining of severe intermittent low abdominal pain x 2 hours. His symptoms began after he awoke from sleep to urinate, and have been unremitting since. No history of trauma. He vomited once, 20 minutes prior to arrival. His abdominal exam is benign. He appears very uncomfortable and anxious. You astutely perform a GU exam, with findings consistent with your final diagnosis.

  1. What is the diagnosis you cannot miss?
  2. What signs would you expect to find classically on physical exam?
  3. What imaging findings are classic?

 

This patient has testicular torsion. While other diagnoses must be considered including GI conditions (appendicitis, gastroenteritis, IBD, incarcerated inguinal hernia) and GU conditions (renal colic, epididymitis, orchitis, UTI), among many others… the diagnosis of testicular torsion must be high on your differential when approaching a young male with acute onset abdominal or genitourinary pain. Testicular torsion results from poor fixation of the testis to the tunica vaginalis. If fixation of the lower pole of the testis to the tunica vaginalis is insufficient, the testis may twist on the spermatic cord, and lead to ischemia from reduced arterial inflow and venous outflow obstruction.

Your exam should be guided by certain physical exam findings and maneuvers:

                  A swollen scrotum, and tender, swollen, elevated testis.

                 The testis is often high riding and has a transverse lie.

                An absent cremasteric reflex, although not specific.

               Prehn’s sign – elevation of the testicle relieves pain in epididymitis, not in torsion (can’t use to r/o torsion)

Testicular torsion is a clinical diagnosis, however ultrasound can provide better diagnostic certainty (this should be done urgently, while urology is made aware of the case and your already very high clinical suspicion). This is a true emergency. If torsion is repaired within 6 hours of the initial insult, salvage rates of 80-100% are typical. These rates decline to nearly 0% at 24 hours.                            

Left torsion - lack of arterial waveform   

Left torsion – lack of arterial waveform

On Doppler ultrasound flow to the affected testicle is absent, although normal or increased flow may be seen if there has been spontaneous detorsion. The side of the patient’s symptoms should be compared with the asymptomatic side by using the straddle view.

 

References:

Heller, Matt. Institute for Advanced Medical Education, Ultrasound Evaluation of Acute Scrotal Pain.

Beni-Israel T, Goldman M, Bar Chaim S, Kozer E. Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med. Sep 2010;28(7):786-9

Eyre RC. Evaluation of the acute scrotum in adults. October 21,2013. http://www.uptodate.com/contents/evaluation-of-the-acute-scrotum-in-adult-men?source=search_result&selectedTitle=1~13.