27: 17-year-old male with groin pain Flashcards
Causes of Testicular Torsion
Congenital anomaly
A congenital anomaly that results in failure of normal posterior anchoring of the gubernaculum, epididymis, and testis is called a bell clapper deformity because it leaves the testis free to swing and rotate within the tunica vaginalis of the scrotum much like the gong (clapper) inside of a bell, causing an intravaginal torsion. A large mesentery between the epididymis and the testis can also predispose itself to torsion. Contraction of the muscles shortens the spermatic cord and may initiate testicular torsion.
Undescended testes
Although there is little solid evidence, the incidence of testicular torsion is thought to be higher in undescended testes than in normal scrotal testes. Torsion of an undescended testicle often occurs with the development of a testicular tumor, presumably caused by increased weight and distortion of the normal dimensions of the organ.
Recent trauma or vigorous exercise
The patient’s history often indicates recent trauma to the genital area, hard physical work, or vigorous exercise.
Complications of Testicular Torsion: Testicular Loss
Duration of scrotal pain
Percentage of testicular viability
6 hours
90%
more than 12 hours
50%
more than 24 hours
10%
GAPS recommendations are organized into four types of services that address 14 separate topics or health conditions.
Preventing hypertension
Promoting parents’ ability to respond to the healthcare needs of their adolescents
Preventing hyperlipidemia
Preventing the use of tobacco products
Preventing the use and abuse of alcohol and other drugs
Preventing severe or recurrent depression and suicide
Preventing physical, sexual, and emotional abuse
Preventing learning problems
Preventing infectious diseases
Promoting adjustment to puberty and adolescence
Promoting safety and injury prevention
Promoting physical fitness
Promoting healthy dietary habits and preventing eating disorders and obesity
Promoting healthy psychosexual adjustment and preventing the negative health consequences of sexual behaviors
Scrotal Exam Findings
Cremastericreflex
Cremasteric reflex can be assessed by lightly stroking or pinching the superior medial aspect of the thigh. An intact cremasteric reflex causes brisk ipsilateral testicular retraction. Absence of the
cremasteric reflex is a sensitive but non-specific finding for testicular torsion. It can be absent on physical exam in normal testes. It should be assessed after inspection and before palpation of the
testicles.
Blue dot sign
Tenderness limited to the upper pole of the testis suggests torsion of a testicular appendage,especially when a hard, tender nodule is palpable in this region. A small bluish discoloration known
as the “blue dot sign”, may be visible through the skin in the upper pole. This sign is virtually pathognomonic for appendiceal torsion when tenderness is also present.
Prehn sign
Prehn reported that physical lifting of the testicles relieves the pain caused by epididymitis but not pain caused by testicular torsion. A positive Prehn sign is pain that is relieved by lifting of the testicle;
if present this can help distinguish epididymitis from testicular torsion.
GAPS does not address preventing diabetes.
The American Diabetes Association recommends lifestyle changes
and avoiding weight gain for diabetes prevention in adolescents. Fasting plasma glucose levels should be checked
every two years in high-risk children and adolescents, beginning at 10 years of age. The United States Preventive
Service Task Force (USPSTF) has not addressed screening youths for diabetes.
cervical screening
Women should have their first cervical cancer screening at age 21 and can be rescreened less frequently than
previously recommended, according to guidelines issued by the American College of Obstetricians and
Gynecologists (ACOG).
Sexually Transmitted Infection Screening, Presentation, & Diagnosis in the Sexually Active Female
Patients with chlamydia present with dysuria, discharge (penile or vaginal), pain with sex, abdominal or testicular pain, breakthrough bleeding or can be asymptomatic. Diagnosis is made by nucleic acid amplification test of urine, endocervical sample, or urethral sample.
Patients with gonorrhea can be either asymptomatic, or have dysuria, discharge (penile or vaginal), pain with sex, abdominal or testicular pain, or breakthrough bleeding. Diagnosis is made by nucleic acid amplification test of urine, endocervical sample, or urethral sample; gonococcal culture for rectal or
pharyngeal specimens.
Presenting symptoms of trichomonas include vaginal discharge with odor or itching, so testing for T. vaginalis should be performed in women seeking care for vaginal discharge. But trichomonas can also be asymptomatic and screening for T. vaginalis can be considered in those at high risk for infection, such as women who have new or multiple partners (the situation presented in this question), have a history of STIs, exchange sex for payment, and use injection drugs. Diagnosis is made by saline wet mount; rapid antigen testing, or Trichomonas culture.
HIV screening is recommended for patients in all health-care settings after the patient is notified that testing
will be performed unless the patient declines (opt-out screening). Persons at high risk for HIV infection
should be screened for HIV at least annually.
Testicular Cancer - Prevalence, Presentation, & Screening Recommendations
Testicular cancer is the most common malignancy affecting males between the ages 15 and 35, although it accounts for only one percent of all cancers in men. It is most common among African-Americans with a frequency of 1.6 per 100,000.
These tumors could present as a nodule or as a painless swelling of the testicle, 30-40% may present with dull ache or heavy sensation in the lower abdomen, perianal area, or scrotum areas. Acute pain is the presenting symptom in ten percent of cases.
There is no evidence to support routine screening for testicular cancer in asymptomatic adolescents and young
adults.
Testicular Tumor Risk Factors
The most common testicular tumor is germ cell tumor. The specific cause of germ cell tumors is unknown, but various factors have been associated with the increased risk.
Genetics play a role in testicular cancer risk. Klinefelter’s syndrome (47xxy) is associated with a higher incidence
of germ cell tumors. For first degree relatives of individuals affected there is approximately six to ten- fold increased
risk for germ cell tumors. Other conditions such as Down syndrome, testicular feminizing syndrome, true hermaphrodites, persistent mullerian syndrome, and cutaneous ichthyosis are at higher risk for developing germ
cell tumors.
Family history also plays an important role in testicular cancer risk. There have been reports of six-fold increased risk among male offspring of a patient with testicular cancer.
Patients with cryptorchidism have 20 to 40-fold increased risk compared with their normal counterparts. Cryptorchidism is the absence of one or both testes from the scrotum, usually as the result of an undescended testis. Orchipexy, even at an early age, appears to reduce the incidence of germ cell tumor only slightly.
Numerous environmental hazards, such as industrial occupations and drug exposures have been implicated in the development of testicular cancer. They include DES, Agent Orange, and solvents used to clean jets and ochratoxin A.
One to two percent of patients with testicular cancer will develop a second primary cancer in the contralateral
testicle. This represents a 500-fold increase in risk compared with normal population.
Non-germ cell tumors
Non-germ cell tumors (Leydig cell tumors and Sertoli cell tumors) constitute the
remaining 5% of primary testicular tumors; these are rare tumors that are malignant in
only about 10% of the cases.
Extragonadal
Lymphoma, leukemia, and melanoma are the most common malignancies that
metastasize to the testicle (extragonadal tumors).
Scrotal Exam Techniques
The skin of the scrotum should be palpated for edema, fluid collection, tenderness, and subcutaneous emphysema. Begin palpation of scrotal contents with the unaffected side.
The normal testis is mobile, and the spermatic cord and epididymis are palpable posteriorly.
1. By gently grasping the testis between the thumb and first two digits, the testicle is
examined from its inferior pole, superiorly.
2. Then palpate the testicle for size, tenderness, (localized or diffuse), lie (high or low within scrotum-the left testicle normally sits slightly lower than the right), and axis (horizontal or vertical).
The epididymis should be examined for size, position, tenderness, and swelling. The epididymis should be palpable as a soft, smooth ridge posterolateral to the testis.
To complete the intra-scrotal evaluation, palpation of all scrotal contents should occur. This includes examination of the spermatic cord to the superficial inguinal ring for tenderness or a “knot” which suggests testicular torsion and any localized fluid collections, such as a hydrocele or spermatocele.
Transillumination
Transillumination may help you determine the etiology of a lesion. For example, a light source shines brightly through a hydrocele.
Treatment of Testicular Torsion
Non-surgical approach
Manual detorsion of the torsed testes, may be attempted, but it is usually difficult because of acute pain during the manipulation. This nonoperative distorsion is not a substitute for surgical exploration.
If the maneuver is successful, orchiopexy (surgical fixation of both testes to prevent retorsion) must still be performed. This should be done in the immediate future, preferably before the patient leaves the hospital.
If full manual reduction of torsion cannot be performed or if there is doubt about the diagnosis and reason to suspect torsion, the scrotum must be explored.
Surgical approach
The testis must be unwound at operation and inspected for viability. If it is not viable, it should be removed. If the testis is viable then orchiopexy should be performed to prevent recurrence. Whether the affected testis is removed or conserved, the contralateral one should undergo orchiopexy as the risk of recurrence on the other side is otherwise high.
Diagnosing Testicular Torsion
Color Doppler ultrasonography can confirm testicular torsion if pain is less severe and the diagnosis is in question. If testicular torsion is present, intratesticular blood flow is either decreased or absent which appears as decreased echogenicity, as compared with the asymptomatic testis. In addition, the torsed testicle often appears enlarged.
Radionuclide scintigraphy is a diagnostic test that uses a radioisotope to visualize testicular blood flow. Patients with testicular torsion have decreased radiotracer in the ischemic testis, resulting in a photopenic lesion.
Radionuclide scintigraphy vs color doppler ultrasonography:
Radionuclide scintigraphy procedure has 100% sensitivity, whereas Doppler ultrasonography only has a sensitivity of 88% and a specificity of 90% in detecting testicular torsion.
Although scintigraphy may be more sensitive for testicular torsion, ultrasonography is faster and more readily available. This is a critical consideration in a condition that warrants a rapid diagnosis.
Color Doppler ultrasonography and scintigraphy demonstrate no statistically significant difference in ability to demonstrate testicular torsion in boys with acute scrotal symptoms and indeterminate clinical presentations.
