Emergency- Testicular Pain

Question 1

How would assess a 25 year old man with testicular pain?

Answer 1

Immediately see the patient as this could be a testicular torsion.
Advise the nurse looking after patient to keep fasted until review.
Assess using ABCDE approach as per ATLS protocol and give O2 if needed, Take bloods- FBC, Coag, CRP U&Es, urinalysis, STI screen
Focussed hx: duration, hx of trauma, hx of testicular pain, testicular lump, assoc LUTs/UTIs. Hx of STIs, associated fever, radiating pain. PMHx, DHx, SHx
Exam with chaperone:
-assess general lie- horizontal [?bell clapper], high riding, swelling erythema
-assess normal testicle first, then abnormal. assess for cremasteric reflex

Clinical suspicion of torsion then call on call consultant for theatre, anaesthetic and theatre team to be aware, bed manager for admission. Consent and mark patient.

Question 2

What is the difference between an intravaginal and extravaginal torsion?

Answer 2

Intravaginal torsion: common in adolescents, due to high investment of the tunica vaginalis to the spermatic cord causing horizontal lie and increasing risk of torsion.

Extravaginal torsion: seen in 1st year of life. Loose attachment between the tunica vaginalis and scrotum. resulting in twisting at a vertical axis.

Question 3

How would you consent for the scrotal exploration?

Answer 3

Confirm patient, name, DOB, side of testis and mark.
Explain indications and alternatives [conservative- risk of missed torsion]
Consent for L/R scrotal exploration +/- L/R bilateral fixation +/- L/R orchidectomy
Risks/ Complications:
Bleeding, haematoma, Loss of testicle, potential effect on fertility, pain, swelling, GA risks

Question 4

Outline the scrotal exploration procedure.

Answer 4

• Clean and drape
• incision over median raphe
• go through layers skin dartos, external spermatic fascia, cremasteric fascia, internal spermatic fascia, tunica vaginalis
• deliver testes and untort if needed. if dusky cover in warm saline soaked swab and give patient 100% oxygen
• if viable and untorted then make three point fixation with non absorbable suture, the fix other side
• if still not sure on viability stab tunica albuginea to see if there’s bleeding
• if normal, do not fix either side, close layers up with absorbable stitches