Paediatrics

Question 1

Learning objectives

Answer 1

Answer

Question 2

Define testicular torsion

Answer 2

• A SURGICAL EMERGENCY. Twisting or torsion of the spermatic cord results, initially, in venous outflow obstruction from the testicle, progressing to arterial occlusion and testicular infarction if not corrected.

Question 3

Explain the aetiology/risk factors of testicular torsion

Answer 3

• Intravaginal (MOST COMMON)
o The spermatic cord twists within the tunica vaginalis
• Extravaginal (usually in neonates)
o The entire testis and tunica vaginalis twist in a vertical axis on the spermatic cord
o Due to incomplete fixation of the gubernaculum to the scrotal wall allowing free rotation
• Risk Factors
o Imperfectly descended testes
o High investment of the tunica vaginalis

Question 4

Summarise the epidemiology of testicular torsion

Answer 4

• Most common cause of acute scrotal pain in 10-18 yr olds

Question 5

Recognise the presenting symptoms of testicular torsion

Answer 5

• Sudden-onset severe hemiscrotal pain
• Abdominal pain
• Nausea and vomiting

Question 6

Recognise the signs of testicular torsion on physical examination

Answer 6

• Swollen, erythematous scrotum on the affected side
• Swollen testicle will lie slightly higher than the unaffected one
• Testicle might lie horizontal
• Thickened cord
• Testicular Appendix
o There may be a visible necrotic lesion on transillumination
• Differential Diagnosis
o Epididymo-orchitis
o Incarcerated inguinal hernia

Question 7

Identify appropriate investigations for testicular torsion

Answer 7

•	Doppler/Duplex Imaging of the Testes
o	Do NOT delay surgery
o	Arterial inflow 
•	REDUCED in testicular torsion
•	INCREASED in epididymo-orchitis

Question 8

Generate a management plan for testicular torsion

Answer 8

• Exploration of the scrotum within 6 hrs of onset of symptoms
• After the testicle is twisted back into place, a bilateral orchidopexy is performed
• This involves suturing the testicle to the scrotal tissue to prevent recurrence
• If the testicle is necrotic, orchidectomy may be performed

Question 9

Identify possible complications of testicular torsion

Answer 9

• Testicular infarction
• Testicular atrophy
• Infection
• Impaired fertility (due to production of anti-sperm antibodies)

Question 10

Summarise the prognosis for patients with testicular torsion

Answer 10

• From the onset of torsion, a testicle may only survive 4-6 hrs
• With prompt surgical intervention, most testicles are salvaged