Urology Flashcards
Testicular torsion
Testicular torsion is the sudden twisting of the spermatic cord within the scrotum. It most commonly affects neonates and young men. Because of the risk of ischemia and possible infarction of the testis, it is considered a urological emergency. Testicular torsion is characterized by sudden-onset unilateral testicular pain, which may radiate to the lower abdomen, with nausea and vomiting. Clinical findings include a high-riding testis with an absent cremasteric reflex. Imaging with duplex ultrasound of the scrotum may be required if the clinical diagnosis is in doubt. If testicular torsion is suspected, prompt surgical exploration within six hours of symptom onset is essential to salvage the testis. Important differential diagnoses, e.g., orchitis and epididymitis, should be ruled out before initiating treatment.
testicular torsion dr deac pimp
Epidemiology
Peak incidence: neonatal period (first 30 days of life) and during puberty.
Aetiology:
Idiopathic
Hypotheses include the bell-clapper deformity (intravaginal torsion; see “Pathophysiology” below) or a prolonged mesorchium
In neonates, the entire tunica vaginalis undergoes torsion (extravaginal torsion).
Iatrogenic
Occurs in very rare cases as a result of trauma.
Pathophysiology
Testicular torsion involves a sudden twisting of the spermatic cord associated with a poorly secured testicle.
Torsion result in venous engorgement with consequent arterial compromise, tissue ischemia, and possible infarction. Irreversible damage occurs after approx. 6–12 hours of torsion.
Clinical features
Abrupt onset testicular pain and/or pain in the lower abdomen
Typically swollen and tender testicle and/or lower abdominal tenderness
Nausea and vomiting
Abnormal position of testicle
Abnormal transverse lie
Scrotal elevation
Possible undescended testes (predisposes to testicular torsion)
Absent cremasteric reflex
Prehn sign: negative
Testicular torsion should always be suspected in a male patient with severe, sudden-onset testicular pain.
Diagnostics
Testicular torsion is typically a clinical diagnosis. Imaging is not routinely indicated but may be considered in patients with atypical clinical features. Because of the significant risk of infertility, diagnostic workup should not delay the management of suspected testicular torsion.
Imaging
Duplex ultrasound of the scrotum [6][7][8]
Indication: inconclusive clinical findings [6]
Characteristic findings [8]
Twisting of spermatic cord (whirlpool sign)
Reduced or absent blood flow to/from the affected testis
Heterogeneous appearance of testicular parenchyma indicates testicular necrosis.
Radionuclide imaging [1][9]
Indications
Inconclusive clinical findings
Evaluate for epididymitis
Characteristic findings
Testicular torsion
Areas that do not absorb radionuclide as a result of decreased blood flow to the affected testis (“Cold spots”)
Asymmetric blood flow
Epididymitis: areas where there is increased radionuclide absorption as a result of increased blood flow in inflammation (“Hot spots”)
Surgical intervention is recommended for suspected testicular torsion, regardless of radiological findings.
Laboratory studies
Not routinely indicated
Urinalysis [6]
Indications: rule out epididymitis
Findings: leukocytes and erythrocytes in the urine suggest epididymitis but do not exclude torsion (see epididymitis).
Ddx:
Torsion of testicular appendage (hydatid of Morgagni)
Description: The hydatid of Morgagni (appendix of the testes) is an embryological remnant on the upper pole of the testes or at the epididymis (the remnant of the Müllerian duct). This hydatid of Morgagni has the potential to rotate. The resultant symptoms resemble acute testicular torsion.
Clinical features
Typically boys 3–5 years old
Insidious unilateral scrotal tenderness
“Blue dot sign”
Imaging: doppler ultrasound may show an enlarged testicular appendix and or mild hydrocele with preserved testicular blood flow
Management: A conservative approach with NSAIDs may be considered. However, if in doubt, surgical intervention is required to examine the testes.
Treatment
Testicular torsion is a medical emergency and should ideally be treated within 6 hours of the onset of symptoms for the best chance of testicular salvage. Manual detorsion in the ER may be attempted prior to surgery for immediate pain relief, but should not delay transferring the patient to the OR.
Exploratory surgery [6][1]
Indication: suspected testicular torsion
Timing: ideally, within 6 hours of symptom onset [1]
Procedure
Immediate surgical exploration of the scrotum with reduction (untwisting) and orchidopexy of the affected testis
Orchidopexy of the contralateral testis is recommended because the risk of testicular torsion on the contralateral side increases with previous or current testicular torsion.
Orchiectomy if the testis is grossly necrotic or nonviable
Manual detorsion [1]
Indication: may be attempted prior to surgery for immediate pain relief or if surgery is not immediately available
Procedure
Rotate the testis laterally toward the thigh ; two-thirds of torsions occur toward the midline.
If lateral rotation does not provide symptom relief, rotate the testis toward the midline; one-third of torsions occur laterally. [11]
Surgery should still be performed in all patients to resolve any possible degree of remaining torsion and to prevent recurrence. [6][6]
Because of the risk of infertility, surgical exploration of the scrotum is recommended in any patient suspected of having testicular torsion, even if manual detorsion has been attempted.
Prognosis:
Timely intervention within the recommended time period (6 hours from symptom onset) → restoration to previous condition
Late or absent surgical intervention → ischemia → necrosis of the testicles
