Chief Complaint

Abdominal Pain

HPI

5-year-old male presents to the emergency department for abdominal pain, which started this morning. Mother reports the pain woke the patient up from sleep. Reports the pain is crampy and patient has been crying since he woke up at 9:00. Mother reports she thinks this happened one other time in the past but the pain improved with Tylenol. He had Tylenol a few hours ago without relief in the pain. No vomiting or diarrhea. No dysuria or urinary frequency. Denies constipation. No measured fevers.

Pertinent Exam Findings

General Appearance: No acute distress.
Gastrointestinal: Abdomen is soft, non-distended and diffusely tender, but maximally periumbilically.
Musculoskeletal: Moving all extremities normally. Neck is supple, non-tender. No meningeal signs.
Skin: Warm, dry, no rashes, atraumatic
Neurologic: Awake, alert, oriented appropriate for age group

ED Course

Labs, KUB, Abdominal US ordered.

Patient without pain on repeat abdominal exam.

Patient having slight return of pain which seemed to be left lower. Testicular exam performed with mother in the room showed a left inguinal mass and undescended left testicle. Mother reports she was told when child was an infant, he didn’t have a left testicle but no other follow-up was arranged. Pain much improved, but concern for intermittent torsing of left testicle so ultrasound ordered.

Urology paged. Testicular torsion on testicular ultrasound.

Pediatric urologist notes given pain has improved query testicle herniation which was reduced or intermittent torsion. Requested patient urgently be transferred to pediatric ED for evaluation for surgery. Mother amenable with this plan. Pt transferred.

Patient taken to the OR from pediatric ED.

Data Interpretation

Labs and imaging: CBC, BMP, UA normal.
Imaging: KUB and abdominal US normal.
Testicular US:

IMPRESSION: 1. Undescended left testicle within the inguinal canal that fails to demonstrate color flow and Doppler waveforms, suggesting torsion/ischemia

Hospital Course

POSTOPERATIVE DIAGNOSES:

1. Left undescended testis.
2. Left intracanalicular torsion.
3. Necrotic left testis.

PROCEDURES PERFORMED:

1. Left groin exploration with simple left orchiectomy.
2. Right scrotal orchidopexy.
3. Ilioinguinal nerve block and cord block for pain management.

Discharged from hospital without complications.

DISCUSSION

Background

Testicular torsion is one of the most serious acute testicular conditions due to the potential for loss of the testicle. It occurs when the testis is improperly attached to the tunica vaginalis and allows for movement of the testicle in the scrotum. This movement allows for torsion of the testis, which causes constriction of the spermatic cord, vein, and arteries. Loss of venous and arterial blood flow leads to ischemia, necrosis, and eventual loss of the testicle.

Testicular torsion most commonly occurs in neonates and during puberty. Approximately 1 in 4,000 males under the age of 25 years develops this condition, with the majority of cases occurring in adolescent boys. There is data suggesting that this increased occurrence in puberty is due to testicular weight gain during this period of development, but the exact cause is uncertain. Risk factors for testicular torsion include bell clapper deformity, cryptorchidism (undescended testicle), trauma, or prior intermittent testicular torsion. Testicular torsion is a can’t miss diagnosis in the emergency department, prompt diagnosis and surgical treatment are paramount to prevent testicular loss.

Diagnosis

Testicular torsion can be diagnosed clinically or via ultrasound. Patients typically present with sudden onset, acute testicular pain or abdominal pain and may have associated symptoms such nausea or vomiting. Physical exam should include a detailed abdominal and genitourinary examination to determine presence and characteristics of the testes. While the cremasteric reflex is absent in the affected testicle in most cases of testicular torsion, it is not absent in every case. For patients where testicular torsion is suspected, a color Doppler ultrasound of the scrotum and testicles can be obtained in an attempt to diagnose testicular torsion. Ultrasound demonstrating reduced or absent flow is diagnostic of testicular torsion, but normal imaging does not rule out testicular torsion due to the possibility of intermittent torsion.

For pediatric patients, the Testicular Workup for Ischemic and Suspected Torsion (TWIST) Score was developed and validated to allow clinicians to reliably diagnose testicular torsion using the following criteria:

• Presence of Testicular Swelling = 2 points
• Presence of Hard Testicle = 2 points
• Absence of Cremasteric Reflex = 1 point
• Presence of High Riding Testicle = =1 point
• Presence of Nausea/Vomiting = 1 point

For patients with a score of ≥5 testicular torsion was diagnosed with a PPV of 100 percent whereas patients with a score of ≤2 ruled out testicular torsion with a NPV of 100 percent.

Management in ED

Once testicular torsion is strongly suspected or confirmed via ultrasound, urological consultation should be obtained without delay. Surgical detorsion and fixation of the testicle should be done immediately to prevent further ischemia and loss of the involved testicle. If urology is not immediately available, manual torsion can be done as a temporizing measure. Manual detorsion should be done without sedation, as pain relief is a sign of successful detorsion. In most cases the testicle is torsed medially, so lateral rotation (in an “open book” fashion) should be attempted initially. However, if there is increased pain or resistance during lateral rotation, stop and perform medial rotation as the testicle may be torsed laterally. Pain relief and normal physical exam findings as well as normal venous and arterial flow on testicular doppler ultrasound suggests successful manual detorsion. The patient will still need emergent urological consultation in the event of a successful manual detorsion.

Prognosis

With testicular torsion, time to definitive surgical treatment is an important prognostic indicator in testicular survival. Each hour that passes increases the risk of testicular infarction and necrosis, ultimately leading to the loss of the involved testicle. It is commonly thought that the window to salvage the testicle in testicular torsion is about 6 to 8 hours. One systematic review assessed survival of the testicle based on time to surgical treatment. Survival of the testicle with surgical treatment during the first six hours was 97.2%, the first 12 hours was 90.4%, hours 13 to 24 was 54.0%, and beyond 24 hours was 18.1%. These results emphasize the importance of not delaying treatment. Even if one suspects the testicle is unsalvageable based on prolonged ischemia, there are chances of survival beyond 24 hours, so every minute counts!

Differential Diagnoses

• • Testicular Torsion
  • DKA
  • Appendicitis
  • Fournier’s Gangrene
  • Constipation
  • Gastroenteritis
  • Scrotal Hematoma
  • Inguinal Hernia
  • Epididymitis/Orchitis

Clinical Pearls

• • Testicular torsion is a can’t miss diagnosis, most common in neonates and adolescents
  • Clinical findings and doppler ultrasound should be used to evaluate for torsion
  • Consult urology immediately if there is a high concern for testicular torsion
  • Manual detorsion can be performed if urology is not immediately available
  • Every minute counts for salvaging the testicle, even beyond the 6 to 8 hour window

References

1. Barbosa JA, Tiseo BC, Barayan GA, et al. Development and initial validation of a scoring system to diagnose testicular torsion in children [published correction appears in J Urol. 2014 Aug;192(2):619]. J Urol. 2013;189(5):1859-1864. doi:10.1016/j.juro.2012.10.056
2. Cornel EB, Karthaus HF. Manual derotation of the twisted spermatic cord. BJU Int. 1999;83(6):672-674. doi:10.1046/j.1464-410x.1999.00003.x
3. Demirbas A, Demir DO, Ersoy E, et al. Should manual detorsion be a routine part of treatment in testicular torsion?. BMC Urol. 2017;17(1):84. Published 2017 Sep 15. doi:10.1186/s12894-017-0276-5
   
4. Edelsberg JS, Surh YS. The acute scrotum. Emerg Med Clin North Am. 1988;6(3):521-546.
5. Kalfa N, Veyrac C, Lopez M, et al. Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum. J Urol. 2007;177(1):297-301. doi:10.1016/j.juro.2006.08.128.
6. Kass EJ, Lundak B. The acute scrotum. Pediatr Clin North Am. 1997;44(5):1251-1266. doi:10.1016/s0031-3955(05)70556-3
7. Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatr Emerg Care. 2019;35(12):821-825. doi:10.1097/PEC.0000000000001287
   
8. Munden MM, Williams JL, Zhang W, Crowe JE, Munden RF, Cisek LJ. Intermittent testicular torsion in the pediatric patient: sonographic indicators of a difficult diagnosis. AJR Am J Roentgenol. 2013;201(4):912-918. doi:10.2214/AJR.12.9448
9. Naouar S, Braiek S, El Kamel R. Testicular torsion in undescended testis: A persistent challenge. Asian J Urol. 2017;4(2):111-115. doi:10.1016/j.ajur.2016.05.007
10. Williamson RC. Torsion of the testis and allied conditions. Br J Surg. 1976;63(6):465-476. doi:10.1002/bjs.1800630618

Authors

Aaron Wolfe, DO, FACEP, Director of Education for Emergency Medical Minute and Clinical Associate Faculty for Rocky Vista University College of Osteopathic Medicine

Jack Spartz MSIV

Peter Haskins MSIV

Josh Wahba MSIV