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Friday, 8 May 2015

Testicular Torsion

Anatomy

The spermatic cord starts at the deep inguinal ring, then enters the scrotum at the superficial inguinal ring.
The testicular appendage, of hydatid of Morgagni, is a remnant of the Mullerian duct in 90% of cases. It can become twisted, mimicking symptoms of testicular torsion.

Pathophysiology
The testicle can twist and tighten up around the spermatic cord. The twist can happen outside of the scrotum, normally at the external inguinal ring, or inside of the scrotum. Inside is more common, especially in adolescents and young adults, especially if there is a bell clapper deformity.


In 5-8% of cases, this twisting is triggered by mild or moderate trauma.

Epidemiology
Occurs soon after birth, or at puberty.
Incidence in males <25 is 1 in 4000

Although it has no physiological function, it can be medically significant in that it can, occasionally, undergo torsion (i.e. become twisted), causing acute one-sided testicular pain and may require surgical excision to achieve relief. 1/3 of patients present with a palpable "blue dot" discoloration on the scrotum. This is nearly diagnostic of this condition. Although if clinical suspicion is high for testicular torsion, a surgical exploration of the scrotum is warranted.

Symptoms
Sudden onset, severe testicular pain - in 2/3 of the canal
Half of all torsions start in the night time
Pain not relieved by elevation of the scrotum
Swelling of the testis or scrotum, oedema or erythema of scrotal skin
Pain may be referred to abdominal or inguino-scrotal regions
No fever or urethral discharge

Signs
High riding testicle with horizontal lie
Loss of cremesteric reflex - Prohn's sign
Large testicle
Blue dot sign - more indicative of testicular appendage torsion

Undescended testes are at higher risk - empty scrotum, painful lump in the groin

Intermittent Testicular Torsion
May get spontaneous de-torsion. Short periods of groin pain + vomiting, then spontaneous relief.


TWIST Score

Proposed score for assessing testicular torsion in children
Finding                          Points
Testicular swelling          2
Hard testicle                  2
Absent cremasteric reflex  1
Nausea or vomiting          1
High-riding testicle          1

Treatment
Analgesia
Urgent Exploration
Consider manual detorsion if urologist not available - "open the book" - twist outward and laterally. May need to be done 2-3x for complete pain relief.


References
http://wikem.org/wiki/Testicular_torsion
http://radiopaedia.org/articles/testicular-torsion
http://emj.bmj.com/content/17/5/381.full
http://www.bmj.com/content/341/bmj.c3213?sso=
http://www.emrap.org/episode/2011/december/testicular
http://wikem.org/wiki/Testicular_Torsion
http://dontforgetthebubbles.com/testicular-trouble/
http://academiclifeinem.com/patwari-academy-videos-testicular-torsion-and-acute-scrotal-pain/
http://dontforgetthebubbles.com/saving-balls-101-inguinoscrotal-masses/
http://learning.bmj.com/learning/module-intro/testicular-torsion.html?moduleId=10029430&searchTerm=%E2%80%9Ctorsion%E2%80%9D&page=1&locale=en_GB
http://learning.bmj.com/learning/module-intro/scrotal-swellings-diagnosis-management.html?moduleId=5003328&searchTerm=%E2%80%9Ctorsion%E2%80%9D&page=1&locale=en_GB
http://www.enlightenme.org/learning-zone/tummy-pain%E2%80%A6again

http://dontforgetthebubbles.com/saving-balls-101-acute-scrotum/

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