Is It Testicular Torsion Or Not

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How to differentiate between testicular torsion and acute testicular disorders before taking the patient to O.R., is one of the most important questions that phases E.R. physicians & urologists in medicine, & I wish this presentation will help you in answering such questions when encountered

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Is It Testicular Torsion Or Not

  1. 1. Is It torsion or not <ul><li>Main References are from emedicine articles by web MD : </li></ul><ul><li>Testicular torsion , article by Timothy J Rupp , MD, FACEP, Associate Medical Director, Children's Medical Center of Dallas, Texas </li></ul><ul><li>Epididymitis , article by Catherine Tubridy , MD, Staff ER Physician, State University of New York Downstate/Kings County Hospital Centers </li></ul><ul><li>Torsion of the Appendices and Epididymis , article by Jason S Chang , MD, Staff Physician, Section of Emergency Medicine, Yale New Haven Hospital </li></ul><ul><li> </li></ul>Presented by: Ahmad Kharrouby PGY 3 Urology Conference
  2. 2. Introduction <ul><li>A child or adolescent with acute scrotal pain, tenderness, or swelling should be looked on as an emergency situation </li></ul>
  3. 3. <ul><li>The list of differential diagnoses for an acute scrotum is extensive </li></ul><ul><li>In all instances it is imperative to rule out torsion </li></ul>
  4. 4. Differential diagnosis of acute scrotum Campbell-Walsh Urology 9 th edition
  5. 5. <ul><li>In adolescent males, testicular torsion is the most frequent cause of testicle loss </li></ul><ul><li>Acute epididymitis is the most common cause of acute scrotum </li></ul><ul><li>Whereas torsion of testicular appendices is the leading cause of acute scrotum in children </li></ul>
  6. 6. Unilateral Bilat. 10% Unilateral Side Moderate to severe moderate severe Severity acute insidious sudden Pain onset Appendicular torsion epidedimitis Torsion
  7. 7. History in torsion: <ul><ul><li>Sudden onset pain </li></ul></ul><ul><ul><li>severe </li></ul></ul><ul><ul><li>Unilateral </li></ul></ul><ul><ul><li>Less commonly it is acute </li></ul></ul><ul><ul><li>50% of have had episodes of intermittent pain </li></ul></ul><ul><ul><li>Can occur with activity, or develop during sleep </li></ul></ul><ul><ul><li>Other symptoms: </li></ul></ul><ul><ul><ul><li>Scrotal swelling </li></ul></ul></ul><ul><ul><ul><li>Nausea and vomiting (30%) </li></ul></ul></ul><ul><ul><ul><li>Abdominal pain (30%) </li></ul></ul></ul><ul><ul><ul><li>Fever (16%) </li></ul></ul></ul><ul><ul><ul><li>Urinary frequency (4%) </li></ul></ul></ul>
  8. 8. History in epidedimitis <ul><ul><li>Insidious onset pain </li></ul></ul><ul><ul><li>swelling </li></ul></ul><ul><ul><li>frequency, urgency, or dysuria </li></ul></ul><ul><ul><li>Retention in older patients </li></ul></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>Abdominal or flank pain </li></ul></ul><ul><ul><li>Bilateral epididymal involvement (10%) </li></ul></ul><ul><ul><li>Urethral discharge </li></ul></ul><ul><ul><li>Previous UTIs and unprotected intercourse </li></ul></ul><ul><ul><li>Associated with Henoch-Schonlein purpura & amiodarone </li></ul></ul>
  9. 9. History in appendicular torsion <ul><ul><li>Acute pain with a more gradual onset than torsion </li></ul></ul><ul><ul><li>mild to severe </li></ul></ul><ul><ul><li>Patients may endure pain for several days before seeking medical attention </li></ul></ul><ul><ul><li>Located to the superior pole, a key distinguishing factor from torsion </li></ul></ul><ul><ul><li>Systemic symptoms and urinary symptoms are absent </li></ul></ul>
  10. 10. Physical Exam in torsion <ul><ul><li>Diffuse tenderness </li></ul></ul><ul><ul><li>Elevated position </li></ul></ul><ul><ul><li>Horizontal lie </li></ul></ul><ul><ul><li>Swelling </li></ul></ul><ul><ul><li>Ipsilateral loss of cremasteric reflex </li></ul></ul><ul><ul><li>-ve Prehn sign </li></ul></ul><ul><ul><li>Fever (uncommon) </li></ul></ul>
  11. 11. Physical exam in epidedimitis <ul><ul><li>Edematous tender epididymis </li></ul></ul><ul><ul><li>Erythematous scrotum </li></ul></ul><ul><ul><li>Scrotal fixation to epididymis </li></ul></ul><ul><ul><li>Reactive hydrocele </li></ul></ul><ul><ul><li>+ve Prehn sign (not reliable) </li></ul></ul><ul><ul><li>Urethral discharge (10%) </li></ul></ul><ul><ul><li>Fever with progression </li></ul></ul>
  12. 12. Physical exam in appendicular torsion <ul><ul><li>Afebrile </li></ul></ul><ul><ul><li>Normal scrotum usually </li></ul></ul><ul><ul><li>Cremasteric reflex present </li></ul></ul><ul><ul><li>Tenderness localized to upper pole </li></ul></ul><ul><ul><li>Blue dot sign is pathognomonic (21%) </li></ul></ul><ul><ul><li>Vertical orientation is preserved </li></ul></ul><ul><ul><li>The combination of a blue-dot sign with, nontender testes excludes torsion </li></ul></ul>
  13. 13. <ul><li>A recent study in 2005 scored 3 key historical elements as predictors for testicular torsion </li></ul><ul><ul><li>Onset of pain less than 6 hours </li></ul></ul><ul><ul><li>Absence of cremasteric reflex </li></ul></ul><ul><ul><li>Diffuse testicular tenderness </li></ul></ul><ul><li>Out of 141 subjects, in the absence of any of these elements, none of the subjects had testicular torsion </li></ul><ul><li>With all 3 elements present, 87% were diagnosed with testicular torsion </li></ul>Reference: Karmazyn B, Steinberg R, Kornreich L. Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys.  Pediatr Radiol . Mar 2005;35(3):302-10
  14. 14. Lab Studies in torsion <ul><ul><li>Urinalysis </li></ul></ul><ul><ul><ul><li>usually normal </li></ul></ul></ul><ul><ul><ul><li>In 30% elevated WBCs </li></ul></ul></ul><ul><ul><li>CBC elevated WBC count in 60% </li></ul></ul>
  15. 15. Lab Studies in Epididymitis <ul><ul><li>Urinalysis - Pyuria or bacteriuria (50%) </li></ul></ul><ul><ul><li>CBC - Leukocytosis </li></ul></ul>
  16. 16. Lab Studies in appendicular torsion <ul><li>Usually normal </li></ul>
  17. 17. Imaging Studies <ul><li>Testicular torsion is a clinical diagnosis </li></ul><ul><li>Imaging studies usually are not necessary; ordering them wastes valuable time when the definitive treatment is surgical </li></ul>
  18. 18. Imaging Studies <ul><ul><li>Color-coded Doppler ultrasonography </li></ul></ul><ul><ul><ul><li>This type of ultrasonography assesses perfusion of the testicle and anatomy of the scrotal contents </li></ul></ul></ul><ul><ul><ul><li>A normal testicle with markedly diminished Doppler wave pulsation represents torsion </li></ul></ul></ul><ul><ul><ul><li>A thickened enlarged epididymis with increased Doppler wave pulsation represents epididymitis </li></ul></ul></ul><ul><ul><ul><li>In appendicular torsion </li></ul></ul></ul><ul><ul><ul><ul><li>Testicular appendage appears as a lesion of low echogenicity with a central hypoechogenic area </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Normal blood flow to the testis, with an occasional increase on the affected side that possibly is due to inflammation </li></ul></ul></ul></ul><ul><ul><ul><li>Color Doppler has a sensitivity of 86%, specificity of 100%, and accuracy of 97% in the diagnosis of testicular torsion </li></ul></ul></ul>
  19. 19. Imaging Studies <ul><li>In prepubertal patients, this method of imaging is somewhat controversial because the prepubertal testis has low-velocity blood flow, and color Doppler ultrasonography is less accurate in these instances </li></ul><ul><li>As a result, a negative ultrasonographic result does not necessarily exclude testicular torsion </li></ul>
  20. 20. Imaging Studies <ul><ul><li>Radionuclide scintigraphy </li></ul></ul><ul><ul><ul><li>Radionuclide scintigraphy is used to assess testicle perfusion </li></ul></ul></ul><ul><ul><ul><li>Decreased perfusion suggests torsion </li></ul></ul></ul><ul><ul><ul><li>Increased or normal perfusion suggests epididymitis but may occur with torsion </li></ul></ul></ul><ul><ul><ul><li>The positive pathognomonic sign for testicular appendix torsion is the hot-dot sign, which is an area of increased tracer uptake </li></ul></ul></ul><ul><ul><ul><li>Radionuclide scans have a sensitivity of 90-100% accuracy in detecting testicular blood flow </li></ul></ul></ul>
  21. 21. Important <ul><li>In high clinical suspicion, surgical exploration is essential </li></ul>
  22. 22. Under Investigation <ul><li>The use of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to help differentiate epididymitis from testicular torsion </li></ul><ul><li>A prospective study evaluated 120 patients with the diagnosis of an acute scrotum </li></ul><ul><li>serum CRP and ESR were drawn at ER arrival </li></ul><ul><li>Of the 46 patients diagnosed with epididymitis, 44 (95.6%) had elevation of CRP level </li></ul><ul><li>of the 23 with torsion, 1 (4%) had elevation of CRP level </li></ul><ul><li>and, of the 51 other patients with other noninflammatory causes of acute scrotum, none had significant elevation of CRP level </li></ul><ul><li>The authors proposed cutoff values of distinguishing epididymitis from noninflammatory causes of acute scrotum of 24 mg/L for CRP level and 15.5 mm/h for ESR. </li></ul><ul><li>The use of ESR and CRP is also promising, but again further investigations are necessary </li></ul>
  23. 23. Thank You

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