Tarimo BM

1. Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Department of Emergency Medicine
Johns Hopkins University

2. 2
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Objectives
Discuss the epidemiology and prevention
of torsion
Review the pathophysiology of torsion
Discuss the means of diagnosing torsion
Discuss diagnostic and laboratory studies
relevant to torsion
Discuss the case management and
treatment of torsion

3. 3
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Introduction
Urologic emergency
 Important to differentiate testicular torsion from other
complaints of testicular pain.
 Delay in diagnosis can lead to loss of the testicle.
 Magoha in the East African Medical Journal reported
the overall salvage rate was low at 21% with an
orchidectomy rate of 79
Prompt diagnosis of testicular torsion and
differentiation of this condition from epididymitis
can be difficult

4. 4
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Key points
Prompt diagnosis
Immediate surgical referral
Rapid definitive treatment
 salvage of the testicle

5. 5
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Morbidity
Salvage rate of 80-100% possible in
patients who present within 6 hours of
pain.
 Difficult in remote and underserviced areas
After 6-8 hours, the salvage rate markedly
decreases
 Near 0% at 12 hours.

6. 6
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Epidemiology
Young males < 30 years old
 Typically: 12-18 years
 Peak age: 14 years
 Smaller peak during first year of life

7. 7
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Pathophysiology
Twisting of the spermatic cord upon itself
 Obstruction of the blood vessels supplying the
testis and epididymis
The typical testicle is covered by the
tunica vaginalis,
 Attaches to the posterolateral surface of the
testicle
 Allows for little mobility

8. 8
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Pathophysiology
If high attachment of the tunica vaginalis,
testicle can rotate freely on the spermatic
cord
In neonates, testicle frequently has not
descended into the scrotum
 Becomes attached within the tunica vaginalis
 Mobility of the testicle predisposes it to torsion

9. 9
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies

10. 10
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies

11. 11
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Causes
Congenital anomaly
Undescended testicle
Sexual arousal and/or activity
Trauma
Exercise
Active cremasteric reflex

12. 12
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Presentation
History: sudden onset of severe unilateral
scrotal pain.
Scrotal swelling
Nausea and vomiting (20-30%)
Abdominal pain (20-30%)
Fever (16%)
Urinary frequency (4%)

13. 13
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Clinical Findings
Testicle painful to palpation
Frequently elevated in position when compared
to the other side
Horizontal lie of the testicle
Enlargement and edema of the testicle;
 Edema may involve the entire scrotum
Scrotal erythema
Ipsilateral loss of the cremasteric reflex
No relief of pain upon elevation of scrotum
Fever (uncommon)

14. 14
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Differential Diagnosis
Epididymitis/orchitis
Hernia
Hydrocele
Scrotal abscess
Fournier’s gangrene
Appendicitis

15. 15
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Diagnosis
Lab studies
 Urinalysis
Usually normal
White blood cells in urine 30% of the time
 CBC
Normal or elevated WBC count in as many as 60%
of patients who have torsion

16. 16
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Diagnosis
Torsion is a CLINICAL diagnosis!
Imaging studies
 Ultrasonography and color doppler
Demonstrate arterial blood flow to the testicle
Identify scrotal anatomy and other testicular
disorders

17. 17
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Normal Testicle
Plain ultrasound

18. 18
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Testicular Torsion Normal testicle

19. 19
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Scrotal wall
Blood supply to testicle

20. 20
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies

21. 21
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Treatment
Pain relief
Manual detorsion
Surgical/Urological consultation

22. 22
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Treatment-Pain Relief
Essential to quality patient care
Mild analgesic after diagnosis or awaiting
further studies
Judicious and cautious adminstration
Morphine sulfate narcotic drug of choice
 Starting dose: 0.1 mg/kg (iv/im/sc)
 Maintenance dose: 5-20 mg/70kg every 4 hrs
 Reversible with naloxone

23. 23
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Treatment-Manual Detorsion
“Opening of a book"
 Physician standing at the patient's feet
Relief of pain – successful detorsion
Goal: reestablish or increase blood flow to
previously ischemic testicle
Never delay operative intervention
Success in 30-70% of patients

24. 24
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies

25. 25
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Treatment-Consultation
Early surgical consultation is mandatory
Definitive treatment is surgery
 Detorsion
 Orchiopexy.

26. 26
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Disposition
Early diagnosis: 100% salvage rate
Transfer to another institution where
surgery can be performed if no surgeon is
available at your hospital.
Complications
 Infarction of testicle
 Loss of testicle
 Infection

27. 27
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Summary
Clinical diagnosis
Time is testicle
Emergent urological consultation
Transfer to appropriate facility

28. 28
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Case
11 year old boy complains of intermittent
pain in his right testicle for the past 2 days.
Now constant pain for the past 3 hours.
Denies trauma.
PE:
 Tender right testicle, slightly elevated, red and
swollen
What would you do?

29. 29
Testicular Torsion
Center for International Emergency
Disaster and Refugee Studies
Key Points
Diagnose suspected testicular torsion.
Immediate/prompt consult
 Surgery/Urology
Pain medication
Image study
Attempt detorsion
Definitive: surgery
 Detorsion and Orchiopexy