This case discussion describes a 15-year-old boy who presented with sudden lower abdominal pain during sleep. Examination revealed an elevated, tender left testis. Though ultrasound was normal, a diagnosis of testicular torsion was made based on history and physical exam findings. Testicular torsion occurs when the spermatic cord twists, cutting off blood supply to the testis. Prompt diagnosis and surgical intervention are important to prevent loss of the testis from delayed treatment.

1. Case Discussion: “Don’t Forget the Testis”
By: Muhamad Na’im B. Ab Razak
th
4 year medical student, University Sains Malaysia.
15 years old Malay boy with history of imperforated anus and has undergone surgery presented
with sudden onset lower abdominal pain that occurs during sleep which is sharp in nature,
radiating to the left thigh 3 hour before the admission and associated with one episode of fainting
after micturation. FBC shows elevated white blood cell and his blood pressure is low for two
readings.
Discussion
Since patient has history of imperforated anus and underwent surgery, there should be high
suspiciousness of bowel problems. Elevated white blood cell count may suggest the infection.
However, when patient presenting with acute abdomen, one should always be suspicious of non-
abdominal cause of the pain especially if the location of the pain is at the lower abdomen.
Therefore, the adjacent organ like uterus, bladder, kidney and testis must be examined.
The examination of the testis reveals elevated left testis, negative translumination test, swelling,
tender to palpation and the pain increase upon elevation of left testis. (Differentiate it from
epididymitis in which elevation of testis reduce the pain-Prehn sign)
Ultrasound was done however normal. But, based on history and physical investigation, a
diagnosis of testicular torsion has been made because ultrasound may shows false negative or
false positive result. Identification of Testicular torsion is so important as patient may lose their
testis if there is delayed in intervention. There has been a case whereby a patient presented with
lower abdominal pain with sign of urinary tract infection was discharge with antibiotic come
back 72 hours later with testicular gangrene.
Differential diagnosis includes Epididymitis, orchitis, epididymo-orchitis, Hydrocele, Testis
tumor and Idiopathic scrotal edema.
Testicular torsion is uncommon because normal testis is anchored by tunica vaginalis to the
posterolateral surface of the testis, hence allows a little mobility of the testis.
Abnormality that may lead to testicular torsion includes inversion of the testis, high investment
of the tunica vaginalis causing testis to hang within tunica like a clapper in a bell and separation
of epididymis from the body of the testis.
Testicular torsion particularly occurs in age group 10 and 25 years old with the peak age is 14
years old. It is often involves the left testis.

2. Signs and Symptoms vary with degree of torsion. Usually patient may present with sudden onset
of severe unilateral scrotal pain that may occur 1) with activity 2) trauma or 3) during sleep,
scrotal swelling, nausea and vomiting, abdominal pain, fever, urinary frequency, horizontal lie of
testis, edematous testis, scrotal erethyma, ipsilateral loss of cremastic reflex and pain upon
elevation of testis.
Doppler ultrasound may confirm the absence of the blood supply to the affected testis.
In the first hour of presentation, gentle manipulation of testis may be performed. However, one’s
should be prepared for the emergency surgery. Exploration of torsion may be performed through
scrotal incision. Prevention of re-twisting may be done by suturing the tunica vaginalis and
tunica albuniae with absorbable suture material.
Consent for orchidectomy must be taken as gangrenous testis needs to be removed. A proper
counseling must be given to the patient including the placement of prosthetic testis.
Reference
1) Leslie Tackett McQuiston, "Testicular Torsion", eMedicine
http://emedicine.medscape.com/article/438817-overview
2) Norman S. Williams, Christopher J.K. Bulstrode & P. Ronan O’Connel, “Bailey &
Love’s Short Practice of surgery”, 25th edition, Edward Arnold Ltd, 2008.
3) Timothy J Rupp, "Testicular Torsion", eMedicine
http://emedicine.medscape.com/article/778086-overview