Testicular Torsion Medicine
Torsion occurs when the spermatic cord becomes twisted and prevents blood flow, creating an emergency situation which should be addressed immediately.
Urologists will diagnose your condition based on symptoms, medical history and physical exam of the scrotum. He or she may attempt manual untwisting (detorsion). Surgery may also be necessary.
Pain Management
Torsion of the testis can cause sharp and immediate pain that requires immediate medical intervention. Most often affecting male adolescents, it can also affect infants or older men.
Torsion symptoms often include sudden, intense pain in the scrotum, swelling of the scrotal sac, one or both testicles becoming larger or darker in color, nausea or vomiting and possibly an abnormal cremasteric reflex. Doctors will perform a physical exam of the scrotum while also asking when and why pain first appeared and for how long.
At a physical exam, doctors will press on the scrotum to test for pain and will inquire into any past injuries to the testicles or trauma to the groin area. They may also inspect both testicles to see if there is one that stands higher than the other.
If a doctor suspects a boy of having testicular torsion, he will start treating them by giving an IV and administering pain medications, antinausea medication and monitoring blood pressure and circulation; they may also remove dead testicles surgically before stitching in place the other testicle to keep it from twisting inwards; additionally they will advise them to refrain from sexual activity and physical exercise until healing has taken place.
Urinalysis
Classic symptoms of testicular torsion include sudden, diffuse swelling and tenderness in the scrotal sac as well as loss of cremasteric reflex. Patients exhibiting these characteristics should seek immediate bedside urological review and urgent surgical evaluation without waiting for laboratory tests or radiographs.
Due to their low specificity and sensitivity in diagnosing testicular torsion, laboratory tests should be avoided in patients suffering from this condition. Instead, rapid color Doppler ultrasound imaging may enable early detection of either pulsatile testicular flow (see image below) or not ( see image).
Urine analysis can be an invaluable way of diagnosing infectious epididymitis and orchitis in young children and distinguishing it from torsion. Epididymitis/orchitis occurs most commonly among these children; it results from inflammation caused by viral or bacterial agents; most frequently caused by sexually transmitted organisms like Neisseria gonorrhoeae or Chlamydia trachomatis that often coincide with sexual activity.
Epididymitis and orchitis must also be distinguished from cryptorchidism, an undescended testicle which may be 10 times more likely to torse than its normally-elevated contralateral testicle. Patients presenting with this condition typically exhibit similar history and examination findings; however, relief often comes when leaning forward over their pubis (prehn maneuver).
Studies on 139 emergency department patients who presented with scrotal pain found that only two had true testicular torsion; 28 suffered from epididymitis-orchitis; seven had ureterolithiasis. Seven out of the 11 patients referred to urology unit doctors for evaluation of possible testicular torsion had positive urine dipstick tests showing haematuria, pyuria or nitrituria; all seven of these patients were eventually diagnosed with ureterolithiasis. Contrarily, none of the seven patients referred for evaluation of suspected testicular torsion had positive urine tests with these findings. Urine tests should not be ordered routinely in these instances and only performed when clinical judgment indicates otherwise; otherwise they could lead to unnecessary investigations such as UDT or epididymo-orchitis.
Ultrasound
Ultrasonography (sound wave imaging) is a diagnostic procedure in which sound waves are transmitted into the body to create images of tissues and organs known as sonograms. Ultrasonography can be particularly beneficial when looking for pregnancy complications as well as conducting tissue biopsies or performing anesthesia, intensive care or pain medicine treatments.
Ultrasound imaging is non-invasive and safe for the patient, unlike CT and MRI scans which rely on radiation. It can be used to view internal structures such as the heart, blood vessels, eyeballs, thyroid, lungs and abdomen – as well as monitoring chronic conditions like diabetes or diagnosing infections. Ultrasound can also guide needles for biopsy procedures or certain surgeries. In particular it can be invaluable in managing torsion cases as early urological involvement can reduce time to surgery while increasing likelihood of testicular salvage.
Torsion diagnosis can be made clinically in an emergency department setting; however, ultrasound has proven more accurate. When compared to its unaffected side, an affected testicle will appear enlarged and hypoechoic with decreased blood flow – often times a whirlpool sign can also be visible as can a twisted spermatic cord. Ultrasound may especially prove useful if there is sudden and severe pain in one testicle as well as swelling around it.
Recommendations also call for all emergency room physicians to obtain formal training in point-of-care ultrasound and become familiar with scrotal examination techniques. Such instruction may take place either in an academic setting or online through an e-course; several institutions offer such classes for medical students, residents and emergency medicine fellows.
Power Doppler ultrasound increases sensitivity of diagnosis and visualization of the spermatic cord. If this cord becomes completely twisted, there will no blood flow to the testicle and may need to be surgically removed through orchiopexy surgery – although most boys who undergo orchiopexy still father children and may opt to receive prosthetic replacement testicles later in life.
Surgery
Testicular torsion is an urgent surgical emergency requiring immediate attention from doctors. It occurs when the spermatic cord that runs from a testicle to the scrotum becomes twisted, cutting off blood flow to that organ and potentially killing it. Doctors can usually save it by untwisting it and providing enough blood flow; stitching will also be performed so as to keep another testicle from twisting in future.
Step one in diagnosing torsion involves gathering patient medical history and performing a physical examination, followed by having them lie on their back while checking the scrotum for signs of testicle torsion such as painful swellings or hard lumps. A doctor can then use an ultrasound machine to confirm this diagnosis, as well as gauge how much of its blood supply still operates within each testicle.
Surgery allows doctors to repair torsion by attaching stitches from one testicle to the other; this procedure, known as orchiopexy, can help prevent future torsion of testicles. If one has died prematurely and must be removed for any reason – an orchidectomy – it increases chances of not suffering another torsion episode in future.
Doctors can use Doppler ultrasounds to inspect testicular blood flow using Doppler waves. Doctors should look out for peaks in waveforms that correspond with arterial blood pressure; such peaks will appear as areas with elevated pressure while venous flows will show up as plateaus in waveforms.
While CDUS performed by doctors on duty has increased in sensitivity and specificity over time, this technique should never replace surgical exploration. A torsed testicle can only be saved if detorsing occurs within six hours after symptoms arise.
Should you experience severe groin pain, you should see a doctor immediately. Call Healthdirect on 1800 022 222 and speak with one of their registered nurses – they can assess how serious your case is and decide whether hospital admission is required.
