Testicular pain - walnuts

Testicular trouble

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Jaxxon, a 13 year old boy, forgot to wear his box whilst at cricket training and was hit in the groin by a high speed ball. He thought nothing of it as the pain disappeared after an hour or so but presented to your emergency department at a day later as the pain had returned and was more intense.

 

Bottom Line

  • Testicular torsion is a true surgical emergency
  • Do not neglect the inguino-scrotal exam in the inconsolable infant
  • No part of the history or clinical exam can rule out torsion with 100% reliability
  • Doppler US can aid diagnosis in equivocal cases but if not immediately available should not prevent a trip to the OR

What is your differential diagnosis?

  • Testicular torsion
  • Torsion of the testicular appendage
  • Epididymo-orchitis
  • Testicular rupture
  • Haematocoele
  • Inguinal hernia
  • Henoch-Schoenlein purpura

What is the incidence of testicular torsion and who is at risk?

Torsion occurs in 1 in 4000 men less than 25 years old. It has a bimodal distribution with 65% of cases occurring during puberty due to hormone induced changes in size.

10% of cases occur in boys under one year of age. Some of these torsions may have occurred before delivery!

An undescended testis is at increased risk of torsion as is a testicle subjected to trauma.

What is a bell clapper deformity?

The tunica vaginalis extends over the epididymis and spermatic cord forming a cavity in which the testicle can hang and swing freely – like the clapper of a bell.

They have an increased risk of torsion.

12% of men have this deformity at post mortem.

What factors on history or examination may help you rule out torsion?

Nothing in the history can reliably let you rule out a torsion. The pain is often acute in onset and unremitting. It may wake the patient in the middle of the night and be associated with nausea and vomiting.

Pain due to trauma should settle within an hour or so.

They may also give a history of previous similar incidents when the the testis has torted and detorted spontaneously.

The classical exam finding is of an exquisitely tender, high riding testicle with a horizontal lie though secondary hydrocele may mask this.

What is Prehn's sign?

This is absence of the cremasteric reflex on the side of the affected testicle. It was once thought that if the cremasteric reflex was present then it could not be torsion. Unfortunately a number of case reports have since refuted this. Relying on the presence of the reflex to rule out torsion will lead to trouble.

What about imaging to rule out torsion?

Ischemia and infarction of the testis may occur within 4 hours of torsion though one study has suggested a 90% salvage rate if operated on within 6 hours of onset.

Rates of success drop to 50% by 12 hours.

Time is testicle and if you have a high degree of clinical suspicion then the patient should go to the operating room (regardless of fasting state) for surgical exploration.”

If the history is greater than 12 hours and there is some diagnostic doubt then two methods of imaging modalities may be considered.

Colour flow Doppler US has a quoted sensitivity of 88% and a specificity of 90% and may also be useful in making alternative diagnoses such as epididymo-orchitis, rupture or bleeding. However if the testicle has spontaneously distorted the resultant hyperaemia on ultrasound can be confused for epididymo-orchitis. Tc-99 scintigraphy is 100% sensitive but is not widely available.

Is there anything I can try whilst waiting for the surgeons?

You could try to externally detort the testis.  This does not negate the need for scrotal exploration but may buy you some time.

The key is good procedural sedation and the rotating the affected testicle as if you were opening the pages of a book.

What about a torsion of the appendix of the testicle?

The hydatid of Morgagni (one of five possible testicular appendages) is an embryological remnant of the Mullerian system found in the upper pole of the testis. As puberty hits raging hormones make this, and other appendages swell.  This makes them more likely to twist on their precarious blood supply.

The pain of a torted hydatid is supposed to be more insidious in onset and less intense. As it becomes more ischaemic it can be be visible as a small blue dot on the testicle though this may be masked by a reactive hydrocele.

Treatment is conservative with supportive underwear and NSAID’s but  the diagnosis can be hard to make and so exploration is often needed.

 

Outcome

Given the greater than 24 hour history and possibility of testicular rupture a colour flow Doppler was performed.

This confirmed the presence of a large haematocoele and a non-viable testis. It was removed in the operating room later the same day.

 

References

Ringdahl E, Teague L. Testicular torsion. Am Fam Physician. 2006 Nov 15;74(10):1739-43. Review. Free full text

Cuckow PM, Frank JD. Torsion of the testis. BJU Int. 2000 Aug;86(3):349-53.

Mellick LB. Torsion of the testicle: it is time to stop tossing the dice.Pediatr Emerg Care. 2012 Jan;28(1):80-6. Free full text

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An Emergency Physician with a special interest in education and lifelong learning. When not drinking coffee and reading Batman comics he is playing with his children.

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