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Question answered:11/02/02 Warning! this question is over two years old.

eMedicine offers the following (1):

History:

Physical:

Causes:

Differential Diagnoses

 

Congenital anomaly; bell clapper deformity

Undescended testicle

Sexual arousal and/or activity

Trauma

Exercise

Active cremasteric reflex

Cold weather

Involved 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 involving the entire scrotum

Scrotal erythema

Ipsilateral loss of the cremasteric reflex

Usually, no relief of pain upon elevation of scrotum (elevation may improve the pain in epididymitis [Prehn sign])

Fever (uncommon)

History includes a sudden onset of severe unilateral scrotal pain.

As many as 50% of patients have a history of prior episodes of intermittent testicular pain that has resolved spontaneously (intermittent torsion and detorsion).

Onset of pain can occur more slowly, but this is an uncommon presentation of torsion.

Torsion can occur with activity, be related to trauma, or develop during sleep and includes the following:

• Scrotal swelling
• Nausea and vomiting (20-30%)
• Abdominal pain (20-30%)
• Fever (16%)
• Urinary frequency (4%)

Appendicitis, Acute
Epididymitis
Hernias
Hydrocele
Orchitis
Pediatrics, Appendicitis

Lab Studies:

Urinalysis

• Urinalysis is usually normal.
• The presence of white blood cells (WBCs) can be observed in as many as 30% of patients who have torsion; therefore, do not rely on WBC presence to exclude the diagnosis.

Complete blood count: CBC can be normal or show an elevated WBC count in as many as 60% of patients who have torsion.

Imaging Studies:

• Color Doppler ultrasonography increasingly is being used to demonstrate arterial blood flow to the testicle while providing information about scrotal anatomy and other testicular disorders.

• Plain Doppler ultrasonography is less accurate than color Doppler in assessing testicular blood flow.
• The hospital's radiology department usually provides ultrasound services. Some smaller studies have evaluated emergency medicine physicians performing bedside ultrasound to evaluate for testicular torsion. While these studies have had generally favorable outcomes, diagnostic accuracy is always operator and institution dependent.

Prognosis:

 

GP notebook offers (2): "Presentation is typically with an acutely swollen and painful testis, lower abdominal pain and sometimes, vomiting. The abdominal pain occurs because the testis retains its embryological nerves supply which primarily, is from the T10 sympathetic pathway.There may be a history of mild trauma to the testis or of previous episodes of testicular pain due to torsion and untwisting.The testis lies horizontally, high in the neck of the scrotum. In the early stages, the cord may be palpably thickened. Later, palpation is difficult as the overlying scrotal skin becomes red and oedematous.Pain is not relieved by elevating the twisted testis - negative Prehn's sign. The cremasteric reflex is absent. A neonatal torsion may be without symptoms and simply present as a hard, enlarged testes in a blue scrotum. They tend to present late, and it is more difficult to preserve the testes.

Of boys presenting with acute scrotal swelling only 25% will have torsion of the testis.

References

1. Zwanger M, Rupp T. Testicular Torsion. eMedicine.

If diagnosed early, a near 100% salvage rate for the testicle is possible

Testicular torsion is a clinical diagnosis. Imaging studies usually are not necessary; ordering them wastes valuable time when the definitive treatment is surgical.

If the diagnosis is equivocal, radionuclide scan of the testicles can be helpful to assess blood flow and to differentiate torsion from other conditions.

• Scan is abnormal in torsion when it demonstrates decreased uptake in the affected testicle, suggesting no blood flow to that side.
• Radionuclide scans have a sensitivity of 90-100% accuracy in detecting testicular blood flow.

1. http://network.realmedia.com/RealMedia/ads/adstream_nx.ads/emedicine/ros@Position1?99753247 http://www.gpnotebook.co.uk/TDBpage.cfm?ID=389349401
2. GP Notebook. Testicular Torsion.

 

 

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