March,2008March,2008Dept of Dept of surgerysurgery

SURGICAL EMERGENCY!!

Dr. Fidel Echevarria Fernandez Dr. Fidel Echevarria Fernandez First Degree Specialist in General Surgery First Degree Specialist in General Surgery Thoracic Surgeon Thoracic Surgeon Laparoscopic SurgeonsLaparoscopic Surgeons

Dr. Fredys Arrechea Tartabull Dr. Fredys Arrechea Tartabull First Degree Specialist in Anaesthesiology First Degree Specialist in Anaesthesiology and Resuscitation and Resuscitation Intensive Care Specialist Intensive Care Specialist Master in Clinical ToxicologyMaster in Clinical Toxicology

  

Epidemiology/Risk FactorsEpidemiology/Risk Factors1/4000 males <25 yrs annually1/4000 males <25 yrs annuallyCongenital malformation of processus Congenital malformation of processus vaginalis vaginalis (90% of cases)(90% of cases)

Covered testicle + epididymis + spermatic Covered testicle + epididymis + spermatic cord= free rotation of testis in tunica vaginalis cord= free rotation of testis in tunica vaginalis

BELL CLAPPER DEFORMITYBELL CLAPPER DEFORMITY

Trauma Trauma (4-8% of cases) (4-8% of cases) especially with especially with significant swelling significant swelling

Bell Clapper DeformityBell Clapper Deformity

Epidemiology/Risk Factors Epidemiology/Risk Factors (cont…)(cont…)

Other Other (2-6% of cases):(2-6% of cases):– Increase in testicular volume (puberty)Increase in testicular volume (puberty)– testicular tumortesticular tumor– testicles with horizontal lietesticles with horizontal lie– spermatic cord with long intrascrotal portionspermatic cord with long intrascrotal portion– Cryptorchidism (one or both testes)Cryptorchidism (one or both testes)– Strenuous exerciseStrenuous exercise

Diagnosis is Diagnosis is CRITICAL!!CRITICAL!!

Initially obstructs Initially obstructs venous returnvenous return

Equalization of venous and arterial pressures

Compromised arterial flow

TESTICULAR ISCHEMIA

As soon as 4 hours!!

Testicular TorsionTesticular Torsion

ISCHEMIA vs Salvage RateISCHEMIA vs Salvage RateISCHEMIAISCHEMIA: as soon as 4 hrs: as soon as 4 hrs

almost CERTAIN in 24 hrsalmost CERTAIN in 24 hrs

Salvage Rate:Salvage Rate:90% success if < 6 hrs90% success if < 6 hrs50% success if <12 hrs 50% success if <12 hrs <10% success if >24 hrs<10% success if >24 hrs

Testicular Testicular PAIN!PAIN!

16-42%16-42% acute scrotal pain acute scrotal pain

TESTICULAR TORSIONTESTICULAR TORSION

NOT something you want to NOT something you want to miss!!!miss!!!

Differential Differential DiagnosisDiagnosis

Epididymitis/Orchitis

IncarceratedHernia

Idiopathic Scrotal Edema

Varicocele AppendixAppendix TestisTestis

NO DIFFERENCENO DIFFERENCE in in

PRESENTING PRESENTING SYMPTOMSSYMPTOMS

Clinical ExaminationClinical ExaminationEpididymitisEpididymitis: edematous , orange peel : edematous , orange peel (late),(late), possible pyuria possible pyuria

Appendix TestisAppendix Testis: hard, tender nodule : hard, tender nodule (2-3mm) (2-3mm) on upper pole of testicle, BLUE on upper pole of testicle, BLUE DOT sign, edema, epididymis remains DOT sign, edema, epididymis remains posteriorposterior

Scrotal EdemaScrotal Edema: develops rapidly : develops rapidly obscuring physical exam findingsobscuring physical exam findings

torsedappendage

Clinical Examination Clinical Examination (cont…)(cont…)

Testicular TorsionTesticular Torsion: : – PAIN in scrotum: often described as PAIN in scrotum: often described as

“sharp and debilitating” “sharp and debilitating” – No necessary precipitant eventNo necessary precipitant event– Scrotal erythema and edemaScrotal erythema and edema- Possible Nausea/Vomiting- Possible Nausea/Vomiting– LightheadednessLightheadedness

Clinical Examination Clinical Examination (cont…)(cont…)

Testicular TorsionTesticular Torsion::– Epididymis: medially, laterally or anteriorly Epididymis: medially, laterally or anteriorly (depends on degree of torsion) (depends on degree of torsion) one side one side

– Spermatic cord shortens as it twists higher appearing testis

STRONG EVIDENCE OF TORSION

Clinical Examination Clinical Examination (cont…)(cont…)

Testicular Torsion: NO Cremasteric Reflex (most sensitive finding; 99%) if testicle moves ≥ 0.5 cm = +veTesticle:– Hard– Fixed to dartos & scrotal wall– Larger than unaffected side(due to congestion of blood)

Prehn’s sign negative

Diagnostic ModalitiesDiagnostic Modalities

Doppler UltrasoundDoppler Ultrasound Radionuclide Testing

Surgical Exploration

Imaging: ONLY IF

SUSPICION FOR TORSION =LOW

FasterMore available More sensitive

Evaluation of Acute Scrotal Evaluation of Acute Scrotal PainPain

TreatmentTreatmentRapid Rapid restoration of bloodrestoration of blood flow: flow: CRITICALCRITICALManual detorsionManual detorsion = = quick, noninvasive quick, noninvasive treatmenttreatment rotate testicle away from midline 180 degrees rotate testicle away from midline 180 degrees (done with IV sedation)(done with IV sedation) document return of blood flow document return of blood flow relieves problem acutely, however relieves problem acutely, however elective elective orchipexyorchipexy still recommended still recommended

DON’T DELAY SURGICAL CONSULT!!!DON’T DELAY SURGICAL CONSULT!!! only only definitive resolution of torsiondefinitive resolution of torsion

DON’T MISS THE DIAGNOSISDON’T MISS THE DIAGNOSIS

open book

Most Significant Most Significant ComplicationComplication

Loss of testisLoss of testis may lead to infertility may lead to infertilityCommon Causes of loss of testis:Common Causes of loss of testis:– 58%: DELAY in seeking medical 58%: DELAY in seeking medical

attentionattention– 29%: INCORRECT initial DIAGNOSIS29%: INCORRECT initial DIAGNOSIS– 13%: DELAY in TREATMENT at hospital!13%: DELAY in TREATMENT at hospital!

ConclusionConclusion

Surgical consult if necessarySurgical consult if necessary

DetorsionDetorsion

Exploration of scrotum if doughtful.Exploration of scrotum if doughtful.