13.2 Testicular Torsion - 1 Lecture-TZ
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Transcript of 13.2 Testicular Torsion - 1 Lecture-TZ
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8/12/2019 13.2 Testicular Torsion - 1 Lecture-TZ
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Testicular TorsionCenter for International Emergency
Disaster and Refugee Studies
Department of Emergency MedicineJohns Hopkins University
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2Testicular TorsionCenter for International Emergency
Disaster and Refugee Studies
Objectives
Discuss the epidemiology and prevention
of torsion
Review the pathophysiology of torsion
Discuss the means of diagnosing torsion
Discuss diagnostic and laboratory studies
relevant to torsionDiscuss the case management and
treatment of torsion
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Disaster and Refugee Studies
Introduction
Urologic emergency
Important to differentiate testicular torsion from other
complaints of testicular pain.
Delay in diagnosis can lead to loss of the testicle. Magoha in the East African Medical Journal reported
the overall salvage rate was low at 21% with an
orchidectomy rate of 79
Prompt diagnosis of testicular torsion anddifferentiation of this condition from epididymitis
can be difficult
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Disaster and Refugee Studies
Key points
Prompt diagnosis
Immediate surgical referral
Rapid definitive treatment salvage of the testicle
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Disaster and Refugee Studies
Morbidity
Salvage rate of 80-100% possible in
patients who present within 6 hours of
pain.
Difficult in remote and underserviced areas
After 6-8 hours, the salvage rate markedly
decreases
Near 0% at 12 hours.
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Disaster and Refugee Studies
Epidemiology
Young males < 30 years old
Typically: 12-18 years
Peak age: 14 years
Smaller peak during first year of life
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Disaster and Refugee Studies
Pathophysiology
If high attachment of the tunica vaginalis,
testicle can rotate freely on the spermatic
cord
In neonates, testicle frequently has not
descended into the scrotum
Becomes attached within the tunica vaginalis
Mobility of the testicle predisposes it to torsion
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Disaster and Refugee Studies
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Disaster and Refugee Studies
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Causes
Congenital anomaly
Undescended testicle
Sexual arousal and/or activityTrauma
Exercise
Active cremasteric reflex
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Presentation
History: sudden onset of severe unilateral
scrotal pain.
Scrotal swelling
Nausea and vomiting (20-30%)
Abdominal pain (20-30%)
Fever (16%)Urinary frequency (4%)
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Clinical Findings
Testicle painful to palpation
Frequently elevated in position when comparedto the other side
Horizontal lie of the testicle
Enlargement and edema of the testicle; Edema may involve the entire scrotum
Scrotal erythema
Ipsilateral loss of the cremasteric reflex
No relief of pain upon elevation of scrotum
Fever (uncommon)
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Differential Diagnosis
Epididymitis/orchitis
Hernia
HydroceleScrotal abscess
Fourniers gangrene
Appendicitis
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Diagnosis
Lab studies
Urinalysis
Usually normal
White blood cells in urine 30% of the time
CBC
Normal or elevated WBC count in as many as 60%
of patients who have torsion
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Diagnosis
Torsion is a CLINICAL diagnosis!
Imaging studies
Ultrasonography and color doppler
Demonstrate arterial blood flow to the testicle
Identify scrotal anatomy and other testicular
disorders
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Normal Testicle
Plain ultrasound
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Testicular Torsion Normal testicle
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Scrotal wall
Blood supply to testicle
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Treatment
Pain relief
Manual detorsion
Surgical/Urological consultation
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Treatment-Pain Relief
Essential to quality patient care
Mild analgesic after diagnosis or awaiting
further studies
Judicious and cautious adminstration
Morphine sulfate narcotic drug of choice
Starting dose: 0.1 mg/kg (iv/im/sc) Maintenance dose: 5-20 mg/70kg every 4 hrs
Reversible with naloxone
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Treatment-Manual Detorsion
Opening of a book"
Physician standing at the patient's feet
Relief of painsuccessful detorsion
Goal: reestablish or increase blood flow to
previously ischemic testicle
Never delay operative interventionSuccess in 30-70% of patients
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Treatment-Consultation
Earlysurgical consultation is mandatory
Definitive treatment is surgery
Detorsion
Orchiopexy.
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Center for International Emergency
Disaster and Refugee Studies
Disposition
Early diagnosis: 100% salvage rate
Transfer to another institution where
surgery can be performed if no surgeon is
available at your hospital.
Complications
Infarction of testicle
Loss of testicle
Infection
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Center for International Emergency
Disaster and Refugee Studies
Summary
Clinical diagnosis
Time is testicle
Emergent urological consultationTransfer to appropriate facility
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Center for International Emergency
Disaster and Refugee Studies
Case
11 year old boy complains of intermittent
pain in his right testicle for the past 2 days.
Now constant pain for the past 3 hours.
Denies trauma.
PE:
Tender right testicle, slightly elevated, red and
swollen
What would you do?
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Center for International Emergency
Disaster and Refugee Studies
Key Points
Diagnose suspected testicular torsion.
Immediate/prompt consult
Surgery/Urology
Pain medication
Image study
Attempt detorsionDefinitive: surgery
Detorsion and Orchiopexy