Is It torsion or notIs It torsion or not

Main ReferencesMain References are from are from emedicineemedicine articles by articles by web MDweb MD::Testicular torsionTesticular torsion, article by , article by Timothy J RuppTimothy J Rupp, MD, FACEP, Associate , MD, FACEP, Associate Medical Director, Children's Medical Center of Dallas, Texas Medical Director, Children's Medical Center of Dallas, Texas EpididymitisEpididymitis, article by , article by Catherine TubridyCatherine Tubridy, MD, Staff ER Physician, , MD, Staff ER Physician, State University of New York Downstate/Kings County Hospital CentersState University of New York Downstate/Kings County Hospital CentersTorsion of the Appendices and EpididymisTorsion of the Appendices and Epididymis, article by , article by Jason S ChangJason S Chang, , MD, Staff Physician, Section of Emergency Medicine, Yale New Haven MD, Staff Physician, Section of Emergency Medicine, Yale New Haven HospitalHospital

Presented by: Ahmad Kharrouby PGY 3

Urology Conference

IntroductionIntroduction

A child or adolescent with acute scrotal pain, tenderness, or swelling should be looked on as an emergency situation

The list of differential diagnoses for an acute scrotum is extensive

In all instances it is imperative to rule out torsion

Differential diagnosis of acute Differential diagnosis of acute scrotumscrotum

Campbell-Walsh Urology 9th edition

In adolescent males, testicular torsion is In adolescent males, testicular torsion is the most frequent cause of testicle lossthe most frequent cause of testicle loss

Acute epididymitis is the most common Acute epididymitis is the most common cause of acute scrotumcause of acute scrotum

Whereas torsion of testicular appendices Whereas torsion of testicular appendices is the leading cause of acute scrotum in is the leading cause of acute scrotum in children children

TorsionTorsion epidedimitisepidedimitis AppendiculAppendicular torsionar torsion

Pain onsetPain onset suddensudden insidiousinsidious acuteacute

SeveritySeverity severesevere moderatemoderate Moderate Moderate to severeto severe

SideSide UnilateralUnilateral Bilat. 10%Bilat. 10% UnilateralUnilateral

History in torsion:History in torsion:

– Sudden onset painSudden onset pain– severe severe – UnilateralUnilateral– Less commonly it is acuteLess commonly it is acute– 50% of have had episodes of intermittent pain50% of have had episodes of intermittent pain– Can occur with activity, or develop during sleepCan occur with activity, or develop during sleep– Other symptoms:Other symptoms:

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

History in epidedimitisHistory in epidedimitis

– Insidious onset painInsidious onset pain– swellingswelling– frequency, urgency, or dysuriafrequency, urgency, or dysuria– Retention in older patientsRetention in older patients– NauseaNausea– Abdominal or flank painAbdominal or flank pain– Bilateral epididymal involvement (10%)Bilateral epididymal involvement (10%)– Urethral dischargeUrethral discharge– Previous UTIs and unprotected intercoursePrevious UTIs and unprotected intercourse– Associated with Henoch-Schonlein purpura &

amiodarone

History in appendicular torsionHistory in appendicular torsion

– Acute pain with a more gradual onset than torsionAcute pain with a more gradual onset than torsion– mild to severemild to severe– Patients may endure pain for several days before Patients may endure pain for several days before

seeking medical attentionseeking medical attention– Located to the superior pole, a key distinguishing Located to the superior pole, a key distinguishing

factor from torsionfactor from torsion– Systemic symptoms and urinary symptoms are Systemic symptoms and urinary symptoms are

absentabsent

Physical Exam in torsionPhysical Exam in torsion

– Diffuse tendernessDiffuse tenderness– Elevated positionElevated position– Horizontal lieHorizontal lie– SwellingSwelling– Ipsilateral loss of cremasteric reflexIpsilateral loss of cremasteric reflex– -ve Prehn sign-ve Prehn sign– Fever (uncommon)Fever (uncommon)

Physical exam in epidedimitisPhysical exam in epidedimitis

– Edematous tender epididymisEdematous tender epididymis– Erythematous scrotumErythematous scrotum– Scrotal fixation to epididymisScrotal fixation to epididymis– Reactive hydroceleReactive hydrocele– +ve Prehn sign (not reliable)+ve Prehn sign (not reliable)– Urethral discharge (10%)Urethral discharge (10%)– Fever with progressionFever with progression

Physical exam in appendicular Physical exam in appendicular torsiontorsion

– AfebrileAfebrile– Normal scrotum usuallyNormal scrotum usually– Cremasteric reflex presentCremasteric reflex present– Tenderness localized to upper pole Tenderness localized to upper pole – Blue dot sign is pathognomonic (21%)Blue dot sign is pathognomonic (21%)– Vertical orientation is preservedVertical orientation is preserved– The combination of a blue-dot sign with, The combination of a blue-dot sign with,

nontender testes excludes torsionnontender testes excludes torsion

A recent study in 2005 scored 3 key historical A recent study in 2005 scored 3 key historical elements as predictors for testicular torsionelements as predictors for testicular torsion– Onset of pain less than 6 hoursOnset of pain less than 6 hours– Absence of cremasteric reflexAbsence of cremasteric reflex– Diffuse testicular tendernessDiffuse testicular tenderness

Out of 141 subjects, in the absence of any of Out of 141 subjects, in the absence of any of these elements, none of the subjects had these elements, none of the subjects had testicular torsiontesticular torsionWith all 3 elements present, 87% were With all 3 elements present, 87% were diagnosed with testicular torsion diagnosed with testicular torsion

Reference: Karmazyn B, Steinberg R, Kornreich L. Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys. Pediatr Radiol. Mar 2005;35(3):302-10

Lab Studies in torsionLab Studies in torsion

– UrinalysisUrinalysisusually normalusually normal

In 30% elevated WBCsIn 30% elevated WBCs

– CBC elevated WBC count in 60%CBC elevated WBC count in 60%

Lab Studies in Lab Studies in EpididymitisEpididymitis

– Urinalysis - Pyuria or bacteriuria (50%)Urinalysis - Pyuria or bacteriuria (50%)– CBC - LeukocytosisCBC - Leukocytosis

Lab Studies in appendicular torsionLab Studies in appendicular torsion

Usually normalUsually normal

Imaging StudiesImaging Studies

Testicular torsion is a clinical diagnosisTesticular torsion is a clinical diagnosis

Imaging studies usually are not necessary; Imaging studies usually are not necessary; ordering them wastes valuable time when ordering them wastes valuable time when the definitive treatment is surgicalthe definitive treatment is surgical

Imaging StudiesImaging Studies

– Color-coded Doppler ultrasonographyColor-coded Doppler ultrasonographyThis type of ultrasonography assesses perfusion of the This type of ultrasonography assesses perfusion of the testicle and anatomy of the scrotal contentstesticle and anatomy of the scrotal contentsA normal testicle with markedly diminished Doppler wave A normal testicle with markedly diminished Doppler wave pulsation represents torsionpulsation represents torsionA thickened enlarged epididymis with increased Doppler A thickened enlarged epididymis with increased Doppler wave pulsation represents epididymitiswave pulsation represents epididymitisIn appendicular torsion In appendicular torsion

– Testicular appendage appears as a lesion of low echogenicity Testicular appendage appears as a lesion of low echogenicity with a central hypoechogenic area with a central hypoechogenic area

– Normal blood flow to the testis, with an occasional increase on Normal blood flow to the testis, with an occasional increase on the affected side that possibly is due to inflammation the affected side that possibly is due to inflammation

Color Doppler has a sensitivity of 86%, specificity of 100%, Color Doppler has a sensitivity of 86%, specificity of 100%, and accuracy of 97% in the diagnosis of testicular torsionand accuracy of 97% in the diagnosis of testicular torsion

Imaging StudiesImaging Studies

In prepubertal patients, this method of In prepubertal patients, this method of imaging is somewhat controversial imaging is somewhat controversial because the prepubertal testis has low-because the prepubertal testis has low-velocity blood flow, and color Doppler velocity blood flow, and color Doppler ultrasonography is less accurate in these ultrasonography is less accurate in these instancesinstancesAs a result, a negative ultrasonographic As a result, a negative ultrasonographic result does not necessarily exclude result does not necessarily exclude testicular torsiontesticular torsion

Imaging StudiesImaging Studies

– Radionuclide scintigraphyRadionuclide scintigraphyRadionuclide scintigraphy is used to assess Radionuclide scintigraphy is used to assess testicle perfusiontesticle perfusionDecreased perfusion suggests torsionDecreased perfusion suggests torsionIncreased or normal perfusion suggests Increased or normal perfusion suggests epididymitis but may occur with torsionepididymitis but may occur with torsionThe positive pathognomonic sign for testicular The positive pathognomonic sign for testicular appendix torsion is the hot-dot sign, which is an appendix torsion is the hot-dot sign, which is an area of increased tracer uptakearea of increased tracer uptakeRadionuclide scans have a sensitivity of 90-100% Radionuclide scans have a sensitivity of 90-100% accuracy in detecting testicular blood flowaccuracy in detecting testicular blood flow

ImportantImportant

In high clinical suspicion, surgical In high clinical suspicion, surgical exploration is essentialexploration is essential

Under InvestigationUnder Investigation

The use of C-reactive protein (CRP) and erythrocyte sedimentation The use of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to help differentiate epididymitis from testicular torsionrate (ESR) to help differentiate epididymitis from testicular torsionA prospective study evaluated 120 patients with the diagnosis of an A prospective study evaluated 120 patients with the diagnosis of an acute scrotumacute scrotumserum CRP and ESR were drawn at ER arrivalserum CRP and ESR were drawn at ER arrivalOf the 46 patients diagnosed with epididymitis, 44 (95.6%) had Of the 46 patients diagnosed with epididymitis, 44 (95.6%) had elevation of CRP levelelevation of CRP levelof the 23 with torsion, 1 (4%) had elevation of CRP levelof the 23 with torsion, 1 (4%) had elevation of CRP leveland, of the 51 other patients with other noninflammatory causes of and, of the 51 other patients with other noninflammatory causes of acute scrotum, none had significant elevation of CRP levelacute scrotum, none had significant elevation of CRP levelThe authors proposed cutoff values of distinguishing epididymitis The authors proposed cutoff values of distinguishing epididymitis from noninflammatory causes of acute scrotum of 24 mg/L for CRP from noninflammatory causes of acute scrotum of 24 mg/L for CRP level and 15.5 mm/h for ESR.level and 15.5 mm/h for ESR.The use of ESR and CRP is also promising, but again further The use of ESR and CRP is also promising, but again further investigations are necessaryinvestigations are necessary

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