Larry Mellick, MD, MS, FAAP, FACEP
Professor of Emergency Medicine
Medical College of Georgia
and
Cline Jackson, MD
Emergency Medicine Resident
Medical College of Georgia
Pearl: Don't forget to include testicular torsion in your differential when evaluating lower abdominal pain complaints in young males.
Presentation: An 18 year-old male presented to the emergency department complaining of sharp, mostly right-sided, lower abdominal pain. His complaint of associated nausea was confirmed when he vomited on the triage nurse's shoes. The pain began suddenly during a strenuous workout at the gym 3-4 hours prior to arrival and was becoming more severe. The pain was not easily localized on examination and only diffuse tenderness of the abdomen was noted without signs of peritoneal irritation. In the examination room the patient vomited twice more. The emesis was non-bilious and without evidence of hematemesis. The patient was afebrile and the rest of his vitals signs were within normal limits. His laboratory testing (CBC, liver enzymes and pancreatic markers) was also unremarkable. A detailed sexual history was performed and the patient denied being sexually active or having a penile discharge. While being transferred to a wheelchair for transportation to the CT scan, the patient stated that his pain significantly improved when he sat down. What critical diagnosis was nearly overlooked?
Discussion: This patient's abdominal pain was caused by the torsion of his right testicle. The presence of "abdominal" signs and symptoms does not exclude torsion. Abdominal pain can occur in 20 to 30% of patients with torsion and anorexia, nausea and vomiting are quite common.1,2 If the first ten differential diagnoses of abdominal pain in this age range are all appendicitis, your thinking may be significantly skewed off course. In the evaluation of the young male patient with abdominal pain, the diagnosis of testicular torsion must be considered.
Testicular torsion is the rotation of a testicle on the spermatic cord, resulting in vaso-occlusion and eventually arterial ischemia with testicular infarction. This occurs due to an unusually high attachment of the tunica vaginalis, which normally covers the testicle and attaches to its posterolateral surface. This abnormal junction allows the testicle to freely twist which results in the rotation described above. (See figures 2A and 2B.1) Testicular torsion is the leading cause of testicle loss in boys under eighteen.
Torsion occurs most often in testicles with a transverse lie (the so-called "bell-clapper deformity"); and typically, the physical exam will reveal a firm, swollen and high-riding testicle that is exquisitely tender and has some relief with elevation. Most patients do not report urinary symptoms (only 4% report frequency) and the urinalysis generally does not reveal pyuria, however one should not rely on this to exclude torsion as there may be leukocytes present in up to 30% of patients.1 Presence of a previous torsion and orchipexy surgery can be misleading as well, since it is possible to "re-torse", especially if reabsorbable sutures are used.3
Rapid recognition and treatment is the key to managing torsion in the emergency department. Color Doppler ultrasound exam is the imaging modality of choice (over radionuclide scanning), but if your clinical suspicion is high, ultrasound availability should not delay treatment. Surgical exploration remains the "gold standard" for diagnosis and treatment of testicular torsion. Testicular survivability is measured in hours, with approximately 80-100 percent success rate if patient is taken to surgery within the first 6 hours, but falls to 20% after 10 hours. In hope of restoring some degree of arterial flow and venous return you may attempt to "de-torse" the patient manually in the ED using the "open book technique" of rotating the affected testicle laterally in the manner of folding open the pages of the book. Despite symptom relief, however, all patients should have an urgent urological consult.
References:
- Hals GD, Dietrich D. Diagnosis and Emergency Department Management of Urologic Emergencies in the Male Patient. Part I, Scrotal Disorders. Emergency Medicine Reports; 2002;23(2);17-27.
- Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics 1998;102;73-76.
- Morgan JA, Mellick LB. Testicular torsion following orchiopexy. Pediatr Emerg Care. 1986 Dec;2(4):244-6
Online Sources:
http://www.emedicine.com/emerg/topic573.htm
http://www.aafp.org/afp/990215ap/817.html
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