SCH Intern Presentation 10/02/14 Tony Chen, MD SCH Intern Presentation

CASE 7-day-old male presents to outpatient Urologist for bilateral undescended testes PEx: right testis nonpalpable, left testis palpable at level of pubic tubercle. Birth Hx: 38 wk gestation, normal prenatal US, no complications. Plan:  Karyotype and plan for orchiopexy at 6 months of age

9 weeks later… 10-week old male presents to SCH ED with R inguinal bulge. Pt has been more fussy in 10 days prior to presentation. No changes in urinary or bowel habits, no fevers. Unable to be reduced by provider.  PEx: Tanner 1, physiologic phimosis, R inguinal bulge not tender to palpation, no overlying skin changes. Left testis descended, R undescended.

Differential diagnosis Inguinal hernia (reducible vs. incarcerated) Inguinal lymphadenitis Undescended testis Torsion of appendix testes, epididymitis, or testicular torsion Torsion of undescended testis Amyrand’s Appendicitis.

Testicular Torsion in the setting of cryptorchidism

Definitions Cryptorchidism = “hidden testis” True undescended testis Retractile testis Ectopic testis Testicular Torsion = twisting of the spermatic cord, leading to venous congestion and subsequent ischemia. *The first case report of testicular torsion was in 1840 by Delasiauve in 1840 – a 15 year old male with torsion of an undescended testis.

Embryology

Embryology (cont.)

Epidemiology Rates of Cryptorchidism: Premature Infants: 21-30% Term infants: 2.7-5.9% 1% persist at 1 year of age. Rates of Testicular Torsion: Annual incidence 1 in 4000 males younger than 25 years 5%-12% total pediatric cases occur in 1st year of life  Rates of torsion in cryptorchid testes: Estimated 10x higher than in normal scrotal testes

Diagnosis History: Exam: acute onset pain inguinal swelling difficult to console infant. Exam: tender/firm groin mass empty hemiscrotum

Utility of imaging? Imaging: Duplex Ultrasound Standard of care applied normally to descended testicular torsion (sens 77.8% and spec. 90%) does NOT apply. Misdiagnosis (possibly from operator inexperience) may lead to delay in surgical exploration.

Treatment Emergent surgical exploration with manual detorsion Orchiopexy vs. Orchiectomy Not enough data to support contralateral orchiopexy

Prognosis Salvage rate in normally descended testicle: 70 to 90% if presentation <6 hrs; 60% if <12hrs Salvage rate in Cryptorchid testis: difficult to determine Some studies cite approximately 10% Mano et al.: 0 out of the 7 cryptorchid torsion cases were salvageable. Zilberman et al.: 1 out of 11 cases had normal testis at follow up

Our case… Ultrasound in ED showed normal testicle with adequate blood flow, small hydrocele Scheduled for elective R Orchiopexy and bilateral inguinal hernia repair with outpatient Urologist.

Conclusion Cryptorchid testicular torsion = uncommon combination of 2 common conditions Importance of genital exam in abdominal pain presentations In child presenting with empty hemiscrotum and ipsilateral inguinal pain, consider torsion of undescended testicle and incarcerated inguinal hernia. Torsion of Cryptorchid testis = clinical diagnosis.

references Moore, Catherine Porter, Jonathan K. Marr, and Craig J. Huang. "Cryptorchid testicular torsion." Pediatric emergency care 27.2 (2011): 121-123. Schultz KE, Walker J. Testicular torsion in undescended testes. Ann Emerg Med. 1984;13:567–9 Mano, Roy, et al. "Testicular Torsion in the First Year of Life–Characteristics and Treatment Outcome." Urology 82.5 (2013): 1132-1137. Williamson, R. C. N. "Torsion of the testis and allied conditions." British Journal of Surgery 63.6 (1976): 465-476. Pogorelić, Z., et al. "Testicular torsion in the inguinal canal in children." J Pediatr Urol (2012): 00249-5. Slijper N, Sukhotmik I, Toubi A, et al. Clinical validation of ultrasound Doppler in the diagnosis of torsion of undescended testis. IMAJ. 2007;9:99-101. Candocia FJ, Sack-Solomon KS. An infant with testicular torsion in the inguinal canal. Pediatr Radiol. 2003;33:722-724. Zilberman, D., Inbar, Y., Heyman, Z., Shinhar, D., Bilik, R., Avigad, I., ... & Mor, Y. (2006). Torsion of the cryptorchid testis—can it be salvaged?. The Journal of urology, 175(6), 2287-2289. Davenport M. ABC of general surgery in children. Acute problems of the scrotum. BMJ. 1996;312:435–7.

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