Left Testicular Pain January, 2014 Brendan Gilmore, MS-4

Brief Clinical History 16 M with no PMHx presenting to ED with 5 hour history left testicular pain Patient reports he was running at track practice when he felt acute onset testicular pain, aching in quality, non-radiating predominately left sided Constant, 10/10 in severity Associated with nausea and 3 episodes of emesis He also reported lightheadedness naproxen, rest, and ice with no relief from pain Denies sexually activity, hx of STDs Never had similar symptoms in the past. Denies dysuria, hematuria, trauma “scrotum see swollen and left testicle higher than the right”

Pertinent Physical Exam Findings Tmax: 98.1, HR:89, RR: 20, BP: 128/73 , SpO2 (%): 100 Gen: Cooperative, Moderate distress CV: RRR, no M/R/G Lungs: CTAB Abd: soft, non-tender, non-distended GU: Left testicle retracted, erythematous, edematous, tender to light touch, no relief of pain with elevation (Prehn sign) Normal right testicle. Uncircumcised penis

Differential Diagnosis Testicular Torsion Epididymitis Orchitis Trauma Inguinal hernia Testicular tumor Testicular hydrocele/ varicoceles

Pertinent labs WBC = 7.1 Normal U/A STD panel pending

Differential Diagnosis Testicular Torsion (Cannot Miss) Epididymitis Orchitis Trauma Inguinal hernia Testicular tumor Testicular hydrocele/ varicoceles The salvage rates are approximately 100 % at 3 hours, 83-90 % at 5 hours, 75 % at 8 hours, and 50-70 % at 10 hours. The salvage rates decrease to 10 to 20 % when the testicle remains torsed for more than 10 hours. After 24 hours, salvage of a testicle is rare unless there has been intermittent detorsion.

Options of Diagnostic Imaging US scrotum with Doppler Tc-99m scrotal scintigraphy MRI pelvis (scrotum) without and with contrast MRI pelvis (scrotum) without contrast

US scrotum with Doppler Rating of 9 on the ACR appropriateness criteria Excellent study that is generally available and very sensitive and specific Relative Radiation Level of 0 Provides more specific visualization of both normal and pathological anatomy Sonographic findings can be variable depending on the duration of torsion and extent of vascular compromise.

Absence of flow within the left testicle, which is otherwise normal in in size and echogenicity. The testicle can appear enlarged and hypoechoic and the parenchyma of the testicle will become less homogenous when compared with the unaffected testicle MRN: 6341016

Unilateral diminished or absent flow is the most accurate sign of testicular torsion, but the presence of blood flow does not exclude torsion

Example Transverse scan of both testicles showing normal left testicle and right testicular torsion. Hypoechogenicity of the right testicle.

Example Transverse plane through both testes.  The power Doppler image of the scrotum demonstrates right testicular perfusion.  The swollen left testicle is not perfused.

Attempt at manual detorsion was attempted by the Urology service at the bedside during the time of scanning, however, post manipulation images do not demonstrate evidence of flow.

Testicular Torsion The twisting of the spermatic cord within the tunica vaginalis causes venous compression and subsequent edema of the testicle and cord with ultimate ischemia of the testicle caused by arterial occlusion Approximately 65 percent of cases occur in boys between the ages of 12 and 18 years Patients classically present with an abrupt onset of severe testicular or scrotal pain, usually of less than 12 hours' duration Nearly 90 percent of patients may have associated nausea and vomiting [11,12]. The pain can be isolated to the scrotum or may radiate to the lower abdomen [5,7]. The pain is constant unless the testicle is torsing and detorsing. A typical presentation, particularly in children, is for the patient to awaken with scrotal pain in the middle of the night or in the morning. Many boys report a previous episode of pain [2,5,7,13]. However, one study reported only 8 percent of the patients with torsion had a history of pain in the past [8]. On physical examination, the scrotum may be edematous, indurated and erythematous and the affected testis usually is tender, swollen, and slightly elevated because of shortening of the cord from twisting. The testis may be lying horizontally, displacing the epididymis from its normal posterolateral position. A reactive hydrocele may also be present.

Diagnosis Diagnosis can of testicular torsion can be made clinically, using the following clinical scoring system   ●Nausea or vomiting – 1 point ●Testicular swelling – 2 points ●Hard testis on palpation – 2 points ●High riding testis – 1 point ●Absent cremasteric reflex – 1 point A score ≥5 diagnosed testicular torsion 76 percent sensitive and, 100 percent specific A color Doppler US of the scrotum is performed in patients with equivocal clinical findings when imaging will not significantly delay treatment. Demonstration of decreased testicular perfusion is consistent with testicular torsion.

Treatment and Clinical Outcome Bedside detorsion attempted Repeat U/S shows minimal return of flow to left testicle. Unsuccessful third attempt Decision made to proceed to OR emergently for scrotal exploration and orchiopexy

Works Cited http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/AcuteOnsetScrotalPain.pdf http://www.uptodate.com/contents/evaluation-of-scrotal-pain-or-swelling-in-children-and-adolescents?source=search_result&search=testicular+torsion&selectedTitle=3%7E31 http://www.sonoguide.com/smparts_testicular.htm