1. Testicular and appendix torsion Done by : Nahed AlMutairi NGH F1

2. objectives  Epidemiology  Historical clues  Physical finding  Dx  Management  How to differentiate

3. EPIDEMOLOGY  Testicular torsion, epididymitis, and torsion of the appendix testis constitute the top 3 etiologies of the acute scrotal pain in pediatrics.  Testicular torsion is one of the few true urologic emergencies.  Affecting 1 in 4000 patients younger than 25 years.  the percentage of children with acute scrotal pain diagnosed with testicular torsion ranges from 12% to 45%.  Torsion of the appendix testis ranges from 14% to 67%.

4. Testicular torsion

5.  Torsion of the testicle results from twisting of the spermatic cord  compromises the blood supply.  Torsion may occur :  extravaginally (twisting proximal to the tunica vaginalis)  neonate  intravaginally (twisting within the tunica vaginalis). These are made possible because the tunica vaginalis attaches high on the spermatic cord  “bell clapper” deformity  50%  torsion between the testis and the epididymis.

7.  Extravaginal torsion occurs in the perinatal age group.  Intravaginal torsion occurs in older children.  Pediatric testicular torsion has a bimodal age presentation with a small peak in neonates and a second larger peak in peripubertal children

8. Historical clues (1)Acute onset, often waking a boy up from sleep. (2) presence of nausea/emesis. (3) severe pain not improved by any position. (4) sudden enlargement and redness of the hemiscrotum in a newborn. (5) Fever and painfull voiding uncommon.

9. Physical sign (1)Enlarged, swollen hemiscrotum. (2)Tenderness. (3)Loss of cremasteric reflex. (4)Horizontal lie of the affected testis. **Any boy with abdominal pain must undergo a testicular examination, because testicular torsion may present solely with abdominal pain, without any scrotal complaints.

10. Diagnosis  color Doppler ultrasonography for diagnosing testicular torsion has sensitivity 63% to100% with a specificity of 80% to 100%.  Its noninvasiveness and more importantly, in its ability to differentiate nonsurgical causes of acute scrotum.  Arterial blood flow is absent or diminished in the case of testicular torsion.

11. Testicular Scintigraphy  Testicular scintigraphy utilized since the 1970s.  Uses radionuclide imaging to demonstrate absence of blood flow to the testis caused by obstruction from TOSC.  Obstructed flow leads to delay in radionuclide perfusion that translates into a photopenic image.  Sensitivity 80% to 100%.

12. ** While scintigraphy provides only a “Yes” or “No” answer for TOSC, ultrasound can do the same while also demonstrating a specific diagnosis for the “No” group.

13. Traetment  The only management for testicular torsion is surgical reductions and fixation (bilateral orchiopexy) if viable and orchiectomy if non viable.  In ER :  pain control by administering meperidine, morphine, ketoralac, or nitrous oxide (via inhalation).  Icepacks applied to the affected hemiscrotum  reducing its metabolic rate and oxygen demand.  Supplemental oxygen has also been suggested to super saturate the blood and force more oxygen to the compromised tissue.  US and urology consultations.  Manual detorsion.

14. Manual detorsion  Allow the testicle to remain viable until emergency surgery can be performed.  Testicle more commonly twists medially, toward the contralateral thigh.  Hold the affected testicle between the thumb and forefinger and untwists 360 degrees towards the ipsilateral thigh.  If relief is noted, the testicle should be rotated another 360 degrees or more, because the usual twist is 720 degrees.

18. Fail to diagnose testicular torsion  It may not be suspected /considereding an infant.  The chief complaint may be abdominal pain rather than scrotal pain.  Hx of trauma may confuse dx.  PH. Ex. Finding can be consistent.  Ex of genitalia is omitted.  Diagnostic study such as US is trusted rather than PH Ex finding.  Urologist is not consulted even though the Hx or Ex is worrisome.

19. For how long the torsed testicle remain viable  100% if detorsed within 3 hrs from onset of symptoms.  75% after 8 hrs.  10% - 20% after 12 hrs.  0% after 24 hrs.

20. Torsion of the appendix testis

21.  The four testicular appendages—appendix testis, appendix epididymis, paradidymis (organ of Giraldes), and vas aberrans—have no known physiologic function.  These pedunculated structures are capable of torsion and, in prepubertal boys, probably twist more often than the testes.  Appendix epididymis and appendix testes accounting for approximately 8% and 90% of appendage torsion, respectively.

23. Symptoms  Like testicular torsion.  Pain and swelling of scrotum.  Lack of systemic symptoms like nausea and vomiting.

24. Physical examination  pain localized to the upper pole of the testis.  Blue spot may be observed through the scrotal “blue dot sign.” This “sign” is pathognomonic for torsion of the appendix testis or epididymis.  Cremasteric reflex is brisk.

25. Management  Self-limiting  Analgesics  bed rest  supportive underwear  Reassurance  Expected symptom resolution within 3 to 5 days  If late in the process and testicular swelling is present, or if the color Doppler US is equivocal, then urologic consultation and surgical exploration are needed to exclude testicular torsion

26. Appendage torsionTesticular torsion prepubertalNeonate/adolescentPeak incidence Prescence of appendages Undesceded testicle,rapid increase in testicular size,failure of prior orchiopexy Risk factor variablesuddenPain onset Less likelyMore likelyNausea/vomiting Less likely Dysurea Less likely Fever Localized to head of affected testicle Testicle, progressing to hemiscrotal involvement Location of swelling/tenderness presentAbsentCremateric reflex Normal position,vertical alignment High riding,transverse alignment Testicle position

28. Refererance

29. Thank you