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

2. 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”

3. 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

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

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

6. 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, % at 5 hours, 75 % at 8 hours, and % 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.

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

8. 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.

10. 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:

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

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

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

14. 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.

15. 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.

16. 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.

17. 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

18. Works Cited