Testicular torsion: Difference between revisions
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**Only indicated for equivocal cases | **Only indicated for equivocal cases | ||
**Unilateral abscence of flow (specific) | **Unilateral abscence of flow (specific) | ||
===TWIST Score=== | |||
*Proposed score for assessing testicular torsion in children | |||
{| class="wikitable" | |||
|- | |||
! Finding !! Points | |||
|- | |||
| Testicular swelling || 2 | |||
|- | |||
| Hard testicle || 2 | |||
|- | |||
| Absent cremasteric reflex || 1 | |||
|- | |||
| Nausea or vomiting || 1 | |||
|- | |||
| High-riding testicle|| 1 | |||
|} | |||
*PPV 100% when >5 pts (Suggesting clinical clearance) | |||
*NPV 100% when <2 pts (Suggesting stat urological consult)<ref>Barbosa, JA, et al. Development of initial validation of a scoring system to diagnose testicular torsion in children. The Journal of Urology. 2013; 189:1853-8.</ref> | |||
*Scores from 2-5 pts require U/S for further assessment | |||
== Work-Up == | == Work-Up == | ||
Revision as of 03:15, 9 January 2015
Background
- Peak incidence in first year of life, 2nd peak incidence at puberty
- Consider torsion in setting of scrotal trauma if pain persists >1hr
- Half of all torsions occur during sleep
Salvage Rates for Detorsion Times
| Rate |
Time |
| 90-100% | <6 hrs |
| 20-50% | 6-12 hrs |
| 0-10% | >24 hrs |
Diagnosis
- History:
- Abrupt onset testicular pain a/w N/V
- May have had intermittent episodes in the past
- Exam:
- Swollen, high-riding testis w/ transverse lie
- Absent cremasteric reflex on affected side (99% Sn)
- Ultrasound
- Only indicated for equivocal cases
- Unilateral abscence of flow (specific)
TWIST Score
- Proposed score for assessing testicular torsion in children
| Finding | Points |
|---|---|
| Testicular swelling | 2 |
| Hard testicle | 2 |
| Absent cremasteric reflex | 1 |
| Nausea or vomiting | 1 |
| High-riding testicle | 1 |
- PPV 100% when >5 pts (Suggesting clinical clearance)
- NPV 100% when <2 pts (Suggesting stat urological consult)[1]
- Scores from 2-5 pts require U/S for further assessment
Work-Up
- UA
- US for equivocal cases
- Lab workup for surgery
Differential Diagnosis
Testicular Diagnoses
- Scrotal cellulitis
- Epididymitis
- Fournier gangrene
- Hematocele
- Hydrocele
- Indirect inguinal hernia
- Inguinal lymph node (Lymphadenitis)
- Orchitis
- Scrotal abscess
- Spermatocele
- Tinea cruris
- Testicular rupture
- Testicular torsion
- Testicular trauma
- Testicular tumor
- Torsion of testicular appendage
- Varicocele
- Pyocele
- Testicular malignancy
- Scrotal wall hematoma
Treatment
- Manual (ED) vs. surgical (urology)
Manual Detorsion
- Indicated if urologist is not immediately available
- Not definitive tx
- Pt still requires emergent urology consult even if successful
- "Open the book" = twist outward and laterally
- Give parenteral analgesia or perform cord block
- Prep skin, palpate and grasp cord at external ring and inject 10mL lidocaine directly into cord
- Hold testicle with left thumb and forefinger
- Rotate testicle outward 180° in medial to lateral direction
- Counterclockwise for right testicle and clockwise for left testicle
- Rotation may need to be repeated 2-3x for complete detorsion/pain relief
- If difficult to detorse or pain is worse after rotation, try to rotate testicle in opposite direction and observe results.
- Rotate testicle outward 180° in medial to lateral direction
- Give parenteral analgesia or perform cord block
Disposition
- To OR or urology
See Also
Source
Tintinalli, Rosen's, ER atlas
- ↑ Barbosa, JA, et al. Development of initial validation of a scoring system to diagnose testicular torsion in children. The Journal of Urology. 2013; 189:1853-8.