Pediatric Torsion

The history, including the onset and severity of pain as well as associated symptoms, is vital in the assessment of the older child with suspected testicular torsion. Patients typically present with sudden-onset severe pain associated with nausea, vomiting, and scrotal swelling. There is no history of fever, irritative voiding symptoms, or urethral discharge. Physical examination demonstrates an enlarged hemiscrotum containing a highriding tender, swollen testicle with no evidence of spermatic cord swelling or inguinal adenopathy. The epidid-ymis may be palpable in an abnormal location due to the testicle's transverse lie. The cremasteric reflex is usually absent and urinalysis is routinely normal. Surgical exploration usually reveals torsion in these cases and should not be delayed by radiologic confirmation (Fig. 8.43). Doppler US should be reserved for those cases in which the diagnosis is questionable.

Pediatric torsion is usually secondary to the bell-clapper deformity and occurs intravaginally. Prompt recognition and surgical detorsion will prevent atrophy and testicular nonfunction. Orchidopexy within 4 h will result in almost certain complete testicular viability; however, some germ and Leydig cell function can still be preserved after 12 h of untreated torsion. Beyond 24 h, nearly complete testicular atrophy occurs despite detorsion and orchidopexy (Rampaul and Hos-

king 1998). As the bell-clapper deformity affects both testes, contralateral orchidopexy should be performed at the time of exploration of the involved testis.

Frequently, torsion of a testicular appendage will present in a similar fashion; however, careful examination will reveal a normal, vertically oriented testicle with an intact cremasteric reflex and pain on palpation limited only to the upper pole of the testicle. Occasionally, the blue-dot sign (which consists of a small bluish discoloration of the overlying scrotal skin) is appreciated as the congested, torted appendix is identified at the level of the upper pole. Doppler US should be performed and can easily diagnose appendix testis or appendix epididymis torsion and rule out testicular torsion proper. Supportive therapy and NSAIDS are the mainstays of treatment.

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