Presentation

The most common age for the development of torsion is early puberty, while the newborn period is the second most common. The vascular compromise results in the rapid onset of swelling because of venous outflow obstruction in the face of continued arterial inflow. The testicle can be completely salvaged with upto6h of torsion, but is unlikely to be salvaged beyond 12 h, so expedient diagnosis and surgical detorsion should be pursued.

Patients generally present with acute testicular pain, often being awoken from sleep with pain. If the patient has mild pain, which has increased over a few days, a torsion of a testicular appendage should be suspected, rather than testicular torsion. If the patient complains of intermittent acute pain, which completely resolves, a diagnosis of intermittent testicular torsion should be suspected (Eaton et al. 2005). In classic testicular torsion, there tends to be nausea and vomiting, along with referred abdominal pain. On inspection, the typical torsion patient is lying quite still on the exam table. A patient who is ambulating easily without pain is unlikely to have torsion. Close inspection of the scrotum may show asymmetric positioning of the testicles with the torsed testicle occupying a high position in the scrotum, which is termed a high-riding testicle. A cremasteric reflex should be elicited next, before palpation, as absence of a cremasteric reflex is associated with torsion. This sign is not fully specific, as a cremasteric reflex can sometimes be elicited with torsion. Next, palpation should occur. When palpating the scrotum, the normal testicle must be palpated first. It should be in a vertical position. Next the spermatic cord of the affected testis is palpated. If painful and swollen, the suspicion of torsion is raised. Finally, the affected testis is palpated. This is often difficult for the patient. Sometimes the epididymis faces anteriorly. Pain at the lower pole of the testis is more likely to signify torsion than pain at the upper pole of the testis, which is where many of the testicular appendages are located. If a hydrocele is present, preventing testicular palpation, and the diagnosis is mostly equivocal, an imaging modality can be obtained to examine the testicle and its flow characteristics, if it can be obtained in a timely manner. Scro-tal ultrasound with color Doppler is widely used (Fig. 12.4), although some institutions have expertise in rapid nuclear medicine imaging with technicium-99m radionuclide scanning looking for blood flow to the testicle, which is equally sensitive (Nussbaum Blask et al. 2002). Occasionally, MRI has been used to evaluate for torsion. However, if the imaging modality cannot be obtained in a timely manner, and the index of suspicion is high, then intraoperative exploration is mandatory.

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