Today we received this 14-year-old boy with sudden onset testicular pain. He has been having the pain persistently since the onset. By the time he got admitted, 4 hours had elapsed from the start of pain. On examination he had an enlarged right testis which was painful to touch. Affected testis seemed to be at a higher level than the other side. Cremasteric reflex was absent.
Clinical findings were highly
suggestive of a testicular torsion. When testicular torsion is high on the
cards, best way to diagnose and treat is to go ahead with surgical exploration.
So, we explored and here’s what we found.
This image shows the affected side testes which was bluish in colour due to severe ischaemia and congestion.
We untorted the testes and wrapped
it in warm normal saline towel and asked the anaesthetists to give 100 percent
oxygen. Here’s what happened after 20 mins.
Colour of the testes came back to
normal pink colour. It was a great relief for the team involved. Here, you can
compare both images to see the marked colour change that we observed.
With this experience, I thought
it is worthwhile examining some facts about clinical assessment of patients
presenting with testicular pain.
This condition is commonly seen
in teenagers (12 to 18). But can happen in any age, even in the intrauterine life
and neonates. Patient’s usually present with severe sudden onset unilateral
testicular pain that persist until they come to hospital.
Possible differential diagnosis
for testicular pain include testicular torsion, torsion of the appendage of the
testes, torsion of the appendage of the epididymis, testicular trauma, epididymo-orchitis.
But, when assessing a patient with testicular pain, it is very important to
keep testicular torsion as one of the leading differential diagnosis as misdiagnosis
may lead to devastating consequences. This is true specially in young children,
as they may not give an accurate history at times. Thus, physical examination
with attention to detail is very important in achieving a confident clinical
diagnosis.
Observation is an important part
of clinical assessment. Torted testes will be at a higher level as the torted cord
will pull the testes upwards. Testes will also lie at a more transverse plane
than the normal axis. Affected side will look a bit oedematous as well.
One tip in palpation of the
testis is to start the examination from the lower pole.
Patients with torsion of the
appendage of the epididymis or the appendage of the testis will have tender
points at the upper pole of the testes. In these instances, if you start the
palpation from the lower pole, patient’s will not feel pain initially. But as
you ascend towards the upper pole, they will feel pain.
Patients with testicular torsion
will have severe pain even when the lower pole is palpated. Patients with
epididymo-orchitis will have relief of pain when the testis is supported from below.
Absence of cremasteric reflex may
support a diagnosis of testicular torsion. But presence of cremasteric
reflex does not exclude testicular torsion.
In a case of testicular torsion,
spermatic cord will feel thick as well. But these patients will have severe
pain on palpation and in most cases, you will not be able to properly palpate the
cord.
These clinical assessments can be
used effectively to come to a clinical diagnosis. Testicular torsion should be
a clinical diagnosis and patients should undergo testicular exploration when clinically
suggested.
Ultrasound scan assessment has not shown to be useful in ruling out testicular torsion. Thus usefulness of ultrasound scan assessment is doubtful.
0 Comments