Clinical CT for June 2016
by Adam Blumenberg MD
Special thanks to Mark Silverberg MD
A 12 year-old boy presents to the emergency department at 7:00AM Sunday morning with 2 hours of left sided abdominal pain, waxing & waning nausea and vomiting. Vital signs are within the normal range and abdomen is soft and non-tender. Genitourinary examination reveals high-riding and tender left testicle and diminished cremasteric reflex. The above ultrasound image is obtained.
- What is the diagnosis?Acute testicular torsion.
- What historical and physical examination findings are typical of this disease? What other diagnoses must be considered?Testicular or abdominal pain, high-riding testis, abnormal cremasteric reflex, and nausea/vomiting. According to a 2012 study in Urology, nausea and/or vomiting had an odds ratio 21.6 while an abnormal cremasteric reflex had an OR of 4.8.
Other diagnoses to consider include epididymitis/orchitis, STI, sexual abuse, mumps, hernia, trauma, and abscess.
- What is the emergency department management of this condition? What if you do not have immediate access to a specialist?As with other ischemic processes (such as MI) time is tissue, and a patient with testicular torsion requires emergent re-establishment of perfusion. Ensure that your urology colleagues evaluate the patient promptly, and expedite preoperative lab tests such as type & screen. If you do not have access to urology service, consider manual de-torsion. The “opening of a book” is the most commonly used non-operative method to detorse a testicle.
- What is the patient’s disposition?Urology for emergency orchiplexy (possibly bilateral).
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