Clinical CT - June 2016

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.
http://www.ncbi.nlm.nih.gov/pubmed/22386422
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.
http://emedicine.medscape.com/article/778086-overview#a2
What is the patient’s disposition?
Urology for emergency orchiplexy (possibly bilateral).