Diagnosis and treatment of the acute scrotum

Testicular torsion must be considered in any patient who complains of acute scrotal pain and swelling. Torsion of the testis is a surgical emergency because the likelihood of testicular salvage decreases as the duration of torsion increases. Conditions that may mimic testicular torsion, such as torsion of a testicular appendage, epididymitis, trauma, hernia, hydrocele, varicocele and Sch?nlein-Henoch purpura, generally do not require immediate surgical intervention. The cause of an acute scrotum can usually be established based on a careful history, a thorough physical examination and appropriate diagnostic tests. The onset, character and severity of symptoms must be determined. The physical examination should include inspection and palpation of the abdomen, testis, epididymis, scrotum and inguinal region. Urinalysis should always be performed, but scrotal imaging is necessary only when the diagnosis remains unclear. Once the correct diagnosis is established, treatment is usually straightforward.     

Consideration of Testicular Torsion in Young Males With Abdominal Pain Is Essential: A Case Review

Testicular torsion is a surgical emergency and requires prompt recognition and treatment. Health care personnel often forget this differential diagnosis in males who present with abdominal pain as their only complaint. There is a 4- to 6-hour window from the onset of symptoms to the surgical intervention to salvage the testes. It is imperative for health care personnel to consider testicular torsion in any male presenting with abdominal pain and to complete a genitourinary examination. The purpose of this case review is to highlight the importance of a genitourinary examination in recognizing testicular torsion.     

Blunt scrotal trauma: emergency department evaluation and management

Blunt scrotal trauma may result in a variety of injuries, including testicular rupture, torsion, dislocation, hematoma, or contusion, as well as epididymal, scrotal, and urethral injuries. Testicular rupture occurs in 50% of patients with traumatic hematocele, and is probably frequently misdiagnosed. If not aggressively diagnosed and surgically repaired, testicular rupture may lead to testicular atrophy and loss. Traumatic testicular torsion must also be diagnosed early to preclude testicular loss. Testicular scan, when rapidly available, is indicated in any case of suspected traumatic torsion. If testicular scanning is unavailable or equivocal, surgical exploration is indicated. Once torsion is ruled out, ultrasound is a useful diagnostic technique in acute scrotal trauma to differentiate those scrotal and testicular injuries requiring surgical intervention.     

Torsion of the gallbladder

Herein we report two cases of acute torsion of the gallbladder, including an extremely rare instance of torsion of the fundus of the organ. Because symptoms of torsion of the gallbladder are similar to those of other diseases and because of its rarity, preoperative diagnosis is difficult. The cause of this disorder had not been determined. Torsion of the gallbladder may occur as an acute event or be subtle and recurrent. Because of the potentially catastrophic consequences of delayed surgical intervention, an abdominal operation should be performed early in patients with symptoms suggestive of acute cholecystitis, especially if a mass is palpable. The recommended treatment is cholecystectomy.     

Acute torsion of uterine leiomyoma: CT features

Acute torsion of a subserosal leiomyoma is a rare acute condition that is infrequently diagnosed preoperatively. It is a recognized surgical emergency, especially when additional systemic symptoms are associated. There are two main differential diagnoses: ovary/adnexal torsion and massive infarct inside a common leiomyoma. The diagnosis can be established by computed tomographic features. Ultrasound examination is less sensitive.     

Acute torsion of uterine leiomyoma: CT features

Acute torsion of a subserosal leiomyoma is a rare acute condition that is infrequently diagnosed preoperatively. It is a recognized surgical emergency, especially when additional systemic symptoms are associated. There are two main differential diagnoses: ovary/adnexal torsion and massive infarct inside a common leiomyoma. The diagnosis can be established by computed tomographic features. Ultrasound examination is less sensitive.     

Prospective Validation of Clinical Score for Males Presenting With an Acute Scrotum

Objective

The objective was to validate the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score among pediatric emergency medicine providers for the evaluation of pediatric males presenting with testicular pain and swelling (acute scrotum).

Methods

We conducted a prospective cohort study of males 3 months to 18 years old presenting with an acute scrotum. History and physical examination findings, including components of the TWIST score (hard testicle, absent cremasteric reflex, nausea/vomiting, and high riding testicle) as well as diagnostic results (ultrasound, urine, sexually transmitted infection testing) were recorded. Testicular torsion was confirmed by surgical exploration. Frequencies of patient characteristics, TWIST components, and tests were calculated. We performed the kappa statistic for inter‐rater reliability and calculated the test characteristics and receiver operator characteristics curves for the TWIST score (range = 0–7).

Results

During the study period 258 males were enrolled in the study; 19 (7.4%) had testicular torsion. The mean (±SD) age was 9.8 (±0.3) years. The high‐risk TWIST score of 7 had 100% specificity (95% confidence interval [CI] = 98%–100%) with 100% positive predictive value (95% CI = 40%–100%) for testicular torsion. The area under the curve was 0.82. The kappa statistic for the overall TWIST score was fair at 0.39.

Conclusions

In this prospective validation of the TWIST score among pediatric emergency providers, the high‐risk score demonstrated strong test characteristics for testicular torsion. The TWIST score could be used as part of a standardized approach for evaluation of the pediatric acute scrotum to provide more efficient and effective care.

     

TORSION OF A MALIGNANT UNDESCENDED TESTIS MIMICKING APPENDICITIS

Testicular maldescent is known to be associated with later development of malignancy.¹ The maldescended testis is prone to other complications — in particular, torsion.¹ We report an unusual coincidence of both malignancy and torsion of an intra-abdominal testis which closely simulated a ruptured appendix abscess. This case demonstrates that an intra-abdominal testis can develop acute life-threatening complications which should be considered in any patient with acute abdominal symptoms who has an ‘absent’ testis.     

The acute scrotum

In boys and adolescents, the acute scrotum usually results from one of three diseases: torsion of the spermatic cord, torsion of the appendix testis, or epididymitis. A rapid diagnosis of torsion of the cord, if present, is essential, and as soon as this diagnosis is made, arrangements must be made for timely surgical correction. Although a diagnosis for the acute scrotum in this age group can sometimes be made on the basis of the history, pathognomonic signs, and basic laboratory analysis of the urine and a urethral discharge, in the usual case diagnosis requires a Doppler ultrasound examination (which if positive for torsion makes the diagnosis), a radionuclide scan (for cases negative or indeterminate for torsion on the Doppler examination), or, as a last resort, scrotal exploration. In men, by far the most common cause of the acute scrotum is epididymitis, with the torsions being much less common. In heterosexual young men with epididymitis, N. gonorrhoeae and C. trachomatis are the most likely etiologic organisms; in homosexual men and older men (and boys), E. coli, Pseudomonas sp., and the gram-positive cocci are the most common pathogens. Ceftriaxone plus tetracycline is the initial antimicrobial regimen of choice in heterosexual young men; in the absence of evidence of a sexually transmitted pathogen, one of the antimicrobials effective against common urinary tract pathogens is the initial antimicrobial of choice in all other patients. When torsion of the cord is suspected in adult male patients, the Doppler examination and the radionuclide scan (if the Doppler is negative or indeterminate) can again make the diagnosis or rule it out.     

Ovarian torsion in a premenarcheal girl: MRI findings

Adnexal torsion is an uncommon cause of severe lower abdominal pain in women and is often difficult to distinguish from other acute abdominal conditions. However, adnexal torsion should be considered in premenarcheal girls admitted with acute abdominal pain and evidence of an ovarian mass. Accurate and early radiological diagnosis is mandatory immediately after onset of clinical symptoms in order to preserve the viability of the ovary. Ultrasound (US) is usually the first line examination performed in an emergency setting, but computed tomography (CT) and magnetic resonance imaging (MRI) can be useful in case of ambiguous US findings, especially in patients with sub-acute symptoms and a suspected adnexal mass. This case report describes the additional value of MRI in a premenarcheal girl with sub-acute right fossa pain.     

妇科急腹症超声声像图表现及分析

目的分析各种妇科急腹症的超声声像图特点及误诊原因,探讨超声诊断及鉴别诊断价值。方法对196例妇产科急腹症患者进行回顾性研究,分析超声声像特点,将超声诊断与手术病理结果对比,并分析误诊原因。结果196例患者中宫外孕124例,卵巢黄体破裂32例,卵巢囊肿蒂扭转15例,急性盆腔炎25例,超声诊断符合率92.3%(189/196)。误诊原因为停经史不详,症状、声像图及实验室检查不典型所致。结论超声对妇产科急腹症有很高的诊断价值。但因声像图有许多相似之处,须结合病史、症状、体征和实验室检查。     

睾丸扭转诊疗分析（附38例报告）

目的：总结睾丸扭转的诊疗经验。方法分析2002年～2012年收治的38例睾丸扭转患者的临床资料,所有患者均行超声检查,超声检查提示睾丸、附睾位置改变,睾丸内血流减少或消失。结果36例患者接受手术治疗,其中12例睾丸扭转时间＜6 h患者经手术复位后保留睾丸,2例术后随访发现睾丸较健侧睾丸体积减小。24例扭转时间＞6 h患者中,16例术中发现睾丸坏死行睾丸切除术;复位后睾丸存活5例,睾丸萎缩3例。结论睾丸扭转早期常易误诊,超声检查为首选的辅助检查手段;及早明确诊断、手术探查是避免睾丸坏死、萎缩的关键。     

The Clinical Utility of Serologic Markers in the Evaluation of the Acute Scrotum

OBJECTIVE: To examine the presence of interleukin-1 (IL-1), interleukin-6 (IL-6), and creatine phosphokinase-MM (CPK-MM) in patients with acute scrotal pain and assess their clinical utility in the diagnosis of testicular torsion (TT) and epididymitis. METHODS: Twenty-five patients with acute scrotal pain were prospectively enrolled over a two-year period. History, physical examination, complete blood count, urinalysis, and scrotal ultrasound were performed. Testicular torsion was confirmed by surgical exploration. Epididymitis was diagnosed using physical examination, scrotal ultrasound, and positive urinalysis. Venous blood was assayed for IL-1, IL-6, and CPK-MM in triplicate during the routine drawing of blood in the emergency department. The data are reported as medians +/- interquartile ranges (IQRs). RESULTS: Twenty-five patients with acute scrotal pain were evaluated; 11 with TT, three with torsion of the appendix testis (TAT), ten with epididymitis, and one with varicocele. One patient had both TT and epididymitis. Interleukin-1 was not detectable in either group. The CPK-MM values between TT and epididymitis were virtually identical at 99.8 and 100 IU/L, respectively. The median value for IL-6 was 1. 03 (IQR = 0.19 to 2.86) vs 20.86 (IQR = 2.14 to 65.50) pg/mL in the torsion and epididymitis groups, respectively. The 97.5% CI for the difference of medians of 19.9 was 0.4 to 65.1, p = 0.02. Using receiver operating characteristic (ROC) curve analysis for IL-6, the area under the curve was 0.82 for torsion and 0.67 for epididymitis. Using a cutoff value of IL-6 >/= 1.41 pg/mL, the positive predictive value of IL-6 in diagnosing epididymitis was 78.6%, with a negative predictive value of 100% for TT. There were no cases of missed TT on follow-up. CONCLUSIONS: This preliminary investigation of serologic markers demonstrates that IL-6 is significantly elevated in epididymitis as compared with TT. Creatine phosphokinase-MM and IL-1 were not found to be of diagnostic utility. The small sample size of this study precludes a definitive conclusion as to the utility of these markers in the emergency department. However, IL-6 may be clinically useful as an additional element in differentiating the causes of acute scrotal pain, and further study is warranted.     

Duration of symptoms is the only predictor of testicular salvage following testicular torsion in children: A case-control study

ObjectiveTesticular torsion (TT) is an emergency requiring a prompt diagnosis and surgery to avoid irreversible changes and a complete loss of testis. The present study aimed to identify potential factors that may be predict a testicular salvage after TT in pediatric patients.MethodsConsecutive medical records of all children ≤16 years old with surgically confirmed TT over a period of five years (2011–2016) were collected. Patients were divided into 2 groups according to testicular viability and the type of treatment: Orchidectomy and orchidopexy. The differences between the two groups and potential predictors of testicular salvage were analyzed.ResultsThirty-one boys with TT met the inclusion criteria and were included in the study. The mean age was 13.6 years (range, 10 days - 15.8 years). Testicular salvage was possible in 18 (58.1%) patients. The duration of symptoms and a lesser degree of torsion indicated a testicular salvage in children and adolescents with testicular torsion, but in multivariate analysis only duration of symptoms (time to surgical detorsion) was significantly associated with the risk of non-salvage. At follow-up, testicular atrophy affected 73.3% of the patients treated with orchidopexy.ConclusionDuration of symptoms is the only predictor of successful testicular salvage following testicular torsion in children. It is associated with a substantial risk of testicular loss and atrophy.     

Testicular torsion: a twist to the tale

Testicular torsion is a surgical emergency that requires prompt exploration if testicular viability is to be maintained. Although rare, it is essential to be aware that it may occur despite previous fixation (orchidopexy). Testicular torsion occurring after previous orchidopexy is rare, but recognition of this possibility is essential to prevent testicular infarction and subsequent orchidectomy. During scrotal exploration a wide variety of methods for orchidopexy exist. We present a case of testicular torsion despite previous fixation and discuss the merits of various techniques available for orchidopexy.     

Torsion of the spermatic cord: the main gray-scale and doppler sonographic signs

Scrotal ultrasonography (US) is usually the initial imaging modality for evaluating patients who present with acute pathologic conditions of the scrotum. Acute epididymitis, acute epididymo-orchitis, torsion of the spermatic cord (TSC), and other acute scrotal abnormalities may have similar findings at clinical examination. Pain and swelling make the clinical examination difficult, sometimes practically impossible, potentially resulting in management delays. The objective of this review is to summarize the main clinical signs of the TSC and to illustrate and briefly discuss the US features of this entity, including gray-scale imaging, color Doppler with spectral analysis, and power Doppler sonography. Although TSC can occur at any age, it is most common in adolescent boys. The intensity of the symptoms and the US findings vary with the duration of the torsion, number of twists in the spermatic cord (degree of rotation), and how tightly the vessels of the cord are compressed. An enlarged, more spherical, and diffusely hypoechogenic testis without detectable arterial and venous testicular flow at color and power Doppler US is considered diagnostic of acute testicular ischemia. The presence of a color or power Doppler signal in one part of the testis does not exclude TSC. Positive blood flow but significantly diminished, usually near or inside the mediastinum, may be found, mainly in the partial or incomplete TSC. Identification of a large echogenic extratesticular mass distal to the site of the torsion, frequently misinterpreted as a chronic epididymitis, can be the key to the diagnosis of TSC. When a small arterial sign is found a low amplitude waveform is present with an increased resistive index on the affected side due to a diminished, absent, or reversed diastolic flow. Gray-scale imaging, color Doppler, power Doppler and pulsed Doppler with spectral analysis are very effective to make or exclude the diagnosis of TSC.     

Gastric volvulus. More common than previously thought?

Gastric volvulus is torsion of the stomach, which can compromise the gastric orifices and result in either acute or chronic and intermittent symptoms. We believe that gastric volvulus, especially when partial or intermittent, may be more common than has been previously thought. The condition should be suspected in any patient who has a history of retching or vomiting and has a paraesophageal hiatus hernia or eventration of the diaphragm. The classic triad of retching, severe and constant epigastric pain, and difficulty in passing a nasogastric tube should suggest the presence of acute gastric volvulus. The diagnosis is confirmed by specific findings on the upper gastrointestinal series. Acute gastric volvulus is a surgical emergency. Definitive treatment of recurrent chronic gastric volvulus is usually surgical, although conservative measures may have limited success.     

睾丸扭转的诊断与治疗

目的：提高睾丸扭转的诊治水平。方法：回顾睾丸扭转20例,并结合文献对其发病机理、病理、诊断和治疗进行讨论。结果：早期误诊12例,经CDFI检查后,全部行睾丸切除术,1例术中证实非睾丸扭转。结论：睾丸扭转是青少年阴囊急症的常见病。早期手术探查对提高睾丸存活率有重大意义。     

Intermittent torsion of a normal ovary in a child associated with use of a trampoline

Background

Ovarian torsion is rare in children. It usually occurs in the presence of ovarian or pelvic pathology. The course of symptoms is typically hours to days. Some authors have speculated that sudden acceleration/deceleration movements may precipitate torsion.

Objectives

The objective of this report is to describe a case of intermittent abdominal pain lasting nearly 6 months, which started when the child began playing regularly on a trampoline, and was ultimately diagnosed as intermittent ovarian torsion of an otherwise normal ovary.

Case Report

A 12-year-old girl presented to the Emergency Department (ED) with 2 h of abdominal pain and vomiting. She reported similar episodes over the previous 6 months. Initial ultrasound, obtained between episodes, was normal. Repeat ultrasound at ED presentation showed no blood flow to the left adnexa. Surgery confirmed the ovary to be twisted 1080 degrees and markedly edematous due to vascular engorgement. The family retrospectively identified the onset of the first episode as happening the same week the child had begun playing regularly on a trampoline. After surgery, she no longer played on the trampoline. At follow-up 22 months later, she had had no recurrence of her symptoms.

Conclusion

Intermittent ovarian torsion should be considered as a rare cause of recurrent abdominal pain in children. The presence of blood flow with Doppler ultrasound during acute symptoms does not exclude the diagnosis. Clinicians might also ask about unusual physical activities because several authors have theorized that ovarian torsion could be precipitated by sudden acceleration/deceleration movements.