Turandot Saul, M.D.

February 20, 2008

Xoắn tinh hoàn

True urologic emergency Delayed diagnosis and testicular loss

InfertilityCosmesisMedico-legal

Testicular Anatomy - Tunica Tunica vaginalis

Posterolateral surface of testicle Limits mobility

Bell clapper deformityCongenital12% of males40% bilateral

Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice

Testicular Anatomy - Vascular Testicular artery

Branch off aortaMajor intra-testicular blood

supply

Cremaster and deferential arteryExtra-testicular

Cremaster a.

Testicular Torsion

Testicle rotates on spermatic cord

Venous occlusion, edemaArterial ischemiaInfarction 720º necessary to

compromise testicular a.Males, peak 14 years

Image: Behrman: Nelson Textbook of Pediatrics

History

Severe unilateral scrotal pain

Previous episodes, spontaneous resolution

Related to activity, trauma, during sleep

Nausea, vomiting, abdominal pain, fever

Physical Elevated testicle, tender Loss of cremaster reflex Thick, tender spermatic cord

Brunzel sign – horizontal lie Ger sign - skin pitting at the scrotal base Prehn sign – persistent pain despite elevation

Image: American Family Physician

Diagnosis

Clinical suspicion Nuclear scintigraphy

Radiation, limited availability

UltrasoundAltered echotexture (B-mode)Vascular flow (Color / Spectral / Power Doppler) Alternative diagnosisOperator dependent

Image: Ferri's Clinical Advisor 2008, 10th ed.

Ultrasound for Testicular Torsion

Sensitivity 86%, specificity 100% experienced provider using color / power doppler1

EPs capable of diagnosing with bedside ultrasound2

1Burks et al. Suspected testicular torsion & ischemia: Eval w color doppler. Radiology 1990;175:815-212Blaivas et al. Ultrasonographic diagnosis of testicular torsion by EM physicians. AM J Emerg Med 2000;18:198-200

Logistics Linear Array (7-10 MHz) Scan asymptomatic side first

Positioning Frog leg positionDrape for support and elevationGenerous amount of warm gel

Ultrasound – B-Mode Compare echotexture

(straddle view)

Visualize each testicle in two planes

Ultrasound – B-Mode Normal: homogenous symmetric

Early ischemia: enlargement, no Δ echogenicity

Hemorrhage: hyperechoic areas in an

infarcted testis, heterogenous

• Late ischemia/infarct: hypoechoic

Ultrasound: Color Doppler

NormalIntratesticular artery

TorsionArterial flow absentNormal / increased

in detorsion

Ultrasound: Color Doppler

Early TorsionNo flow, echogenicity similar

Late TorsionHeterogenous echotextureIncreased extra testicular

blood flow

Ultrasound: Spectral Doppler

Arterial waveform Venous waveform

Ultrasound: Spectral Doppler

Extratesticular blood flow- High resistance, low flow

Intratesticular blood flow- Low resistance, high flow

Ultrasound – Power Doppler Power doppler

Increased sensitivity in low flow statesMeasures power of doppler signalPrepubertal patient

Ultrasound: other diagnosis Epididymitis Scrotal abscess Torsion of epididymal appendage Intratesticular hematoma

Pitfalls

False negatives: post-torsion hyperemia, capsular blood flow, power doppler motion artifact

False positives: small testicular volumes

Either: inappropriate gain settings

Atypical presentations mimic epididymitis, appendicitis, renal colic

Treatment

Definitive treatment: surgical detorsion and orchioplexy

Manual detorsion: medial to lateral; “opening a book”May need to rotate 2-3 times for

complete detorsion

Roberts: Clinical Procedures in Emergency Medicine

Testicular Viability

Salvage rate100% detorsed at 3 hours85% at 5 hours75% at 8 hours60% at 10 hours10-20% > 10 hours0% > 24 hours

1Pratter JM et al. Testicular torsion: a surgical emergency. Am Fam Physician 1991;44:834-840

Summary Use saddle view to compare bilaterally B-mode to compare echogenicity Color / Spectral / Power Doppler for flow Image normal side first to set gain settings

Consider clinical picture

References Burks et al. Suspected testicular torsion & ischemia: Eval w color doppler.

Radiology 1990;175:815-21 Pratter JM et al. Testicular torsion: a surgical emergency. Am Fam

Physician 1991;44:834-840 Ferri: Ferri's Clinical Advisor 2008, 10th ed. Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed. Roberts: Clinical Procedures in Emergency Medicine, 4th ed.Dogra, VS etal.

Sonographic Evaluation of Testicular Torsion. Ultrasound Clinics; 2006. Blaivas et al. Ultrasonographic diagnosis of testicular torsion by EM

physicians. AM J Emerg Med 2000;18:198-20 Ringdahl, E et al. Testicular Torsion. American Family Physician

2006;74(10)