ulstermedj00081-0064 (1)
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Ulster Medical Volume 58, N o. 2 , p p . 1 7 5 - 1 76 , 1989. Torsion o f t h e testis revisited E J Mackle, D Gilroy Accepted 9 August 1989. INTRODUCTION Torsion o f t h e testis is a well known entity having been first described i n detail in 1840. T o establish i f t h e management o f torsion o f th e testis h a s changed i n recent years w e have carried out a retrospective review o f cases presenting t o three teaching hospitals a n d t w o district general hospitals i n Northern Ireland over t h three years t o 1985. METHODS Cases o f testicular torsion, presenting t o t h e Belfast City Hospital, Royal Victoria Hospital, T h e Royal Belfast Hospital for Sick Children, Daisy Hill Hospital a nd t he South Tyrone Hospital over three years t o 1985 were reviewed. A total o f 6 6 cases w as identified from theatre l o g a n d hospital activity analysis. Information w a s obtained from t h e operative notes, in-patient charts a n d routine follow-up appointments. RESULTS Torsion o f th e testis occurred i n 6 6 cases. Ages ranged from 4 t o 3 0 with a mean a g e o f 1 6 years. The time from onset o f pain t o surgery ranged from 3 weeks with 3 0 (45 % ) operated o n within 8 hours (Table). Factors responsible for a n operation after this time were late presentation i n 1 9 cases, m i s -diagnosis i n 1 5 a n d delay i n subsequent management i n two. Quality o f result w as based o n operative findings a n d testicular size at follow - u p appointment: 3 9 patients were felt t o havehad a good result a d 2 7 ( 4 1 % ) either required orchidectomy a t t h e TABLE Data o n management a n d result i n 6 6 cases o f torsion o f t h e testis, 1982- 8 . Time t o Result Category operation Number Good B a d Good management 0 - 8 h r 29 2 7 2 >8hr 1 9 8 1 1 Mis-diagnosis 0 - 8 h r 1 1 0 > 8 h r 1 5 1 1 4 Mis-management 0 - 8 h r 0 0 0 > 8 h r 2 2 0 Total 6 6 3 9 2 7 T he Ulster Medical Society, 1989. Department o f Surgery, T h e Queen's University o f Belfast, University Floor, Belfast City Hospital, Belfast BT9 7AB. E J Mackle, FRCSI, Tutor/Registrar. D Gilroy, FRCSI, Tutor/Registrar.
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Transcript of ulstermedj00081-0064 (1)
8/2/2019 ulstermedj00081-0064 (1)
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T h e U l s t e r M e d i c a l J o u m a l , V o l u m e 5 8 , N o . 2 , p p . 1 75- 1 7 6 , O c t o b e r 1 9 8 9 .
T o r s i o n o f t h e t e s t i s r e v i s i t e dE J M a c k l e , D G i l r o y
A c c e p t e d 9 A u g u s t 1 9 8 9 .
INTRODUCTION
T o r s i o n o f t h e t e s t i s i s a w e l l known e n t i t y h a v i n g b e e n f i r s t d e s c r i b e d i n d e t a i li n 1 8 4 0 . To e s t a b l i s h i f t h e management o f t o r s i o n o f t h e t e s t i s h a s c h a n g e d i nr e c e n t y e a r s w e h a v e c a r r i e d o u t a r e t r o s p e c t i v e r e v i e w o f c a s e s p r e s e n t i n g t o
t h r e e t e a c h i n g h o s p i t a l s a n d t w o d i s t r i c t g e n e r a l h o s p i t a l s i n N o r t h e r n I r e l a n d o v e r
t h e t h r e e y e a r s t o 1 9 8 5 .
METHODSC a s e s o f t e s t i c u l a r t o r s i o n , p r e s e n t i n g t o t h e B e l f a s t C i t y H o s p i t a l , R o y a l V i c t o r i a
H o s p i t a l , T h e R o y a l B e l f a s t H o s p i t a l f o r S i c k C h i l d r e n , D a i s y H i l l H o s p i t a l a n d t h eS o u t h T y r o n e H o s p i t a l o v e r t h r e e y e a r s t o 1 9 8 5 w e r e r e v i e w e d . A t o t a l o f 6 6c a s e s w a s i d e n t i f i e d f r o m t h e a t r e l o g a n d h o s p i t a l a c t i v i t y a n a l y s i s . I n f o r m a t i o n
w a s o b t a i n e d f r o m t h e o p e r a t i v e n o t e s , i n - p a t i e n t c h a r t s a n d r o u t i n e f o l l o w - u pa p p o i n t m e n t s .
RESULTS
T o r s i o n o f t h e t e s t i s o c c u r r e d i n 66 c a s e s . A g e s r a n g e d f r o m 4 t o 30 w i t h a m e a na g e o f 1 6 y e a r s . T h e t i m e f r o m o n s e t o f p a i n t o s u r g e r y r a n g e d f r o m 3 h o u r s t o 2
w e e k s w i t h 30 ( 4 5 % ) o p e r a t e d o n w i t h i n 8 h o u r s ( T a b l e ) . F a c t o r s r e s p o n s i b l e f o ra n o p e r a t i o n a f t e r t h i s t i m e w e r e l a t e p r e s e n t a t i o n i n 1 9 c a s e s , m i s - d i a g n o s i s i n
1 5 a n d d e l a y i n s u b s e q u e n t management i n t w o . Q u a l i t y o f r e s u l t w a s b a s e d o no p e r a t i v e f i n d i n g s a n d t e s t i c u l a r s i z e a t f o l l o w - u p a p p o i n t m e n t : 39 p a t i e n t s w e r ef e l t t o h a v e h a d a g o o d r e s u l t a n d 2 7 ( 4 1 % ) e i t h e r r e q u i r e d o r c h i d e c t o m y a t t h e
TABLE
D a t a on m a n a g e m e n t and r e s u l t i n 66 c a s e s o f t o r s i o n o f t h e t e s t i s , 1982- 8 . 5
T i m e t o R e s u l t
C a t e g o r y o p e r a t i o n Number Good B ad
Good management 0 - 8 h r 2 9 2 7 2
>8hr 1 9 8 1 1M i s - d i a g n o s i s 0 - 8 h r 1 1 0
> 8 h r 1 5 1 1 4
M i s - m a n a g e m e n t 0 - 8 h r 0 0 0
> 8 h r 2 2 0
T o t a l 6 6 3 9 2 7
The U l s t e r M e d i c a l S o c i e t y , 1 9 8 9 .
D e p a r t m e n t o f S u r g e r y , T h e Q u e e n ' s U n i v e r s i t y o f B e l f a s t , U n i v e r s i t y F l o o r , B e l f a s t C i t y H o s p i t a l ,B e l f a s t B T9 7AB.
E J M a c k l e , F R C S I , T u t o r / R e g i s t r a r .D G i l r o y , F R C S I , T u t o r / R e g i s t r a r .
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176 T h e U l s t e r M e d i c a l J o u r n a l
t i m e o f e x p l o ra ti o n o r s u b s e q u e n t l y d e v e l o p e d t e s t i c u l a r a t r o p h y . M i s - d i a g n o s i s
r e s u l t e d i n d e l a y i n a p p r o p r i a t e management i n 1 4 (52%) o f t h e 2 7 w i t h a b a dr e s u l t , a n d t w o o f t h e p a t i e n t s who h a d a f a v o u r a b l e o u t c o m e w e r e a l s o m i s -
d i a g n o s e d i n i t i a l l y . O n l y t w o ( 7 % ) o f t h o s e w i t h a b a d r e s u l t w e r e o p e r a t e d o nw i t h i n e i g h t h o u r s o r l e s s , c o m p a r e d w i t h 28 ( 7 2 %) o f t h o s e w i t h a g o o d r e s u l t ;a g o o d o u t c o m e w a s a l s o o b t a i n e d i n 1 1 p a t i e n t s o p e r a t e d o n a f t e r e i g h t h o u r s .
O f t h e 1 6 c a s e s who w e r e m i s - d i a g n o s e d , e p i d i d y m o - o r c h i t i s w a s o r i g i n a l l yd i a g n o s e d i n s e v e n , n o n - s p e c i f i c s c r o t a l p a i n i n t h r e e , n o n - s p e c i f i c a b d o m i n a lp a i n i n t w o , a n d a p p e n d i c i t i s , c o n s t i p a t i o n , t e s t i c u l a r s w e l l i n g a n d t o r s i o n /e p i d i d y m o - o r c h i t i s i n o n e e a c h . A b d o m i n a l o r l o i n p a i n w a s t h e p r e s e n t i n g
c o m p l a i n t i n 1 6 ( 2 4 % ) p a t i e n t s . T o r s i o n o c c u r r e d i n t h r e e c a s e s o f u n d e s c e n d e dt e s t i s w h i c h w e r e a l l d i a g n o s e d a s s t r a n g u l a t e d h e r n i a e b u t n o t c l a s s i f i e d a s
m i s - d i a g n o s i s .
DISCUSSION
T h e a n a t o m i c a l a b n o r m a l i t i e s u n d e r l y i n g t o r s i o n o f t h e t e s t i s a r e w e l l d e s c r i b e d ,
a s i s t h e f a c t t h a t e p i d i d y m o-o r c h i t i s i s r a r e i n a d o l e s c e n t m a l e s .
Wef o u n dt o r s i o n w a s i n i t i a l l y d i a g n o s e d a s e p i d i d y m o - o r c h i t i s i n 1 6 o f 66 c a s e s , l e a d i n g t o
d e l a y i n a p p r o p r i a t e management a n d c o n t r i b u t i n g t o t h e l o s s o f 1 4 t e s t i c l e s .T h e s e d a t a s h o w a l o w e r r a t e o f m i s - d i a g n o s i s t h a n t h a t r e p o r t e d b y Chapmana n d W a l t o n 1 b u t a s i m i l a r r a t e o f t e s t i c u l a r l o s s .
S u r v i v a l o f t h e g e r m i n a l e l e m e n t s i s u n l i k e l y b e y o n d s i x h o u r s o f c o m p l e t ei s c h a e m i a , a n d s u r v i v a l a f t e r t h i s t i m e i s p r o b a b l y r e l a t e d t o i n c o m p l e t e o r
i n t e r m i t t e n t v a s c u l a r o c c l u s i o n . 2 T h e c a s e f o r u r g e n t e x p l o r a t i o n o f y o u n g m a l e sw i t h a c u t e s c r o t a l p a i n , w i t h o r w i t h o u t a b n o r m a l i t y o n e x a m i n a t i o n , i s w e l le s t a b l i s h e d . 3 T h i s r e v i e w s h o w s t h a t l a c k o f a w a r e n e s s o f t h e c a u s e o f s c r o t a l p a i n
i n y o u n g m a l e s i s s t i l l a p r o b l e m , a n d u n d e r l i n e s t h e i m p o r t a n c e o f e x a m i n i n g t h e
g e n i t a l s i n a n y y o u n g m a l e w i t h a b d o m i n a l p a i n . P r o m p t e x p l o r a t i o n s h o u l d s t i l lb e u n d e r t a k e n e v e n a f t e r e i g h t h o u r s . R e c e n t l y a t t e m p t s h a v e b e e n m a d e t oi m p r o v e p r e - o p e r a t i v e d i a g n o s i s b y m e a n s o f c o m p u t e r - a i d e d d i a g n o s i s a n dr a d i o - i s o t o p e s c a n s . 4 H o w e v e r , u r g e n t h o s p i t a l r e f e r r a l a n d s u b s e q u e n t e x p l o r -a t i o n i n y o u n g m a l e s w i t h s c r o t a l p a i n s h o u l d r e m a i n a p r i o r i t y , e s p e c i a l l y i f t h e
r i s k o f s y m p a t h e t i c o r c h i d o p a t h i a i n t h e c o n t r a l a t e r a l t e s t i s w e r e s u b s t a n t i a t e d , 4a l t h o u g h r e c e n t d a t a s u g g e s t s t h a t a n a b n o r m a l i t y o f s p e r m a t o g e n e s i s p r e c e d e s
t h e e p i s o d e o f t o r s i o n . 5
I n s u m m a r y , t h i s r e v i e w i n d i c a t e s t h a t t h e i n c i d e n c e o f m i s - d i a g n o s i s i n c a s e s o ft o r s i o n r e m a i n s u n a c c e p t a b l y h i g h o c c u r r i n g i n 24 % o f c a s e s r e v i e w e d ,
c o n t r i b u t i n g t o a 4 1 % r a t e o f t e s t i c u l a r l o s s .
We a r e g r a t e f u l t o t h e c o n s u l t a n t s u r g e o n s a t t h e R o y a l B e l f a s t H o s p i t a l f o r S i c k C h i l d r e n , D a i s y H i l l
H o s p i t a l , S o u t h T y r o n e H o s p i t a l , t h e R o y a l V i c t o r i a H o s p i t a l a n d t h e B e l f a s t C i t y H o s p i t a l f o r p e r m i s s i o nt o u n d e r t a k e t h i s r e v i e w .
REFERENCES
1 . Chapman R H , W a l t o n A J . T o r s i o n o f t h e t e s t i s a n d i t s a p p e n d a g e s . B r Me d J 1 9 7 2 ; 1 : 1 6 4 - 6 .
2 . B u r t o n J A . A t r o p h y f o l l o w i n g t e s t i c u l a r t o r s i o n . B r J S u r g 1 9 7 2 ; 5 9 : 422 - 6 .
3 . C a s s A S , C a s s B P , V e e r a r a g h a v a n K . I m m e d i a t e e x p l o r a t i o n o f t h e u n i l a t e r a l a c u t e s c r o t u m i ny o u n g m a l e s u b j e c t s . J U r o l 1 9 8 0 ; 1 2 4 : 8 2 9 - 3 2 .
4 . W i l l i a m s o n R C N . The c o n t i n u i n g c o n u n d r u m o f t e s t i c u l a r t o r s i o n . B r J S u r g 1 9 8 5 ; 7 2 : 5 0 9 - 1 0 .
5 . A n d e r s o n J B , C o o p e r M J , Thomas W E G , W i l l i a m s o n R C N . I m p a i r e d s p e r m a t o g e n e s i s i n t e s t e sa t r i s k o f t o r s i o n . B r J S u r g 1 9 8 6 ; 7 3 : 8 4 7 - 9 .
© The U l s t e r M e d i c a l S o c i e t y , 1 9 8 9 .
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