Saturday, December 26, 2009

A case of Acute testicular pain


We have a 16 years old male here presented to the ER complaining of sudden onset of right testicular pain. The pain woke him up from his sleep and has persisted over the last 3 hrs. His mother says that he has vomited once. His previous medical history includes a similar event a year ago, but on that occasion the pain subsided quickly. He is an asthmatic and uses a salbutamol inhaler.

Only with h/o, what's your differential diagnosis?

Testicular torsion?
Acute epididymo-orchitis?
Torsion of appendix testis?
Infected hydrocele?
Strangulated hernia?
Testicular rupture?
Haemorrhage into a tumour?

On examination

The left hemi-scrotum feels normal but the right side is acutely swollen and tender on palpation. The testicle is elevated when compared to the other side and has an abnormal horizontal lie. The abdomen is soft, non tender, with intact hernial orifices. Vitals are stable, cremesteric reflex is absent.

So, what's your provisional diagnosis?

In this case, testicular torsion should be ruled out unless proven otherwise. Points towards diagnosis of testicular torsion :

1) Age (testicular torsion is common in age group of 10-25 yrs old)
2) Elevated, tender right testicle
3) Abnormal horizontal lie (risk factor for torsion)
4) Cremesteric reflex is absent (bear in mind that presence of this reflex doesn't rule out testicular torsion!)

If doppler's ultrasound is immediately available, a results showing interrupted blood supply to the testis is diagnostic.
However, if the diagnosis is in doubt, PLS peform surgical exploration to confirm the diagnosis. If not, he CAN SUE YOU BECOZ you've caused him to lose his precious balls.

Remember, you've only 4-6 hours (starting from the time of onset of pain) to salvage the balls.
However, if the patient presented within the first hour after onset of pain, it's sometimes possible to untwist the cord manually, which if succesful, the affected testicle is out of danger and surgery can be planned later.

And, surgical correction is bilateral, since congenital defects often involves both sides.

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