EMERGENCY CASE CONFERENCE
Testicular Torsion Anthony Thomas, MD Judith E. Tintinallh M D - editor Detroit, Michigan
INTRODUCTION
Judith E. Tintinalli, MD. The case for discussion today is that of a 38year-old man with testicular pain. The guest speaker is Anthony Thomas, MD, assistant professor of urology at Wayne State University. CASE REPORT The patient presented to the emergency department complaining of intermittent right testicular pain for three weeks. On physical examination, the vital signs were normal. The right testicle was tender, but not swollen, and had a horizontal lie. The results of urinalysis were within normal limits. The diagnosis of epididymitis, rule out testicular torsion, was considered. The urologic consultant's diagnosis was intermittent testicular torsion. At surgery that evening, the testicle was not torsed and it appeared grossly normal. Bilateral orchiopexies were performed. The patient's hospital course was uneventful and he was discharged three days later. Anthony Thomas, MD. In the differential diagnosis of acute scrotal or testicular pain, this chief complaint can be associated with a number of diagnoses. It could mean an incarcerated inguinal hernia, or acute appendicitis. Testicular pain may develop secondary to urethral obstruction from calculi. The most common local disorders causing acute scrotal or testicular pain are testicular torsion and epididymitis, but testicular tumor and urinary phlegmon should also be considered. Physical Examination Every patient with acute abdominal pain, acute scrotal pain or swelling, should have a careful abdominal and genital examination. Palpate the abdomen and check the inguinal rings for evidence of hernim Examine the testes bimanually and palpate carefully and gently. The normal size of the testis is between 4 and 6 cm in length, 21/2 and 3 cm wide, and 3 cm deep. The epididymis and vas deferens should be readily felt. In examining the penis, palpate the entire shaft and check for urethral discharge and skin lesions, making sure to retract the foreskin so the glans can be seen. The testicles do not lie at the same level. The left usually is a little lower than the right. This is important in the differential diagnosis of the acute scrotum, because with torsion, as the testicle twists on the spermatic cord, it rides up and usually rests higher than normal. If, in a patient with left testicular pain, the left testicle is higher than the right, this is suspicious of a torsion. Determine if the testes are aligned vertically, which is normal, or horizontally, which is abnormal and more prone to terse. During examination to detect a horizontal lie, the patient has to be standing upright. The ~lignment can be detected by both observation and palpation. If the testes are aligned horizontally, the epididymis is superior and posterior. From the Departments of Urology and Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan. Address for reprints: Judith E. Tintinalli, MD, Detroit General Hospital, 1326 St. Antoine, Detroit, Michigan 48226. 8:1 (Ja~tl"ary) 1979
JACEP
28/49
causes c r e m a s t e r i c muscle contraction, p u l l i n g up the a b n o r m a l testes and f a c i l i t a t i n g torsion, is specula. t i v e . H o w e v e r , t o r s i o n d o e s n o t s e e m to be ira. m e d i a t e l y r e l a t e d to direct t r a u m a . The d e v e l o p m e n t a l v a r i a t i o n s t h a t predispose to torsion a r e the b e l l c l a p p e r testis, produced by high in. v e s t m e n t of t h e testicle, e p i d i d y m i s , and spermatic cord by the t u n i c a vaginalis; a n d a n a b n o r m a l rela. tionship b e t w e e n the t e s t i s a n d epididymis,~often due to a n a b n o r m a l i t y of t h e mesorchium. 1 R e m e m b e r that both testes a r e a n o m a l o u s so b o t h a r e prone to torsion. Torsion of testicle was f i r s t described in 1840,2 b u t u n t i l a b o u t 1935, only a b o u t 300 cases were reported in the l i t e r a t u r e . 3 Since then, it has become a well recognized entity. The m a j o r i t y of torsions occur in two periods, first, from the n e w b o r n period to 1 y e a r of age, a n d some m a y occur in undescended testes. A second p e a k incidence occurs a r o u n d puberty.8, 4 To m y knowledge, the oldest recorded p a t i e n t w i t h torsion of the testicle is 78, 3 so it is not j u s t a disease of y o u n g men. To elimin a t e the diagnosis of torsion a n d s a y t h a t our patient h a d e p i d i d y m i t i s on the basis of his age alone would be incorrect. T h i r t y - e i g h t - y e a r - o l d m e n can develop torsion a n d t h e presence of h o r i z o n t a l l y l y i n g testes should s t r o n g l y suggest t h e diagnosis in such a pat i e n t w i t h acute t e s t i c u l a r pain. M a n y people with torsion end up w i t h a d e a d t e s t i s because t h e y do not seek medical a t t e n t i o n in t i m e or because t h e i r condition is misdiagnosed as epididymitis. According to one study, 5 i f s u r g e r y is performed w i t h i n the first four to six hours, a b o u t 85% of the testicles are salvageable. W i t h i n t h e first t e n hours, a b o u t 60% are salvageable; after ten hours, only 20% are s a l v a g e a b l e , and after 24 hours, p r a c t i c a l l y none a r e salvageable. S u d d e n a n d intense t e s t i c u l a r p a i n is the commonest p r e s e n t i n g s y m p t o m of torsion. Lower abdom- , i n a l pain, especially in children,I, 4 or even lower back p a i n , m a y be t h e i n i t i a l m a n i f e s t a t i o n . A n o r e x i a ,
A varicocele m a y be e v i d e n t when t h e p a t i e n t is s t a n d i n g up. If the varicocele does not d r a i n when the p a t i e n t lies down, this suggests the presence of occlusion of the r e n a l vein or vena cava, m o s t often by tumor. A t e s t i c u l a r m a s s detected on e x a m i n a t i o n t h a t t r a n s i l l u m i n a t e s l i g h t is c h a r a c t e r i s t i c of a hydrocoele. In most cases, the failure to detect t r a n s i l l u m i n a t i o n with a hydrocoele is due to the fact t h a t it was a t t e m p t e d in a room t h a t was not d a r k enough. Broom closets a r e e x c e l l e n t for this purpose. The presence of t e s t i c u l a r t e n d e r n e s s and e d e m a m a y m a k e clinical e v a l u a t i o n very difficult. One incorrect s t a t e m e n t you m a y r e a d is t h a t if you lift t h e testicle up a n d it relieves the pain, t h e diagnosis is epididymitis, a n d if it does not relieve the pain, it is torsion. This m a n e u v e r is t o t a l l y u n r e l i a b l e in t e r m s of differential diagnosis.
TESTICULAR TORSION The p a t i e n t discussed today had a h i s t o r y of int e r m i t t e n t t e s t i c u l a r p a i n for about t h r e e weeks. A t the t i m e of surgery, he did not have a torsion. He h a d i n t e r m i t t e n t t o r s i o n , t h a t is, t h e s p e r m a t i c c o r d t w i s t e d a n d s p o n t a n e o u s l y unwound. A b o u t 30% of men wit h t e s t i c u l a r torsion give a h i s t o r y of r e p e a t e d episodes of t e s t i c u l a r p a i n t h a t resolve spontaneously. ~ Also, some i n d i v i d u a l s h a v e a prior history of strenuous a c t i v i t y j u s t before torsion develops. 2 W h e t h e r t h i s
F i g . 1. The scrotum is edematous and the left testicle is high in the scrotum (top). These findings are suggestive of torsion. Operative findings in a case of torsion of the left testicle (bottom). The involved testicle is cyanotic and there is evidence of marked venous thrombosis. This patient had a left orchiectomy and an orchiopexy on the right.
F i g . 2. 99m Technetium testicular scan illustrating lack of perfusion of the left testicle.
5o/29
JACEP
8:1 (January) 1979
nausea, and vomiting may also occur. The temperature may be normal or slightly elevated. Scrotal edema and erythema, and testicular tenderness are nearly invariably present. Thus, there should be a high clinical suspicion of torsion in anyone with painful scrotal swelling, especially if the testicle is high in the scrotum, or if there is a horizontal lie (Figure 1), and especially in the absence of urethritis and with a negative urinalysis. The ultrasonic stethoscope, or Doppler, can aid in the diagnosis.6, 7 The absence of blood flow is compatible with torsion (Figure 2). However, false positive or false negative results may be obtained if the sensitivity is incorrect. The Doppler is only as effective as the skill of the individual performing the test. Another aid to diagnosis is the testicular scan. 8 The torsed testicle will exhibit decreased activity, since its blood supply has been interrupted. A tumor with central necrosis, or a testicular abscess, can also give this appearance on scan. 8 However, the clinical history may differentiate between them. In epididymo, orchitis, the testicular scan shows increased activity in the affected testicle when compared to the opposite side.
most common cause of testicular pain and swelling seen in a city-county hospital and is often associated with gonococcal urethritis. The history is germrally that of gradually increasing testicular pain over a number of days, with urethral discharge that may be profuse. Fever is often present. On physical examination, the epididymis is enlarged and tender. If inflammation is marked, it is often difficult to define the testis from the epididymis. One important piece of information in making the diagnosis is obtaining a two-cup urine specimen. The first 10 cc of urine should be compared with a midstream collection. If the patient has urethritis, the first 10 cc of urine will generally have polymorphonuclear neutrophil leukocytes on microscopic examination. The midstream specimen may be clear because the urethra has been flushed out, and the bladder urine is not infected. If the first urine specimen is normal, I would strongly question the diagnosis of epididymitis although it is not definitely ruled out. Epididymitis is generally treated with 4.8 million units procaine penicillin intramuscularly and 1 gm probenecide orally, or tetracycline 1.5 gm orally t h e n f 0 0 mg orally four times a day for ten days if the patient is allergic to penicillin. Hospitalization is necessary if the patient is febrile and toxic. If the patient can be treated as an outpatient, a scrotal s u p port, ice pack and analgesics provide symptomatic relief. It is sometimes difficult to make the diagnosis of epididymitis and eliminate the possibility of torsion with certainty. I h a v e seen torsion along with urinary tract infection. In such a case, use of the Doppler or scan may be helpful. If there is any question in the physician's mind t h a t torsion might be present, surgery would seem indicated.
Torsion of the Testicular Appendages
Torsion of the testis should be differentiated from torsion of the testicular appendages, which include the appendix testis and appendix epididymis, t h e paradidymis, and the vas aberrans. 9 Torsion of the appendix testis is most cOmmon2 It occurs primarily around the age of puberty, but can also occur in adults and infants. The patient will often feel the pain localized to the upper pole of the testis. When examining the patient with good lighting, the light will reflect off the swoU.en appendix testis and will create a little blue dot in the skin - - the "blue dot" sign. Since the descent of the testes is normal, on palpation there is a vertical lie of the testis. All males have an appendix testis, and thus are all prone to torsion of the appendix. Torsion of the testicular appendages is generally b e n i g n and self-limited, with r e s o l u t i o n of symptoms in about a week or so. -9 It is generally preoperatively misdiagnosed as testicular torsion or epididymitis. 9 Q U E S T I O N : Would you advise an emergency physician to t r y and detorse a testicle in the emergency department? Dr. T h o m a s : Only in a situation where a surgeon or urologist were unavailable. The only time I personally would a t t e m p t to detorse a testicle in t h e emergency department is if the operating suites were unavailable for a number of hours because more critical cases were given priority. After producing local anesthesia, I would try twisting the testis outward, since most torsions twist inward. However, in most cases, local edema is so severe that it is impossible to detorse the testicle outside the operating suite. QUESTION: How do you manage the patient in whom intermittent torsion is suspected? Dr. T h o m a s : The urologist should be called if intermittent torsion is suspected. This is an indication for orchiopexy. The patient should not be discharged without proper knowledge of his condition and the consequences should he elect not to undergo surgery.
TESTICULAR TUMOR Torsion can sometimes be confused with testicular tumor, and the converse. I had a patient, sucessfully treated for torsion, who developed a rapidly growing testicular mass soon afterwards. It became apparent that the torsion caused necrosis and hemorrhage into a microscopic focus of tumor, although this situation is :rare. On occasion, a torsed testicle of several days du:ration will appear swollen, rock hard, and nontender, ;and will resemble a tumor. The initial signs and symptoms of testicular tumor may be swelling and a sensation of heaviness. Pain may develop secondary to a rapid increase in size, or because of hemorrhage into the tumor. Local trauma may simply direct the patient's attention to the area. On examination, a testicular mass may be observed or palpated. Or the testes may appear symmetric, but if one is a little heavier, it should raise the suspicion of a tumor. Testicular tumors are not as common as prostatic or bladder carcinoma. Of all patients with malignant disease, about 2% are testicular tumors. The tragedy is that they arise in young men during the reproductive years. Recently, we have been trying to teach our male patients to examine themselves monthly, just as women are taught to examine their breasts. Fortunately, today we can cure the majority of these patients if they are seen early in the course of the disease. Therefore, it is important to consider the diagnosis when confronted with testicular pain and swelling. An error in diagnosis, or the failure to obtain
EPIDIDYMITIS In my experience, epididymitis is probably the
I]:1 (January) 1979
JACEP
30/51
urologic consultation, may mean that the next time~ the patient is seen, metastases have developed and cure is impossible. The urologist should make a preoperative diagnosis of tumor, since tumors have to be approached through an inguinal incision, whereas torsion is approached through a scrotal incision.I, l°,n The testicle is drained via the iliac nodes, not the inguinal nodes, as with the scrotum. So, if a scrotal incision is used for a tumor, the scrotum is contaminated, and the potential now exists for dissemination of tumor through the inguinal and retmperitoneal nodes.
Consequently, I have the patient standing only w h e n checking for a varicocele. If the patient is very anxious, the testes m a y be d r a w n up to the perineum, m a k i n g the examination more difficult. If that happens, a w a r m cloth over the scrotum for five minutes will relax the testes.
REFERENCES 1. Parker RN, Robison JR: Anatomy and diagnosis of torsion of the testicle,J Urol 106:243-247, 1971. 2. Delasiauve: Rev. Med. Frac et Estrang, Paris, p. 363, 1640, in Ewert EE, Hoffman HA. J Urol 51:551, 1944. 3. Skoglund RN, McRoberts JN, Ragde H: Torsion of the spermatic cord: A review of the literature and an analysis of 70 new cases. J Urol 104:604-607, 1970. 4. Moharik NH, Krahn HP: Acute scrotum in children with emphasis on torsion of the spermatic cord. J Urol 104:601603, 1970. 5. Allan WR, Brown RB: Br M e d J 1:1396, 1966. 6. Levy BJ: The diagnosis of torsion of the testicleusing the Doppler ultrasonic stethoscope. J Urol 113,'63, 1975. 7. Pedersen JF, Holm HH, Hald T: Torsion of the testis diagnosed by ultrasound. J Urol 113:66-68, 1975. 8. Hahn LC, Nadel NS, Gitter M H , et ah Testicular scanning. A new modality for one preoperative diagnosis of testicular torsion. J Urol 113:60-62, 1975. 9. Skoglund RN, McRoberts JW, Ragde H: Torsion oftesticufar appendages. Presentation of 43 new cases and a collective review. J Urol 104:598-601, 1970. 10. Staulsity WJ, Early KS, Magoss IV, et ah Surgical management of testis tumor. J Urol 111:205-208, 1974. 11. Skinner DG, Leadbetter WF: The surgical management of testis tumors. J Urol 106:84-88, 1971.
URINARY PHLEGMON
A urinary phlegmon is an extravasation of urine outside the urethra, usually due to urethral stricture from old gonococcal disease. The scrotum is acutely inflamed, edematous, tender, and may be necrotic; and the testicles are generally unaffected. The scrotum is infected with purulent, gas-producing organisms. Unless antibiotic therapy is promptly initiated, and debridement performed within 24 hours, the mortality rate is extremely high. Q U E S T I O N : Are there any helpful hints that you can recommend for examining the patient with testicular pain? It can be extremely difficult to examine patients who are very sensitive. Dr, T h o m a s : The best thing to do is to have the patient lie down so he will relax. With children, use a well-lighted room and look at the scrotum from different angles. Often you can detect swelling just with observation. I have had a number of patients who became light-headed or fainted when they were examined standing up. I had one child with testicular torsion who had a generalized seizure when I examined him.
52/31
JACEP
8:1 (January) 1979
Testicular Torsion Anthony Thomas, MD Judith E. Tintinallh M D - editor Detroit, Michigan
INTRODUCTION
Judith E. Tintinalli, MD. The case for discussion today is that of a 38year-old man with testicular pain. The guest speaker is Anthony Thomas, MD, assistant professor of urology at Wayne State University. CASE REPORT The patient presented to the emergency department complaining of intermittent right testicular pain for three weeks. On physical examination, the vital signs were normal. The right testicle was tender, but not swollen, and had a horizontal lie. The results of urinalysis were within normal limits. The diagnosis of epididymitis, rule out testicular torsion, was considered. The urologic consultant's diagnosis was intermittent testicular torsion. At surgery that evening, the testicle was not torsed and it appeared grossly normal. Bilateral orchiopexies were performed. The patient's hospital course was uneventful and he was discharged three days later. Anthony Thomas, MD. In the differential diagnosis of acute scrotal or testicular pain, this chief complaint can be associated with a number of diagnoses. It could mean an incarcerated inguinal hernia, or acute appendicitis. Testicular pain may develop secondary to urethral obstruction from calculi. The most common local disorders causing acute scrotal or testicular pain are testicular torsion and epididymitis, but testicular tumor and urinary phlegmon should also be considered. Physical Examination Every patient with acute abdominal pain, acute scrotal pain or swelling, should have a careful abdominal and genital examination. Palpate the abdomen and check the inguinal rings for evidence of hernim Examine the testes bimanually and palpate carefully and gently. The normal size of the testis is between 4 and 6 cm in length, 21/2 and 3 cm wide, and 3 cm deep. The epididymis and vas deferens should be readily felt. In examining the penis, palpate the entire shaft and check for urethral discharge and skin lesions, making sure to retract the foreskin so the glans can be seen. The testicles do not lie at the same level. The left usually is a little lower than the right. This is important in the differential diagnosis of the acute scrotum, because with torsion, as the testicle twists on the spermatic cord, it rides up and usually rests higher than normal. If, in a patient with left testicular pain, the left testicle is higher than the right, this is suspicious of a torsion. Determine if the testes are aligned vertically, which is normal, or horizontally, which is abnormal and more prone to terse. During examination to detect a horizontal lie, the patient has to be standing upright. The ~lignment can be detected by both observation and palpation. If the testes are aligned horizontally, the epididymis is superior and posterior. From the Departments of Urology and Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan. Address for reprints: Judith E. Tintinalli, MD, Detroit General Hospital, 1326 St. Antoine, Detroit, Michigan 48226. 8:1 (Ja~tl"ary) 1979
JACEP
28/49
causes c r e m a s t e r i c muscle contraction, p u l l i n g up the a b n o r m a l testes and f a c i l i t a t i n g torsion, is specula. t i v e . H o w e v e r , t o r s i o n d o e s n o t s e e m to be ira. m e d i a t e l y r e l a t e d to direct t r a u m a . The d e v e l o p m e n t a l v a r i a t i o n s t h a t predispose to torsion a r e the b e l l c l a p p e r testis, produced by high in. v e s t m e n t of t h e testicle, e p i d i d y m i s , and spermatic cord by the t u n i c a vaginalis; a n d a n a b n o r m a l rela. tionship b e t w e e n the t e s t i s a n d epididymis,~often due to a n a b n o r m a l i t y of t h e mesorchium. 1 R e m e m b e r that both testes a r e a n o m a l o u s so b o t h a r e prone to torsion. Torsion of testicle was f i r s t described in 1840,2 b u t u n t i l a b o u t 1935, only a b o u t 300 cases were reported in the l i t e r a t u r e . 3 Since then, it has become a well recognized entity. The m a j o r i t y of torsions occur in two periods, first, from the n e w b o r n period to 1 y e a r of age, a n d some m a y occur in undescended testes. A second p e a k incidence occurs a r o u n d puberty.8, 4 To m y knowledge, the oldest recorded p a t i e n t w i t h torsion of the testicle is 78, 3 so it is not j u s t a disease of y o u n g men. To elimin a t e the diagnosis of torsion a n d s a y t h a t our patient h a d e p i d i d y m i t i s on the basis of his age alone would be incorrect. T h i r t y - e i g h t - y e a r - o l d m e n can develop torsion a n d t h e presence of h o r i z o n t a l l y l y i n g testes should s t r o n g l y suggest t h e diagnosis in such a pat i e n t w i t h acute t e s t i c u l a r pain. M a n y people with torsion end up w i t h a d e a d t e s t i s because t h e y do not seek medical a t t e n t i o n in t i m e or because t h e i r condition is misdiagnosed as epididymitis. According to one study, 5 i f s u r g e r y is performed w i t h i n the first four to six hours, a b o u t 85% of the testicles are salvageable. W i t h i n t h e first t e n hours, a b o u t 60% are salvageable; after ten hours, only 20% are s a l v a g e a b l e , and after 24 hours, p r a c t i c a l l y none a r e salvageable. S u d d e n a n d intense t e s t i c u l a r p a i n is the commonest p r e s e n t i n g s y m p t o m of torsion. Lower abdom- , i n a l pain, especially in children,I, 4 or even lower back p a i n , m a y be t h e i n i t i a l m a n i f e s t a t i o n . A n o r e x i a ,
A varicocele m a y be e v i d e n t when t h e p a t i e n t is s t a n d i n g up. If the varicocele does not d r a i n when the p a t i e n t lies down, this suggests the presence of occlusion of the r e n a l vein or vena cava, m o s t often by tumor. A t e s t i c u l a r m a s s detected on e x a m i n a t i o n t h a t t r a n s i l l u m i n a t e s l i g h t is c h a r a c t e r i s t i c of a hydrocoele. In most cases, the failure to detect t r a n s i l l u m i n a t i o n with a hydrocoele is due to the fact t h a t it was a t t e m p t e d in a room t h a t was not d a r k enough. Broom closets a r e e x c e l l e n t for this purpose. The presence of t e s t i c u l a r t e n d e r n e s s and e d e m a m a y m a k e clinical e v a l u a t i o n very difficult. One incorrect s t a t e m e n t you m a y r e a d is t h a t if you lift t h e testicle up a n d it relieves the pain, t h e diagnosis is epididymitis, a n d if it does not relieve the pain, it is torsion. This m a n e u v e r is t o t a l l y u n r e l i a b l e in t e r m s of differential diagnosis.
TESTICULAR TORSION The p a t i e n t discussed today had a h i s t o r y of int e r m i t t e n t t e s t i c u l a r p a i n for about t h r e e weeks. A t the t i m e of surgery, he did not have a torsion. He h a d i n t e r m i t t e n t t o r s i o n , t h a t is, t h e s p e r m a t i c c o r d t w i s t e d a n d s p o n t a n e o u s l y unwound. A b o u t 30% of men wit h t e s t i c u l a r torsion give a h i s t o r y of r e p e a t e d episodes of t e s t i c u l a r p a i n t h a t resolve spontaneously. ~ Also, some i n d i v i d u a l s h a v e a prior history of strenuous a c t i v i t y j u s t before torsion develops. 2 W h e t h e r t h i s
F i g . 1. The scrotum is edematous and the left testicle is high in the scrotum (top). These findings are suggestive of torsion. Operative findings in a case of torsion of the left testicle (bottom). The involved testicle is cyanotic and there is evidence of marked venous thrombosis. This patient had a left orchiectomy and an orchiopexy on the right.
F i g . 2. 99m Technetium testicular scan illustrating lack of perfusion of the left testicle.
5o/29
JACEP
8:1 (January) 1979
nausea, and vomiting may also occur. The temperature may be normal or slightly elevated. Scrotal edema and erythema, and testicular tenderness are nearly invariably present. Thus, there should be a high clinical suspicion of torsion in anyone with painful scrotal swelling, especially if the testicle is high in the scrotum, or if there is a horizontal lie (Figure 1), and especially in the absence of urethritis and with a negative urinalysis. The ultrasonic stethoscope, or Doppler, can aid in the diagnosis.6, 7 The absence of blood flow is compatible with torsion (Figure 2). However, false positive or false negative results may be obtained if the sensitivity is incorrect. The Doppler is only as effective as the skill of the individual performing the test. Another aid to diagnosis is the testicular scan. 8 The torsed testicle will exhibit decreased activity, since its blood supply has been interrupted. A tumor with central necrosis, or a testicular abscess, can also give this appearance on scan. 8 However, the clinical history may differentiate between them. In epididymo, orchitis, the testicular scan shows increased activity in the affected testicle when compared to the opposite side.
most common cause of testicular pain and swelling seen in a city-county hospital and is often associated with gonococcal urethritis. The history is germrally that of gradually increasing testicular pain over a number of days, with urethral discharge that may be profuse. Fever is often present. On physical examination, the epididymis is enlarged and tender. If inflammation is marked, it is often difficult to define the testis from the epididymis. One important piece of information in making the diagnosis is obtaining a two-cup urine specimen. The first 10 cc of urine should be compared with a midstream collection. If the patient has urethritis, the first 10 cc of urine will generally have polymorphonuclear neutrophil leukocytes on microscopic examination. The midstream specimen may be clear because the urethra has been flushed out, and the bladder urine is not infected. If the first urine specimen is normal, I would strongly question the diagnosis of epididymitis although it is not definitely ruled out. Epididymitis is generally treated with 4.8 million units procaine penicillin intramuscularly and 1 gm probenecide orally, or tetracycline 1.5 gm orally t h e n f 0 0 mg orally four times a day for ten days if the patient is allergic to penicillin. Hospitalization is necessary if the patient is febrile and toxic. If the patient can be treated as an outpatient, a scrotal s u p port, ice pack and analgesics provide symptomatic relief. It is sometimes difficult to make the diagnosis of epididymitis and eliminate the possibility of torsion with certainty. I h a v e seen torsion along with urinary tract infection. In such a case, use of the Doppler or scan may be helpful. If there is any question in the physician's mind t h a t torsion might be present, surgery would seem indicated.
Torsion of the Testicular Appendages
Torsion of the testis should be differentiated from torsion of the testicular appendages, which include the appendix testis and appendix epididymis, t h e paradidymis, and the vas aberrans. 9 Torsion of the appendix testis is most cOmmon2 It occurs primarily around the age of puberty, but can also occur in adults and infants. The patient will often feel the pain localized to the upper pole of the testis. When examining the patient with good lighting, the light will reflect off the swoU.en appendix testis and will create a little blue dot in the skin - - the "blue dot" sign. Since the descent of the testes is normal, on palpation there is a vertical lie of the testis. All males have an appendix testis, and thus are all prone to torsion of the appendix. Torsion of the testicular appendages is generally b e n i g n and self-limited, with r e s o l u t i o n of symptoms in about a week or so. -9 It is generally preoperatively misdiagnosed as testicular torsion or epididymitis. 9 Q U E S T I O N : Would you advise an emergency physician to t r y and detorse a testicle in the emergency department? Dr. T h o m a s : Only in a situation where a surgeon or urologist were unavailable. The only time I personally would a t t e m p t to detorse a testicle in t h e emergency department is if the operating suites were unavailable for a number of hours because more critical cases were given priority. After producing local anesthesia, I would try twisting the testis outward, since most torsions twist inward. However, in most cases, local edema is so severe that it is impossible to detorse the testicle outside the operating suite. QUESTION: How do you manage the patient in whom intermittent torsion is suspected? Dr. T h o m a s : The urologist should be called if intermittent torsion is suspected. This is an indication for orchiopexy. The patient should not be discharged without proper knowledge of his condition and the consequences should he elect not to undergo surgery.
TESTICULAR TUMOR Torsion can sometimes be confused with testicular tumor, and the converse. I had a patient, sucessfully treated for torsion, who developed a rapidly growing testicular mass soon afterwards. It became apparent that the torsion caused necrosis and hemorrhage into a microscopic focus of tumor, although this situation is :rare. On occasion, a torsed testicle of several days du:ration will appear swollen, rock hard, and nontender, ;and will resemble a tumor. The initial signs and symptoms of testicular tumor may be swelling and a sensation of heaviness. Pain may develop secondary to a rapid increase in size, or because of hemorrhage into the tumor. Local trauma may simply direct the patient's attention to the area. On examination, a testicular mass may be observed or palpated. Or the testes may appear symmetric, but if one is a little heavier, it should raise the suspicion of a tumor. Testicular tumors are not as common as prostatic or bladder carcinoma. Of all patients with malignant disease, about 2% are testicular tumors. The tragedy is that they arise in young men during the reproductive years. Recently, we have been trying to teach our male patients to examine themselves monthly, just as women are taught to examine their breasts. Fortunately, today we can cure the majority of these patients if they are seen early in the course of the disease. Therefore, it is important to consider the diagnosis when confronted with testicular pain and swelling. An error in diagnosis, or the failure to obtain
EPIDIDYMITIS In my experience, epididymitis is probably the
I]:1 (January) 1979
JACEP
30/51
urologic consultation, may mean that the next time~ the patient is seen, metastases have developed and cure is impossible. The urologist should make a preoperative diagnosis of tumor, since tumors have to be approached through an inguinal incision, whereas torsion is approached through a scrotal incision.I, l°,n The testicle is drained via the iliac nodes, not the inguinal nodes, as with the scrotum. So, if a scrotal incision is used for a tumor, the scrotum is contaminated, and the potential now exists for dissemination of tumor through the inguinal and retmperitoneal nodes.
Consequently, I have the patient standing only w h e n checking for a varicocele. If the patient is very anxious, the testes m a y be d r a w n up to the perineum, m a k i n g the examination more difficult. If that happens, a w a r m cloth over the scrotum for five minutes will relax the testes.
REFERENCES 1. Parker RN, Robison JR: Anatomy and diagnosis of torsion of the testicle,J Urol 106:243-247, 1971. 2. Delasiauve: Rev. Med. Frac et Estrang, Paris, p. 363, 1640, in Ewert EE, Hoffman HA. J Urol 51:551, 1944. 3. Skoglund RN, McRoberts JN, Ragde H: Torsion of the spermatic cord: A review of the literature and an analysis of 70 new cases. J Urol 104:604-607, 1970. 4. Moharik NH, Krahn HP: Acute scrotum in children with emphasis on torsion of the spermatic cord. J Urol 104:601603, 1970. 5. Allan WR, Brown RB: Br M e d J 1:1396, 1966. 6. Levy BJ: The diagnosis of torsion of the testicleusing the Doppler ultrasonic stethoscope. J Urol 113,'63, 1975. 7. Pedersen JF, Holm HH, Hald T: Torsion of the testis diagnosed by ultrasound. J Urol 113:66-68, 1975. 8. Hahn LC, Nadel NS, Gitter M H , et ah Testicular scanning. A new modality for one preoperative diagnosis of testicular torsion. J Urol 113:60-62, 1975. 9. Skoglund RN, McRoberts JW, Ragde H: Torsion oftesticufar appendages. Presentation of 43 new cases and a collective review. J Urol 104:598-601, 1970. 10. Staulsity WJ, Early KS, Magoss IV, et ah Surgical management of testis tumor. J Urol 111:205-208, 1974. 11. Skinner DG, Leadbetter WF: The surgical management of testis tumors. J Urol 106:84-88, 1971.
URINARY PHLEGMON
A urinary phlegmon is an extravasation of urine outside the urethra, usually due to urethral stricture from old gonococcal disease. The scrotum is acutely inflamed, edematous, tender, and may be necrotic; and the testicles are generally unaffected. The scrotum is infected with purulent, gas-producing organisms. Unless antibiotic therapy is promptly initiated, and debridement performed within 24 hours, the mortality rate is extremely high. Q U E S T I O N : Are there any helpful hints that you can recommend for examining the patient with testicular pain? It can be extremely difficult to examine patients who are very sensitive. Dr, T h o m a s : The best thing to do is to have the patient lie down so he will relax. With children, use a well-lighted room and look at the scrotum from different angles. Often you can detect swelling just with observation. I have had a number of patients who became light-headed or fainted when they were examined standing up. I had one child with testicular torsion who had a generalized seizure when I examined him.
52/31
JACEP
8:1 (January) 1979
