Positively Painful Private Parts II: Testicular Torsion

It should be no surprise that acute testicular torsion is a surgical emergency. The testicle twists on the spermatic cord which leads to the following sequence:

  • Venous compression
  • Edema of testicle and cord
  • Arterial occlusion
  • Ischemic testicle

The risk 1/4000 for males < age 25. There is a bimodal distribution, with rates peaking in the neonatal period and again during puberty. For the purposes of this post, we’ll be focusing on older children, as the neonatal form often occurs in utero. Almost two-thirds of cases (65%) occur between ages 12 and 18 years. The pubertal peak is thought to be due to increasing testicular volume (cue endocrinologist with orchidometer in hand).

As noted in part I of the series the bell clapper deformity occurs when the testis is not fixed to the tunica vaginalis posteriorly and it is free to rotate. This leads to an increased risk of torsion. The incidence is in the population is approximately 1/125 and is usually present bilaterally. It goes without saying that though patients may have the deformity, most don’t torse.

The classic presentation begins with the abrupt onset of pain, with most cases being recognized in under 12 hours. There can be associated nausea, vomiting and referred lower abdominal pain.In a retrospective review from Kadish, 1998, only 8% had pain prior to the “main” episode. On exam, the ipsilateral scrotum is edematous. It can be red or dusky in color depending on the length of time since onset of symptoms. The testis is tender, elevated and may have a horizontal lie. The cremaster reflex is absent in many cases – but this isn’t diagnostic.

I can’t reiterate this enough, but testicular torsion should ideally be a clinical diagnosis. If you suspect it call a Urologist ASAP. Most cases where my pre-test probability for torsion were low, did not have torsion. Indeed, an ultrasound isn’t perfect, having a Sensitivity of 69-100% and specificity of 77-100%. the treatment is detorsion of the affected testis (if viable) and fixation (orchiopexy) of both testis. If you remember anything from this post I want you to remember the point below clearly signalled by big, bold red letters:

Viability rates

  • Within 4-6 hours 100%

  • 12-24 hours 20%

  • >24 hours 0%

Males with a history of testicular torsion may have increased risk of infertility even when a viable de-torsed testis is left in scrotum because of immune-mediated injury to contralateral testis. Some scientists theorize that anti-sperm antibodies are produced during the period of ischemia. This is far from hard science as other studies have failed to show that anti-sperm antibodies are present. There can be cases of intermittent torsion which are challenging to diagnose. We do know that:

  • 80% have bell clapper deformity
  • Pain is brief and resolves quickly (minutes)
  • Eaton et al, 26% had nausea and vomiting, 21% pain awakened patient from sleep

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Positively Painful Private Parts I: History and Physical

This is the beginning of a new series – the focus will be limited to the 50% of the population – but, in reading the theme I think you’ll understand why we left the girls out. The first post will focus on how to do an effective H&P focused on acute testicular and scrotal pain.

History

First and foremost you’ll want to know about the acuity – did the pain start gradually or was it abrupt. More abrupt should worry you about torsion – but could also suggest epididymitis, or torsion of the appendix testis/epididymis, Was there trauma? Most patients will remember… If there has been a change in size it could be due to increased testicular volume or fluid in the scrotal sac (hydroceles and hernias will increase in size with Valsalva). If a patient sexually active think epididymitis/orchitis.  Patients with testicular pain and difficulty voiding should worry you about UTI, trauma or mass. Kidney stones have pain that radiates to the groin. Especially when the pain increases nausea and vomiting will often be seen in patients with testicular torsion.

Physical Exam

Let’s be honest. Most patients aren’t excited about standing and coughing. I don’t care so much about the coughing, but the standing is important. If the patient can do so please have them stand for the exam. This will give you a better assessment of  the anatomy and any asymmetry. Always get a chaperone if you and/or the patient are uncomfortable. respect the patient’s privacy and close doors and curtains. You’ll want to make sure you assess and address the following:

Symmetry

Normally the left hangs lower. Also testicular volume should be relatively symmetric. As torsion occurs venous outflow is the first thing that is compromised – so you’ll see unilateral swelling.

Testicular lie

The testicle is normally in a more vertical orientation. The bell clapper deformity describes a horizontally oriented testicle which is due to incomplete posterior anchoring to the gubernaculum. The testicle can become horizontally oriented because it is free to swing in the tunica vaginalis. It occurs in 1/125 males and peaks around adolescence.

Cremasteric reflex

Gentle vertical stroking of the inner thigh will cause elevation of the ipsilateral hemiscrotum. The muscle innervation is L1-L2, and thus spinal cord pathology at that level will also impact the reflex. Its absence is concerning for cases of torsion, but not pathognomonic. According to Paul et al, 2004 in children under 11 years, the sensitivity was 75%, specificity 83.9%, accuracy 83.3%, while boys ≥11 years had a sensitivity of 100%, specificity 89%, and accuracy of 90.1%.

Also don’t forget to examine the:

  • Inguinal folds
  • Penis and urethra
  • Pubic hair
  • Abdomen
  • Femoral pulses

In upcoming posts we’ll look at specific diagnoses more in depth – namely torsion, torsion of the appendix testis and appendix epididymis and epididymitis.

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Tech Tuesdays: Make a map of regional referring hospitals using Google’s My Maps

I was recently thinking about the number of facilities that refer patients to our ED in good ole Cincinnati, OH and I realized that the number is quite large. I also wanted to understand better their locations as it relates to transit time for patients coming to the ED. So I made a custom Google Map, which I embedded below.

Anyone with a Google account can do this, and it shouldn’t take long to make a custom map if you have a list of the addresses of referring facilities. Read more on the My Maps feature via Google’s Maps Blog.

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Briefs: Neither pyogenic, nor granuloma

A school age child presents with a lesion on their cheek that has been oozing blood for the past several hours. The parents noted a small red bump several weeks prior to presentation, but he says that it just started bleeding in class. The school officials were freaked out and called an ambulance – mom and dad meet you in the ED and this is what you see.

This lesion is known as a pyogenic granuloma. Interestingly it is not a granuloma – instead a lobular capillary hemangioma. It is also not pyogenic – there’s no pus – and the cause is not related to injury or infection. They most commonly appear on the face, and are seen in children with a female predominance. At first they can be small – fewer than a few millimeters. They can grow rapidly and exceed a few centimeters. They are particularly fragile, and often bleed without provocation. At first they are intensely red due to capillary proliferation, later achieving a pinker hue. They can also be seen on the oral mucosae and gingiva, and are especially noteworthy as a cause of nosebleeds if they occur in the nasal septum. In pregnant women they often appear in the third trimester and have thus achieved the nickname granuloma gravidarum.

The treatment for a bleeding pyogenic granuloma starts with pressure. This will stop bleeding in most cases, but the lesion will still be friable. Because 3/5 pediatric cases appear on the face cosmetic concerns certainly exist when it comes to therapy. That’s why I find it hard to recommend cauterizing with silver nitrate in a willy-nilly fashion if the bleeding has stopped. I would only recommend applying silver nitrate to very small (definitely subcentimeter) lesions and applying EMLA beforehand. Other treatments used by dermatologists and plastic surgeons (which are not available/practical in the Pediatric Emergency Department) include:

  • Shave removal with electrocautery
  • Primary excision
  • Pulse-dye laser

One study indicated that shave excision was faced with a recurrence rate of almost 40%. If you are at all concerned about the cosmetic outcome it is best to refer.

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Fracture Fridays: A chip off the old bucket handle

The case

An infant presents with swelling of the ankle after being picked up from the babysitter. He has been able to pull to stand and cruise for a while now, but appears to be in pain when he attempts to bear weight after he pulls up to stand. X-Rays reveal the following.Uploadimg-nonaccidentaltrauma11201495937500

Diagnosis

This is a metaphyseal corner fracture. AKA a metaphyseal chip fracture. It is very concerning for non-accidental trauma. It is though to occur when a limb is grabbed or twisted forcefully, perhaps while the child is being shaken, and the corner of the metaphysis shears off. It may present with pain and discomfort – or be seen incidentally on X-Rays obtained in a skeletal series. It is related to the “bucket handle” fracture which is more significant in terms of the degree of shearing. See the sample image below with both a corner and bucket handle fracture.

Corner fracture above, and bucket handle fracture below

Corner fracture above, and bucket handle fracture below

Management

This fracture does not require reduction or operative repair in the vast majority of cases unless the displacement is extreme. More importantly, as this fracture can be considered pathognomonic for non-accidental trauma, discovery of a corner fracture should prompt a more thorough workup. In the case above, this would include a skeletal survey, head CT and labs designed to screen for intraabdominal injury (AST, ALT, amylase, lipase, CBC, urinalysis, troponin).

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Instagramography: Radiology education on Instagram

It’s no secret that youngsters like Instagram. For the unfamiliar, it is an “online mobile photo-sharing, video-sharing and social networking service that enables its users to take pictures and videos.” The Division or Radiology at Cincinnati Children’s Hospital Medical Center has set up an education-focused Instagram page with a plethora of great images and cases. Add it to the list of ways to get more experience with fancy medical pictures.

Check them out at CincyKidsRad on Instagram

Screen Shot 2014-09-04 at 10.52.42 AM Screen Shot 2014-09-04 at 10.53.25 AM

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