Testicular Torsion

You are the urology CT1 asked to see a 14-year-old boy who experience sudden onset severe left testicular and lower abdominal pain 4 hours ago whilst climbing on a school trip. He has attended with his mother who is very worried as he has vomited twice. How would you proceed? 

Example answer introduction

I suspect that this young man may have testicular torsion and I would got to assess him immediately. I would take a focused history, perform a focused examination and request the relevant investigations depending on my clinical suspicions. I would then initiate treatment and escalate to my registrar for senior review. 

Initial Assessment and Simultaneous Resuscitation:

 

On arrival assess and manage the patient using an A to E approach according to the Paediatric Advanced Life Support algorithm.

  • Airway

  • Breathing - O2 saturations, work of breathing - intercostal recession, use of accessory muscles - if any concerns give oxygen

  • Circulation - pulse, blood pressure, central and peripheral capillary refill time, urine output - consider catheterisation, IV access and bloods as above. 

  • Fluid bolus - Paediatrics give 20ml/kg of crystalloid solution (not dextrose)

  • Disability - AVPU, pupillary response, blood glucose

  • Exposure - look for signs of shock

During the acute phase state remember to provide constant reassessment. 

Focused history​

  • Allergies

  • Medications 

  • Past medical history – Pre-natal, birth weight, vaccinations

  • Last meal

  • Events leading up to this point – history of trauma, duration of symptoms, nausea and vomiting, dysuria, frequency, hesitancy, urgency, haematuria, nocturia, when last passed urine and amount, previous similar episodes that may have resolved spontaneously (torsion-detorsion)

Examination

  • Inspect – swelling, hydrocoele, erythrema, high-riding testicle, transverse lie

  • Palpate – tenderness, warmth, absent cremasteric reflex, Prehn's sign, transillumination

  • Abdominal examination – hernia, appendicitis

Initial management

If I suspected a testicular torsion, further investigations should not delay prompt exploration in theatre as we have 6 hours from onset of pain to explore the testicle. Therefore, I would inform the urology registrar immediately and prepare the patient for theatre. In the interim I would -

 

  • Keep nil-by-mouth

  • Analgesia according to the WHO pain ladder

  • Inform emergency theatres and anaesthetist on call

  • Keep patient and any relatives informed

  • Document, document, document!!!

Escalation
I would inform the Registrar to review the patient in a timely manner, to ensure my diagnosis and management plan were correct.
THIS IS AN EMERGENCY AND THEREFORE URGENT ESCALATION IS REQUIRED IF THERE IS ANY DEGREE OF CLINICAL SUSPICION
It may be expected of you to put the patient on the emergency list so close communication with theatre staff and anaesthetics may be necessary. 
Useful Resources

Testicular torsion and the acute scrotum: current emergency management

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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