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.
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Airway
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Breathing - O2 saturations, work of breathing - intercostal recession, use of accessory muscles - if any concerns give oxygen
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Circulation - pulse, blood pressure, central and peripheral capillary refill time, urine output - consider catheterisation, IV access and bloods as above.
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Fluid bolus - Paediatrics give 20ml/kg of crystalloid solution (not dextrose)
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Disability - AVPU, pupillary response, blood glucose
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Exposure - look for signs of shock
During the acute phase state remember to provide constant reassessment.
Focused history
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Allergies
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Medications
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Past medical history – Pre-natal, birth weight, vaccinations
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Last meal
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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
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Inspect – swelling, hydrocoele, erythrema, high-riding testicle, transverse lie
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Palpate – tenderness, warmth, absent cremasteric reflex, Prehn's sign, transillumination
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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 -
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Keep nil-by-mouth
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Analgesia according to the WHO pain ladder
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Inform emergency theatres and anaesthetist on call
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Keep patient and any relatives informed
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Document, document, document!!!