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

ASK FOR A CHAPERONE

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

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