Testicular Torsion Fani Final
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Transcript of Testicular Torsion Fani Final
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TesticularTesticular
TorsionTorsion
Dr Malik Irfan AhmedDr Malik Irfan Ahmed
MO SUIIMO SUII
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Epidemiology/Risk FactorsEpidemiology/Risk Factors
1/4000 males
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Epidemiology/Risk Factors (cont)Epidemiology/Risk Factors (cont)
Other (2-6% of cases): Increase in testicular volume (puberty)
testicular tumor
testicles with horizontal lie spermatic cord with long intrascrotal portion
Cryptorchidism (one or both testes)
Strenuous exercise
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PathophysiologyPathophysiology
The testicle is typically covered bythe tunica vaginalis.
The tunica vaginalis attaches to theposterolateral surface of the testicleand allows for little mobility of thetesticle within the scrotum.
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Types Of testicular TorionsTypes Of testicular Torions
Two Types
Intravaginal
Extravaginal
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Intravaginal testicularIntravaginal testiculartorsiontorsion
In patients who have an inappropriatelyhigh attachment of the tunica vaginalis,the testicle can rotate freely on thespermatic cord within the tunica vaginalis.
This congenital anomaly, called the bellclapper deformity, results in the long axisof the testicle to become orientedtransversely rather than cephalocaudal.
Present in approximately 12% of males 40% of which have the abnormality in thecontralateral testicle as well.
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The bell clapper deformity allows the testicle totwist spontaneously on the spermatic cord,causing venous occlusion and engorgement,with subsequent arterial ischemia causing
infarction of the testicle. Experimental evidence indicates that 720
torsion is required to compromise flow throughthe testicular artery and result in ischemia.
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Bell Clapper DeformityBell Clapper Deformity
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Extravaginal testicularExtravaginal testiculartorsiontorsion
In the neonatal age group, the testiclefrequently has not yet descended into thescrotum, where it becomes attached within
the tunica vaginalis. This mobility of the testicle predisposes it to
torsion .
Inadequate fusion of the testicle to the
scrotal wall, moreover, typically occurswithin the first 7-10 days of life.
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Other Causes/PrecipitatingOther Causes/Precipitatingfactorsfactors
Sexual arousal and/or activity
Trauma Exercise
Active cremasteric reflex
Cold weather
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Diagnosis isDiagnosis isCRITICAL!!CRITICAL!!
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Initially obstructsInitially obstructsvenous returnvenous return
Equalization of venous and
arterial pressures
Compromised arterial flow
TESTICULAR ISCHEMIA
As soon as4 hours!!
Testicular TorsionTesticular Torsion
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ISCHEMIA vs Salvage RateISCHEMIA vs Salvage Rate
ISCHEMIA: as soon as 4 hrs almostCERTAIN in 24 hrs
Salvage Rate:
90-99% success if < 6 hrs
50% success if
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TesticularTesticular PAIN!PAIN!16-42% acute scrotal pain
TESTICULAR TORSION
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HistoryHistory
History includes a sudden onset of severe unilateral scrotalpain.
As many as 50% of patients have a history of priorepisodes of intermittent testicular pain that has resolvedspontaneously (intermittent torsion and detorsion).
Onset of pain can occur more slowly, but this is anuncommon presentation of torsion.
Torsion can occur with activity, be related to trauma, ordevelop during sleep and includes the following: Scrotal swelling Nausea and vomiting (20-30%)
Abdominal pain (20-30%) Fever (16%) Urinary frequency (4%)
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PhysicalPhysicalExaminationExamination
Involved testicle painful to palpation; frequentlyelevated in position when compared with theother side
Horizontal lie of the testicle
Enlargement and edema of the testicle; edemainvolving the entire scrotum Scrotal erythema Ipsilateral loss of the cremasteric reflex Prehn sign -Ve
Fever (uncommon) Epididymis: medially, laterally or anteriorly
(depends on degree of torsion) one side
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DifferentialDifferentialDiagnosisDiagnosis
Epididymitis/Orchitis
IncarceratedHernia
IdiopathicScrotal Edema
VaricoceleTorsion of
Appendix Testis
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Other Problems to beOther Problems to be
ConsideredConsidered
Traumatic rupture
Traumatic hematoma Torsion of testicular appendage
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Lab StudiesLab Studies Complete blood count:
CBC can be normal or show an elevated WBC count in asmany as 60% of patients who have torsion
Urinalysis Urinalysis result is usually normal. The presence of white blood cells (WBCs) can be observed in
as many as 30% of patients who have torsion
Acute-phase proteins (C-reactive protein [CRP]): Elevationin acute-phase proteins, namely the CRP, has beenpostulated as a diagnostic aid in differentiatinginflammatory causes of acute scrotal pain (epididymitis)
from noninflammatory causes (testicular torsion).
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Diagnostic ModalitiesDiagnostic Modalities
Doppler UltrasoundDoppler UltrasoundRadionuclide Testing
Surgical Exploration
Imaging:ONLY IF
SUSPICION FORTORSION =LOW
Faster More available Plain doppler has lessaccuracy than color one More sensitive
E l f l PE l i f A S l P i
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Evaluation of Acute Scrotal PainEvaluation of Acute Scrotal Pain
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Line of ManagementLine of Management Early diagnosis and prompt urologic referral is
essential since time is critical in salvage of thetesticle.
Mild analgesic pain relief can be administered
once testicular torsion has been diagnosed orwhile awaiting further studies.
Attempt manual detorsion, which can beattempted with pain relief as the guide forsuccessful detorsion. The procedure is similar to
the "opening of a book" when the physician isstanding at the patient's feet.
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book
Most torsions twist inward and toward the mid line; thus,manual detorsion of the testicle involves twisting outwardand laterally.
For example, in a suspected torsion of the right testicle, thephysician is in front of the standing or supine patient and holdsthe patient's right testicle with the left thumb and forefinger.
The physician then rotates the right testicle outward 180 in amedial to lateral direction.
Rotation of the testicle may need to be repeated 2-3 times forcomplete detorsion and to provide pain relief to the patient.
For the patient's left testicle, the physician uses the right thumband forefinger and rotates the patient's left testicle in anoutward direction 180 from medial to lateral.
Manual detorsion is successful in 30-70% of patients.
open
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Orchipexy is the Surgery of thechoice for testicular torsion
Should be performed on unaffectedside as well.
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Most Significant ComplicationMost Significant Complication Infarction of testicle
Loss of testicle
Infection
Infertility secondary to loss oftesticle
Cosmetic deformity
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Thank you
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