RENAL AND GENITOURINARYEMERGENCIESTESTICULAR TORSIONThe tunica vaginalis normally surrounds the testicle and attaches to the scro-
tal wall and epididymis posteriorly, anchoring the testicle in place. In patients
at risk for testicular torsion, the tunica vaginalis attaches higher up on the
spermatic cord, leaving a redundant spermatic cord and a mobile testicle (bell-
clapper deformity). Torsion occurs with twisting of the testicle on the spermatic
cord resulting in venous, or rarely, arterial occlusion. This results in rapid
swelling and edema of the testis.
SYMPTOMS
■ May occur at any age, but peaks in the first year of life and at puberty
■ About half may report similar pain that resolved spontaneously.
■ Severe onset of unilateral testicular pain that occurs with trauma, strenu-
ous activity, or sleep
■ Nausea/vomiting, abdominal pain
■ Urgency, frequency, and dysuria
EXAM
■ Elevated (or “high-riding”) testicle with a transverse lie
■ Loss of the cremasteric reflex
■ Tender, firm, swollen testicle
■ Prehn sign (relief of pain with elevation of testicle) is notreliable in differ-
entiating torsion from epidymitis.
■ Bell-clapper deformity (horizontal lie) of contralateral testicle
DIAGNOSIS
■ Torsion is a clinical diagnosis, but if this diagnosis is equivocal, Doppler
ultrasound or radionuclide scanning can be used to evaluate blood flow to
the testicle.
TREATMENT
■ Immediate urology consult
■ Supportive care with analgesia
■ Attempt manual detorsion (medial to lateral twisting or “open-book”)
method.
■ Definitive surgical intervention with exploration and possible orchiopexy
A 60-year-old diabetic male presents to the ER complaining of 2 days of
scrotal pain. On examination, the patient has tenderness to palpation of the
underside of the scrotum and the perineum, with slight erythema. The
patient’s pain seems out of proportion to his physical exam findings, and the nurse
is concerned that he may be drug-seeking. What diagnosis should be strongly con-
sidered in this patient?
Fournier gangrene should be considered, especially in a diabetic male. The
patient may complain of scrotal, rectal, or genitalia pain out of proportion to exami-
nation findings of warmth, erythema, and edema. Mortality in these patients is
about 20%.The loss of the cremasteric
reflex is the most accurate
sign of testicular torsion.