Authored and Copyedited by Dr. Mandy Peach

Big thanks to Dr. Paul Paul for leading discussion.

All cases are imaginary but highlight important learning points

Case

A 72 yo male presents with acute onset L sided scrotal pain radiating to the groin ongoing 3 hours. In triage he denied any associated trauma. He has no history of scrotal issues. He has vomited once from the pain. He took a leftover morphine tablet he had post knee surgery and that helped temporarily. He denies any fever or diarrhea. He was well prior to the onset of pain.

PMH: OA with R TKA, DLP

Vitals: BP: 157/92 HR 102 RR 20 O2 98% RA T – 36.7

The department is in critical overcapacity, with admitted patients being boarded in hallways. While the nurse is triaging she is interrupted three times with questions from both staff and patients asking when they are to be seen. A testicular exam is not completed at that time.

What is the differential for acute scrotal pain in an adult¹?

• Epididymitis/epididymo-orchitis
• Fournier’s gangrene
• Trauma
• Inguinal hernia
• Mumps orchitis
• Testicular cancer
• Henoch-Schönlein purpura
• Acute idiopathic scrotal edema
• Post-vasectomy pain
• Referred pain
• Testicular torsion

This patient had no history of trauma, and was otherwise well. He was afebrile and had suspected elevated BP and HR secondary to pain. Tylenol and advil are administered.

2 hours have passed, the patient continues to have ongoing pain and presents back to triage as he has started vomiting again. Repeat vitals are unchanged.

When finally assessed by a physician there is extensive L sided scrotal edema and redness. It is exquisitely tender. The testicle appears to be lying abnormally. You are concerned for torsion.

 

Other than a swollen, red testicle what are other signs/symptoms of torsion²?

• Acute onset of unilateral testicular pain: the presentation can actually vary; Some present with gradually increasing pain, others fluctuating pain if the testicle is intermittently undergoing torsion and detorsion and some have minimal pain. The patient may describe the pain as radiating to the abdomen, groin or flank.

20% of patients with torsion complain of lower abdominal pain.

 

• Affected testicle lying high and horizontal: seeing this certainly increases the odds of the patient having torsion, but depending on timing of presentation and swelling it may be difficult to determine the position of the testicle.

 

• Absent cremasteric reflex: With an intact cremasteric reflex lightly stroking the inner thigh will cause the ipsilateral testicle to retract/elevate³. In torsion, the twisting of the spermatic cord interrupts this reflex. However, the sensitivity of this sign is only 60%

Presence of a normal cremasteric reflex does not rule out torsion

• Swelling is a sensitive, but not specific sign. It can be found in a number of conditions as listed in the differential above.
• Nausea/vomiting may be associated, if present there is increased likelihood of torsion (OR 8.87)⁴ but it is a non-specific sign seen in many presentations. It’s importance is when it is seen in conjunction with the other signs of torsion.

What is Prehn’s sign and what is its utility in assessing for torsion²?

In epididymitis, elevation of the affected testicle can result in relief of scrotal pain. This is Prehn’s sign. If the pain is worsened with this maneuver it is thought to be associated with torsion. This technique is not reliable in differentiating epididymitis from torsion. One study found the majority of patients with torsion, over 90%, had a positive Prehn’s sign.

Combining all these findings into the TWIST score for pediatric patients under the age of 18 years can help guide management in cases where it is unclear⁵.

High risk with 7 points – PPV 100% for torsion

<5 points – NPV 96%

To avoid missing irreversible ischemia, use this took as a rule  in score only – if a score of 7 consult urology directly to consider surgical intervention without doppler ultrasound².

This patient is in his 70’s, why would we even consider torsion¹?

Torsion typically happens in neonates and postpubertal males, but it can occur in adult males. One retrospective chart review found that 39% of hospitalized males with torsion were age 21 and over. Although rare, it can happen in older adults.

In any male with abdominal pain, regardless of age, consider testicular torsion

This male has pain ongoing for hours, what are the odds the testicle is salvageable²?

Previous thought was that 6 hours was the window and that after that the testes is beyond salvage. However, there are longer survival percentages greater than 6-8 hours depending on the history (ie. Intermittent torsion) leading to a range in timelines for irreversible ischemia.  Therefore, regardless of duration of pain, the case should be treated as a surgical emergency.

So, you urgently call urology for consult. They expect to be in house within 20 minutes. They are requesting a formal ultrasound in the meantime. It’s now after midnight so the ultrasound tech has to be called in. Time is ticking, so you grab your ultrasound probe.

What is the evidence for point-of-care ultrasound in testicular torsion?

Sensitivity 88-100%

Specificity 90%²

One chart review of pediatric patients presenting with symptoms suspicious of torsion found point of care scrotal ultrasound performed by pediatric EM physicians was 100% sensitive and 99.1% specific⁶.

What are the findings concerning for testicular torsion on ultrasound?

Many – it depends on the timing.

From a blood flow perspective

• Initially as the spermatic cord twists the venous system is most susceptible to obstruction. So if very early, there may be normal appearance of blood flow.
• As time goes on venous flow may look to still be present, but looks less compared to unaffected testicle.
• Before, or after, venous flow completely obstructs, arterial flow can show signs of impending obstruction as well with a high resistance pattern on doppler.
• Finally, there will be no flow present in the testicle and it may shows signs of necrosis.

Obtaining doppler to confirm both venous and arterial flow is imperative when assessing for torsion

Other signs on ultrasound

• Enlarged, edematous testicle
• Surrounding fluid within the scrotum
• Loss of homogenous appearance with hypoechoic areas of infarct
• Whirlpool sign showing the twisted spermatic cord

Review some images:

Normal appearance testicle⁷ with flow

Absence of flow (note the affected testicle is also quite edematous)

Normal venous appearance⁷ – a low flow pattern that stays consistent

Normal arterial appearance⁷ – notice the peak and gradual trough associated with systole and diastole

High resistance pattern⁸ concerning for impeding arterial obstruction

Whirlpool sign⁹ – notice the yellow coloration of doppler in this image. This is power doppler – it is more sensitive than color doppler for picking up on low flow states¹⁰. It is not indicative of direction of flow, just intensity of flow ie. Brighter = more flow.

You see absence of flow on the affected testicle of your patient.

The urologist is in house and you review the images on PoCUS – the patient is brought to the OR.

What if you were rural and transport would be hours? Should you attempt to detort the testicle manually?

The open book maneuver where you ‘open’ or turn the testicle outward to attempt to detort¹¹ is only recommended if there is an anticipated delay of hours to the OR.

The reason? Poor success rate, up to a 1/3 of patients will actually be torting in the opposite direction².

Bottom line:

• Suspect testicular torsion in any male, of any age, with abdominal pain.
• Many classic findings are not reliable to rule out torsion
• Use bedside ultrasound to assess for color doppler flow, consider using power doppler to detect low states. Findings vary but classically – no flow in the testicle is seen with torsion.
• Ischemic time is variable, and longer than initially thought, treat every presentation as a surgical emergency regardless of timing of presentation.
• High suspicion? Don’t wait for formal imaging – call urology.

 

Interested in PoCUS for other scrotal presentations? Review this awesome post by Dr. Rawan AlRashed, PoCUS fellow

Scrotal Pain – Scrotal PoCUS in a nutshell

 

References and further reading:

1. Eyre, RC. 2022. Acute scrotal pain in adults. UpToDate. Retrieved June 13, 2022 from https://www.uptodate.com/contents/acute-scrotal-pain-in-adults?search=scrotal%20pain%20adult&source=search_result&selectedTitle=1~45&usage_type=default&display_rank=1#H1816144542
2. Helman, A. Krakowsky, Y. Wolpert, N. Testicular Torsion: A Diagnostic Pathway. Emergency Medicine Cases. July, 2020. https://emergencymedicinecases.com/testicular-torsion. Accessed [June 13, 2022]
3. Image from https://www.quora.com/What-is-a-cremasteric-reflex
4. Tali Beni-Israel, Michael Goldman, Shmual Bar Chaim, Eran Kozer. Clinical predictors for testicular torsion as seen in the pediatric ED. The American Journal of Emergency Medicine, Volume 28, Issue 7,2010. Pages 786-789,ISSN 0735 6757,https://doi.org/10.1016/j.ajem.2009.03.025. (https://www.sciencedirect.com/science/article/pii/S0735675709001569)
5. Barbosa JA, Tiseo BC, Barayan GA, et al. Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urol. 2013;189(5):1859-1864.
6. Friedman N, Pancer Z, Savic E, Tseng F, Lee MS, Mclean L et al. 2019. Accuracy of point-of-care ultrasound by pediatric emergency physicians for testicular torsion. Journal of Pediatric Urology. VOLUME 15, ISSUE 6, P608.E1-608.E6, DECEMBER 01, 2019DOI:https://doi.org/10.1016/j.jpurol.2019.07.003
7. Personal ultrasound images from a case of suspected testicular torsion. Deidentified.
8. Ultrasound of Testicular Torsion. EMRAP. Viewed on https://emergencymedicinecases.com/testicular-torsion/
9. Patel MS. 2020 Whirlpool sign (testicular torsion). Radiopedia. Accessed June 14, 2022 https://radiopaedia.org/articles/whirlpool-sign-testicular-torsion
10. Agolah 2022. Power Doppler. Radiopedia. Accessed June 14 2022 https://radiopaedia.org/articles/power-doppler-1?lang=us
11. Modified from: Cronan KM, Zderic SA. Manual detorsion of the testes. In: Textbook of Pediatric Emergency Procedures, 2nd ed, King C, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2008. Assessed June 14, 2022 https://www.uptodate.com/contents/image?imageKey=EM%2F112358