Tag Archives: urology

Testicular Torsion – EM Reflections January 2022

Posted on by

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

 

Continue Reading

EM Reflections – May 2020

Posted on by

Thanks to Dr Paul Page for leading the discussions this month

Edited by Dr David Lewis 

Discussion Topics

  1. Seizure disorder and safe discharge 

    • Consider risk factors for adverse outcome of discharge for all patients with recurrent seizure disorder
    • Use a checklist

  2. Competency and Capacity

    • Multidisciplinary consultation is paramount in deciding capacity
    • Special circumstances include vulnerable adults and pregnancy

  3. Testicular Torsion

    • Time = Testicle viability
    • Do not delay definitive management

Seizure disorder and safe discharge 

Case

A patient presents with recurrent seizures. They have a past medical history of schizophrenia and mental health delay. Following appropriate ED management with complete resolution of seizures and full recovery of the patient – what is the recommended disposition?

Seizure disorder is a common presentation to the Emergency Department. This EM Cases post provides an excellent summary for the ED approach to resolved seizures:

Ep 132 Emergency Approach to Resolved Seizures

 

ED approach to resolved seizures – Summary pdf

In this study – Ethanol withdrawal or low antiepileptic drug levels were implicated as contributing factors in 177 (49%) of patients. New‐onset seizures were thought to be present in 94 (26%) patients. Status epilepticus occurred in only 21 (6%) patients.

73% of patients were discharged.

 

 

 

Disposition

Most authors recommend admission for patients presenting with FIRST Seizure Episode. Patients with a past medical history of recurrent seizure disorder are more likely to be discharged than admitted.

However – this EBMedicine article cites an incidence of 19% seizure recurrence rate within 24 hours of presentation, which decreased to 9% if patients with alcohol related events or focal lesions on CT were excluded. They suggest, that at present, there is insufficient evidence to guide the decision to admit. They recommend this decision be tailored to the patient, taking into consideration the patient’s access to follow-up care and social risk factors (eg, alcoholism or lack of health insurance). Patients with comorbidities, including age > 60 years, known cardiovascular disease, history of cancer, or history of immunocompromise, should be considered for admission to the hospital.

 

Considerations For Safety On Discharge

Patients and their families should be counseled and instructed on basic safety measures to prevent complications (such as trauma) during seizures. For example, patients should be advised to avoid swimming or cycling following a seizure, at least until they have been reassessed by their neurologist and their antiepileptic therapy optimized, if needed. A particularly important point for seizure patients is education against driving. Although evidence remains controversial on this issue, there is general agreement that uncontrolled epileptic patients who drive are at risk for a motor vehicle crash, with potential injury or death to themselves and others. For this reason, most states do not allow these patients to drive unless they have been seizure-free on medications for 1 year. According to population survey data, 0.01% to 0.1% of all motor vehicle crashes are attributable to seizures

Competency and Capacity

Case

A young female patient with a history of polysubstance drug abuse presents with a psychotic episode. She refuses treatment. What are the competency and capacity implications? She is also pregnant. Does this change the the competency and capacity implications?

This LitFL post provides and excellent outline for Competency and Capacity in the ED:

Capacity and Competence

This article published by the RCPSC provides a useful outline from a Canadian perspective – with the following objectives.

  1. To clarify the role of decisional capacity in informed consent
  2. To discuss problems associated with decisional capacity and addiction

RCPSC – Decisional Capacity

 

 

Capacity in Pregnancy

Recommendations from the American College of Obstetricians and Gynecologists

On the basis of the principles outlined in this Committee Opinion, the American College of Obstetricians and Gynecologists (the College) makes the following recommendations:

  • Pregnancy is not an exception to the principle that a decisionally capable patient has the right to refuse treatment, even treatment needed to maintain life. Therefore, a decisionally capable pregnant woman’s decision to refuse recommended medical or surgical interventions should be respected.
  • The use of coercion is not only ethically impermissible but also medically inadvisable because of the realities of prognostic uncertainty and the limitations of medical knowledge. As such, it is never acceptable for obstetrician–gynecologists to attempt to influence patients toward a clinical decision using coercion. Obstetrician–gynecologists are discouraged in the strongest possible terms from the use of duress, manipulation, coercion, physical force, or threats, including threats to involve the courts or child protective services, to motivate women toward a specific clinical decision.
  • Eliciting the patient’s reasoning, lived experience, and values is critically important when engaging with a pregnant woman who refuses an intervention that the obstetrician–gynecologist judges to be medically indicated for her well-being, her fetus’s well-being, or both. Medical expertise is best applied when the physician strives to understand the context within which the patient is making her decision.
  • When working to reach a resolution with a patient who has refused medically recommended treatment, consideration should be given to the following factors: the reliability and validity of the evidence base, the severity of the prospective outcome, the degree of burden or risk placed on the patient, the extent to which the pregnant woman understands the potential gravity of the situation or the risk involved, and the degree of urgency that the case presents. Ultimately, however, the patient should be reassured that her wishes will be respected when treatment recommendations are refused.
  • Obstetrician–gynecologists are encouraged to resolve differences by using a team approach that recognizes the patient in the context of her life and beliefs and to consider seeking advice from ethics consultants when the clinician or the patient feels that this would help in conflict resolution.
  • The College opposes the use of coerced medical interventions for pregnant women, including the use of the courts to mandate medical interventions for unwilling patients. Principles of medical ethics support obstetrician–gynecologists’ refusal to participate in court-ordered interventions that violate their professional norms or their consciences. However, obstetrician–gynecologists should consider the potential legal or employment-related consequences of their refusal. Although in most cases such court orders give legal permission for but do not require obstetrician–gynecologists’ participation in forced medical interventions, obstetrician–gynecologists who find themselves in this situation should familiarize themselves with the specific circumstances of the case.
  • It is not ethically defensible to evoke conscience as a justification to attempt to coerce a patient into accepting care that she does not desire.
  • The College strongly discourages medical institutions from pursuing court-ordered interventions or taking action against obstetrician–gynecologists who refuse to perform them.
  • Resources and counseling should be made available to patients who experience an adverse outcome after refusing recommended treatment. Resources also should be established to support debriefing and counseling for health care professionals when adverse outcomes occur after a pregnant patient’s refusal of treatment.

Further Reading:

Ethically Justified Clinically Comprehensive Guidelines for the Management of the Depressed Pregnant Patient

How Do I Determine if My Patient has Decision-Making Capacity?

 

Testicular Torsion

Case

A 12 year old boy presents with scrotal discomfort in the early hours of the morning. The department is very busy and the waiting time to be seen is 4 hours. What triage category is this presenting complaint? If a diagnosis of torsion is considered, how quickly should definitive management be initiated?

Ramachandra et al. demonstrated through multivariate analysis of the factors associated with testicular salvage, that duration of symptoms of less than 6 h was a significant predictor of testicular salvage. They found that the median duration of pain was significantly longer in patients who underwent orchiectomy versus orchidopexy. Similar findings were seen with respect to time to operating room from initial presentation. They concluded that time to presentation is in fact the most important factor in determining salvageability of the testicle in testicular torsion. If surgical exploration is delayed, testicular atrophy will occur by 6 to 8 h, with necrosis ensuing within 8 to 10 h of initial presentation. Salvage rates of over 90% are seen when surgical exploration is performed within 6 h of the onset of symptoms, decreasing to 50% when symptoms last beyond 12 h. The chance of testicular salvage is less than 10%, when symptoms have been present for over 24 h

Factors influencing rate of testicular salvage in acute testicular torsion at a tertiary pediatric center.

Ramachandra P, Palazzi KL, Holmes NM, Marietti S

West J Emerg Med. 2015 Jan; 16(1):190-4.

[PubMed]

 

 

This study (Howe et al). confirmed the relationship between duration of torsion and testicle viability and also found a relationship between the degree of torsion

 

 

AAFP Review of Testicular Torsion: Diagnosis, Evaluation, and Management

 

 

 

 

 

 

Continue Reading

ED Rounds – How Big Are Your Stones

Posted on by

‘How big are your stones….David?’

A Renal Colic Presentation by Brian Ramrattan

 

 

 

 

 

Passing a Stone?

  • <5mm likely to pass without intervention
  • >10mm unlikely to pass without intervention
  • Increased intervention requirements with larger stones
  • Likelihood of stone passing also affected by position
    • Stones at the vesicoureteric junction more likely to be passed than those in the proximal ureter

 

 

Download (PDF, 6.16MB)

Continue Reading