The incidence of acute torsion of the spermatic cord (TOSC) has been estimated to be 4.5 cases per 100,000 population.1 Others have cited an annual incidence of 1 in 4000 males under 25.2 While not especially common in the emergency department (ED), these cases are important to the patient, the clinician, and the consultants who might be needed. Sorting out the etiology can be vexing. Doing so frequently involves not only examination but also imaging and consultation with surgery or urology colleagues. When faced with an acutely swollen and painful scrotum, the surgeon must decide quickly whether or not to explore the scrotum, and if a testicular torsion is found, choose between testicular salvage and removal. Both decisions can have consequences for the patient. The outcome for the patient is as dependent on the time elapsed from the onset of the attack, as it is on the decisions of the surgeon.
A 14-year-old, previously healthy male presents to the ED on a typically busy Friday evening complaining of scrotal pain that started 2 days ago. His mom is visibly upset and states that the patient was taken to his primary pediatrician 2 days ago for a separate complaint, but he denied having pain despite being asked if anything else was bothering him. When questioned, the patient states he did have scrotal pain at that time, but he was too embarrassed to say anything. Further history reveals that the pain was acute in onset, sharp, left-sided, and has progressively gotten worse. He denies dysuria or other urinary complaints, and there have been no fever or chills. The patient denies suffering any trauma. He admits to nausea but has not vomited. The remainder of the review of systems is negative. The physical examination is remarkable for a tender, swollen left hemiscrotum. The left testis is high-riding compared to the right, and the patient fails to display a cremasteric reflex on the affected side. The right testis is nontender, and the remainder of the examination is noncontributory. You inform the patient’s mom of the likely diagnosis and of your plan to obtain an ultrasound and consult urology. As you walk down the hall, your mind is racing. Is this testicular torsion? What else could it be? How will you determine the diagnosis definitively? Is there something you should be doing right now? You have heard some people say that an attempt to manually detorse is indicated. Is that true? Can it make matters worse? If you do decide to do it, which way should you try to flip the testis? Will ultrasound guidance help you choose the best direction? You also realize the clock is ticking. How long has the problem been going on? When will the function of the organ become irreparably damaged? Is there a time limit on how long the testis itself can survive a torsion of its blood supply? What diagnostic studies should you order? Should you notify the urology 2011service now or wait till you know the diagnosis? Are there any pharmaceuticals you should administer to minimize the injury? If this teen had spoken up sooner, would the outcome have been affected? What should you do first?
Acute scrotal emergencies are not the most frequent crisis faced in an emergency department (ED). It is said that an acute scrotum occurs with 1/20th of the frequency of an acute abdomen.3 Cincinnati Children’s Hospital found that in a 2 year period, there were 238 acute scrotal emergencies which represented only 0.13 % of their ED patients.4 The incidence of acute TOSC has been estimated to be 4.5 cases per 100,000 population.1 Others have cited an annual incidence of 1:4000 males under 25, with torsion presenting most often during 2 time periods of a males life. The first peak in incidence involves those under a year of age, and the second peak occurs around age 13.2,5 These cases are important to the patient, the clinician, and the consultants who might be needed. Sorting out the etiology can be vexing. Doing so frequently involves not only examination but also imaging and consultation with surgery or urology colleagues. When faced with an acutely swollen and painful scrotum, the surgeon must decide quickly whether or not to explore the scrotum. If a testicular torsion is found, the surgeon must choose between testicular salvage and removal. Both decisions can have consequences for the patient.
This month’s issue of Pediatric Emergency Medicine Practice will delve into the problem of the male with a possible TOSC. The authors examine existing literature to develop a strong strategy for clinicians that explains what to do and when to do it in the diagnosis and treatment of TOSC.
Ovid MEDLINE® and PubMed were searched for literature published in core English-language clinical journals from 1970-2010 on the subject of human subjects aged 1 month to 18 years with TOSC. Search terms included torsion, testicular cord, and spermatic cord. Results containing patients with neonatal testicular torsion were excluded. This search resulted in 640 articles. Modifiers were added in order to filter the search. “Diagnosis” resulted in 160 articles, “treatment” in 119, “incidence” in 56, “ultrasound” in 65, “risk factors” in 19, and “outcomes” in 14. These lists were reviewed for appropriate articles as were the reference pages of thorough review articles and other papers related to testicular torsion.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.
Martin I. Herman; Jonathan Jacobs
October 1, 2011