Case (5)

[Admin]

Musa Ali is a 14-year-old adolescent male, who is a keen soccer player. He is brought to the emergency
department by his parents having woken in the night with severe pain in his scrotum. On examination he is
systemically well but in obvious distress. The right side of the scrotum appears swollen, congested and
remarkably tender to palpation. He underwent an exploratory operation.
Questions:
1 What is the most likely diagnosis?

2 What other diagnosis would you consider?

3 What would the testis look like and how might this influence  treatment?
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Thanks
By: Dr.Mahdi 

[Admin]

The 15 point of this case goes to Mustafa, who answered it correctly and this was his answer:

Assalamu Caleikum
 
1. The clinical presentation of our patient is suggestive for testicular torsion.
explanation: Patients  classically present with an abrupt onset of severe testicular or scrotal pain, usually of less than 12 hours duration. Patients may have associated nausea and vomiting . The pain can be isolated to the scrotum. A typical presentation, particularly in children, is for the patient to awaken with scrotal pain in the middle of the night or in the morning. Many boys report a previous episode of pain.
On physical examination, the scrotum may be edematous and the affected testis usually is tender, swollen, and slightly elevated because of shortening of the cord from twisting. The testis may be lying horizontally, displacing the epididymis from its normal posterolateral position. An examination reveals a swollen, tender, retracted testicle (bell-clapper deformity). The cremasteric reflex (elevation of the testis in response to stroking of the upper inner thigh) is absent in nearly all cases of torsion, but it also may be absent in boys without torsion, particularly if they are younger than 30 months.
2. Alternative diagnosis would be appendical torsion or acute epididymitis as it may be indistinguishable from testicular torsion.
3. The treatment for a torsed testicle that remains viable involves surgical detorsion and fixation (orchiopexy) of both testes. Orchiectomy is performed if the testicle is nonviable. The viability of a torsed testicle is dependent on the duration and completeness of torsion.
According to three articles, typical rates of viability according to duration of torsion have been described as follows
Detorsion within 4 to 6 hours — 100 percent viability
Detorsion after 12 hours — 20 percent viability
Detorsion after 24 hours — 0 percent viability
take home message: an immediate consultation to urologist must be made at the emergency department. Surgery performed within 4 to 6 hours of onset of pain has better than a 90% testicular salvage rate. Therefore, unless the evidence for a competing diagnosis is overwhelming, surgery should not be delayed by diagnostic studies such as Doppler ultrasound. As a temporizing measure, the emergency physician may attempt to manually detorse the testicle by elevating the affected testicle toward the inguinal ring and rotating the epididymis medially .
 
WSC WR WB
 
Mustafa

Thanks Dr.Mustafa