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An atypical presentation of testicular torsion: a case report.

Introduction

Testicular torsion is a urologic emergency in which twisting of the spermatic cord results in ischemic injury to the affected testicle. The incidence has been widely reported as affecting 1 in 4000 males under the age of 25 and accounting for 25-33% of acute scrotum cases in the pediatric population. (1,2) Patients most commonly present with testicular pain, a high-riding testicle with a possible horizontal lie, and an absent cremasteric reflex on the affected side. Presenting symptoms may also include abdominal pain, nausea and vomiting, and a general ill appearance. Unfortunately, these symptoms overlap with other conditions including acute epididymo-orchitis, and quite often it is scrotal exploration that confirms the diagnosis. In this article we present a case of testicular torsion which was atypical in its etiology and presenting symptoms.

Case Report

An 18 year old Mexican male presented to the emergency department (ED) after sustaining a fall at a construction site. He fell approximately 7-10 feet out of a window and landed straddling a pile of lumber. He arrived in the ED four hours later and upon immediate examination, was observed to be resting comfortably in bed. He exhibited no signs of distress and complained only of moderate (6/10) pain in his left testicle. The testicle was tender, appearing high-riding and with a horizontal lie. His cremasteric reflex was absent on the left side but present on the right. Color doppler ultrasound revealed absent blood flow to the left testicle (Figure 1), thus the patient was urgently taken to the OR for scrotal exploration and evaluation for testicular torsion.

Intraoperatively, the left spermatic cord was discovered to be torsed 720 degrees, resulting in a dusky, deep purple appearance of the left testicle. After manual detorsion we bathed the testicle in 30cc of papavarine with 10cc doses every 15 minutes and following a significant waiting period, it appeared to return to its natural color. We deemed it salvageable and performed a bilateral orchiopexy. The patient was ultimately discharged home the next morning and follow-up imaging 3 weeks later confirmed normal testicular blood flow (Figure 2). He continued to do well at 3 and 6 month follow up visits with normal testicular examinations and no complaints of scrotal pain.

Discussion

Testicular torsion was first described by Delasiuave in 1840 and the first review article on isolated case reports was written in 1901 by Scudder. (3) Torsion may be extravaginal (proximal to the tunica vaginalis) or intravaginal (within the tunica vaginalis). Intravaginal torsion and its associated bellclapper deformity (defect of testicular mesentery) occurs in 65-80% of cases. Other congenital factors associated with torsion include hypermobile testes, horizontal testicular lie, hyperactive cremasteric reflex and defective gubernacular attachment. (4) As torsion is a time-sensitive condition, delayed presentation and longer symptom duration lead to higher rates of orchiectomy. Multiple series including two meta-analyses by Visser and Heyns report testicular salvage rates of 90% if detorsion is performed within 6 hours of the onset of symptoms, 50% at 12 hours and 10-25% at 24 hours. (4-6,10)

One unique aspect of our patient's case of testicular torsion was the traumatic etiology. Traumatic torsion as a clinical entity has a reported incidence of 4-8%, (5,7) discussed in the literature as isolated case reports. Salvage rates have been reported in the range of 0-100%, with results being time-dependent. As trauma is an uncharacteristic cause of torsion, multiple pitfalls exist in the proper diagnosis and treatment. Patients may be delayed in presentation due to thinking that their symptoms were due to trauma only and would resolve over time. (5,8) Physicians may also be more inclined to clinically diagnose the condition as a traumatic scrotal hematoma or even acute epididymo-orchitis, thus further delaying treatment. One may also consider hydrocele or hematocele in the differential diagnosis. One report cited misdiagnosis (74%) as the leading cause of malpractice claims related to testicular torsion; acute epididymitis/epididymoorchitis were the suspected diagnoses and interestingly, 3 of the 28 misdiagnosed cases were deemed traumatic in origin. (9) As such, one must be wary not to overlook traumatic insult as a cause of torsion and our patient's presentation with a straddle injury provided an opportunity for this important consideration. Table 1 presents our suggested list of differential diagnostic considerations for causes of atypical testicular torsion.

Our patient's lack of distress also provided an obstacle to the torsion diagnosis. Four hours post-injury, he complained only of left testicular pain without associated symptoms. Aside from the characteristic appearance of the scrotum/testicle, torsion patients tend to appear visibly uncomfortable due to their significant amount of pain. Considerable pain, testicular/ scrotal edema and an indurated, dark-appearing testicle are the most common presenting symptoms. Further, nausea, vomiting and abdominal pain may be experienced in 5-7% of cases. (11) Unfortunately, other conditions such as epididymitis may present itself in a similar fashion, with pain and edema being present more than half of the time, and scrotal erythema noted in approximately one-third of patients. (11) This case demonstrates a situation where an atypical etiology and uncharacteristic presentation may have prevented the proper diagnosis from being made.

Conclusion

Testicular torsion of a traumatic etiology is a rare, yet significant injury which, due to its rare occurrence and atypical patient presentation, may deter evaluating physicians from making an accurate diagnosis. One must be vigilant and strongly consider torsion in the differential diagnosis of traumatic testicular injury. A high clinical index of suspicion is paramount in avoiding a misdiagnosis and potential loss of the affected testicle.

References

(1.) Williamson, RC. Torsion of the testis and allied conditions. Br J Surg, 1976;63(6):465-476.

(2.) Sessions AE, Rabinowitz R, Hulbert WC, Goldstein MM, Mevorach RA. Testicular Torsion: direction, degree, duration and disinformation. J Urol, 2003;169(2):663-665.

(3.) Scudder CL. Strangulation of the Testis by Torsion of the Cord. A Review of All Recorded Cases, together with the Report of One Recent Case. Ann Surg, 1901;34(2):234-248.

(4.) Chan JL, Knoll JM, Depowski PL, Williams RA, Schober JM. Mesorchial Testicular Torsion: Case Report and a Review of the Literature. Urology, 2009;73(1):83-86.

(5.) Seng YA and Moissianc K. Trauma induced testicular torsion: a reminder for the unwary. J Accid Emerg Med, 2000;17(5):381-382.

(6.) Ringdahl E and Teague L. Testicular Torsion. Am Fam Physician, 2006;74(10):1739-1743.

(7.) Elsaharty S, Pranikoff K, Magoss IV, Sufrin G. Traumatic torsion of the testis. J Urol, 1984;132(6):1155-1156.

(8.) Bayne AP, Madden-Fuentes RJ, Jones EA et al. Factors associated with delayed treatment of acute testicular torsion--do demographics or interhospital transfer matter? J Urol, 2010;184(4 Suppl):1743-1747.

(9.) Matteson JR, Stock JA, Hanna MK, Arnold TV, Nagler HM. Medicolegal aspects of testicular torsion. Urology, 2001;57(4):783-786.

(10.) Visser AJ and Heyns CF. Testicular Function after Torsion of the Spermatic Cord. BJU Int., 2003;92(3):200-203.

(11.) Makela E, Lahdes-Vasama T, Rajakorpi H, Wikstrom S. A 19-year review of paediatric patients with acute scrotum. Scand J Surg, 2007;96(1):62-66.

Robert Jansen, MD

Chief Resident, Division of Urology, WVURCBHSC

Henry Fooks, MD

Assistant Professor, Division of Urology, WVURCBHSC

Stanley Zaslau, MD, MBA, FACS

Program Director, Professor and Chief, Division of Urology, Department of Surgery, WVURCBHSC

Table 1: Differential diagnostic
considerations for causes of
atypical testicular torsion.

* Acute epididymitis

* Epididymo-orchitis

* Hydrocele

* Hematocele

* Scrotal hematoma

* Trauma to inguinoscrotal region
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Article Details
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Title Annotation:Scientific Article
Author:Jansen, Robert; Fooks, Henry; Zaslau, Stanley
Publication:West Virginia Medical Journal
Article Type:Clinical report
Geographic Code:1U5WV
Date:Sep 1, 2013
Words:1228
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