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Testicular torsion more common at puberty.

NEW YORK -- Consider acute scrotal pain to be testicular torsion until proved otherwise, Dr. Richard N. Schlussel said at a meeting on pediatric surgery that was sponsored by Columbia University.

However, all scrotal swelling is not necessarily testicular torsion, said Dr. Schlussel, an assistant professor of urology at the university in New York.

Take a complete history, looking for symptoms such as pain at rest, severe pain, and nausea, which tend to correlate with torsion, he said.

Possible differential diagnoses include not only torsion of the spermatic cord, but also torsion of the appendix testis, torsion of the appendix epididymis, epididymitis/epididymo-orchitis, and inguinal hernia / communicating hydrocele.

Trauma is also important to consider, because it can precipitate testicular torsion, Dr. Schlussel said. "Don't discount trauma as something that precludes the diagnosis of torsion."

Other possibilities include dermatologic lesions or allergic reactions, Henoch-Schonlein purpura, idiopathic scrotal edema, tumor, and varicocele, he said.

Start your exam with a history including time of onset and prior episodes. Ask about sudden onset, pain at rest, swelling, severity of pain, nausea, redness, trauma, and family history, Dr. Schlussel advised, adding that no one symptom or physical finding is a litmus test for testicular torsion.

Don't forget to consider age, Dr. Schlussel said. Torsion can occur at any age but is much more common around the age of puberty when the testes start to grow and become more prone to twist. About 50%-60% of scrotal pain in adolescents is torsion, but in the preadolescent population, that figure drops to 25%-35%.

Inspect the area for redness and swelling; in early cases, there may be none, he said.

Check the cremasteric reflex, Dr. Schlussel advised. This reflex can be elicited by stroking the inside of the thigh, which causes the cremasteric fibers to contract and the testis to move upward to the upper scrotum. Almost no patients with a normal cremasteric reflex have testicular torsion, he said.

There are exceptions to this rule, but they are "few and far between," he said. However, if the patient doesn't have a normal cremasteric reflex, it doesn't mean he has testicular torsion, because it's a nonspecific finding that can happen with trauma, infection, hydroceles, and torsion of the appendix testis.

During the physical exam, if testicular torsion has occurred, the testis will generally lie horizontally and will be higher than the other testis.

Also, if the epididymis is in front of the testis, that might signify testicular torsion. When patients have torsion, the testis is diffusely tender, swollen, and the spermatic cord is knotted, he said.

In cases of testicular torsion, getting the patient to surgery quickly is critical to preserving the testis, Dr. Schlussel said. If surgery is performed within 8 hours after symptom onset, the testis can usually be saved.

However, after more than 12 hours, 75% are lost. Salvage rates are also higher with fewer degrees of twist.

Dr. Schlussel said he tells families to call him immediately, regardless of the time, if symptoms occur.

Postoperatively, Dr. Schlussel said, he checks the patient to be sure the testis was salvaged and to assess the testis size.

In cases where the testis was not salvaged during surgery, he counsels families about safe activities with a single testis. Generally, he advises patients that they can play competitive sports, but if they participate in contact sports, he insists that they wear a hard cup.

In terms of fertility, the longer the child had the symptoms prior to surgery, the poorer the fertility.

Fertility is also poorer if the nonviable testis is left in place, he said.
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Title Annotation:Clinical Rounds
Author:Schneider, Mary Ellen
Publication:Pediatric News
Date:Oct 1, 2006
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