turandot saul, m.d. february 20, 2008. xo ắ n tinh hoàn true urologic emergency delayed...
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Turandot Saul, M.D.
February 20, 2008
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Xoắn tinh hoàn
True urologic emergency Delayed diagnosis and testicular loss
InfertilityCosmesisMedico-legal
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Testicular Anatomy - Tunica Tunica vaginalis
Posterolateral surface of testicle Limits mobility
Bell clapper deformityCongenital12% of males40% bilateral
Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice
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Testicular Anatomy - Vascular Testicular artery
Branch off aortaMajor intra-testicular blood
supply
Cremaster and deferential arteryExtra-testicular
Cremaster a.
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Testicular Torsion
Testicle rotates on spermatic cord
Venous occlusion, edemaArterial ischemiaInfarction 720º necessary to
compromise testicular a.Males, peak 14 years
Image: Behrman: Nelson Textbook of Pediatrics
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History
Severe unilateral scrotal pain
Previous episodes, spontaneous resolution
Related to activity, trauma, during sleep
Nausea, vomiting, abdominal pain, fever
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Physical Elevated testicle, tender Loss of cremaster reflex Thick, tender spermatic cord
Brunzel sign – horizontal lie Ger sign - skin pitting at the scrotal base Prehn sign – persistent pain despite elevation
Image: American Family Physician
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Diagnosis
Clinical suspicion Nuclear scintigraphy
Radiation, limited availability
UltrasoundAltered echotexture (B-mode)Vascular flow (Color / Spectral / Power Doppler) Alternative diagnosisOperator dependent
Image: Ferri's Clinical Advisor 2008, 10th ed.
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Ultrasound for Testicular Torsion
Sensitivity 86%, specificity 100% experienced provider using color / power doppler1
EPs capable of diagnosing with bedside ultrasound2
1Burks et al. Suspected testicular torsion & ischemia: Eval w color doppler. Radiology 1990;175:815-212Blaivas et al. Ultrasonographic diagnosis of testicular torsion by EM physicians. AM J Emerg Med 2000;18:198-200
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Logistics Linear Array (7-10 MHz) Scan asymptomatic side first
Positioning Frog leg positionDrape for support and elevationGenerous amount of warm gel
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Ultrasound – B-Mode Compare echotexture
(straddle view)
Visualize each testicle in two planes
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Ultrasound – B-Mode Normal: homogenous symmetric
Early ischemia: enlargement, no Δ echogenicity
Hemorrhage: hyperechoic areas in an
infarcted testis, heterogenous
• Late ischemia/infarct: hypoechoic
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Ultrasound: Color Doppler
NormalIntratesticular artery
TorsionArterial flow absentNormal / increased
in detorsion
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Ultrasound: Color Doppler
Early TorsionNo flow, echogenicity similar
Late TorsionHeterogenous echotextureIncreased extra testicular
blood flow
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Ultrasound: Spectral Doppler
Arterial waveform Venous waveform
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Ultrasound: Spectral Doppler
Extratesticular blood flow- High resistance, low flow
Intratesticular blood flow- Low resistance, high flow
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Ultrasound – Power Doppler Power doppler
Increased sensitivity in low flow statesMeasures power of doppler signalPrepubertal patient
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Ultrasound: other diagnosis Epididymitis Scrotal abscess Torsion of epididymal appendage Intratesticular hematoma
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Pitfalls
False negatives: post-torsion hyperemia, capsular blood flow, power doppler motion artifact
False positives: small testicular volumes
Either: inappropriate gain settings
Atypical presentations mimic epididymitis, appendicitis, renal colic
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Treatment
Definitive treatment: surgical detorsion and orchioplexy
Manual detorsion: medial to lateral; “opening a book”May need to rotate 2-3 times for
complete detorsion
Roberts: Clinical Procedures in Emergency Medicine
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Testicular Viability
Salvage rate100% detorsed at 3 hours85% at 5 hours75% at 8 hours60% at 10 hours10-20% > 10 hours0% > 24 hours
1Pratter JM et al. Testicular torsion: a surgical emergency. Am Fam Physician 1991;44:834-840
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Summary Use saddle view to compare bilaterally B-mode to compare echogenicity Color / Spectral / Power Doppler for flow Image normal side first to set gain settings
Consider clinical picture
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References Burks et al. Suspected testicular torsion & ischemia: Eval w color doppler.
Radiology 1990;175:815-21 Pratter JM et al. Testicular torsion: a surgical emergency. Am Fam
Physician 1991;44:834-840 Ferri: Ferri's Clinical Advisor 2008, 10th ed. Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed. Roberts: Clinical Procedures in Emergency Medicine, 4th ed.Dogra, VS etal.
Sonographic Evaluation of Testicular Torsion. Ultrasound Clinics; 2006. Blaivas et al. Ultrasonographic diagnosis of testicular torsion by EM
physicians. AM J Emerg Med 2000;18:198-20 Ringdahl, E et al. Testicular Torsion. American Family Physician
2006;74(10)