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
Xoắn tinh hoàn
True urologic emergency Delayed diagnosis and testicular loss
InfertilityCosmesisMedico-legal
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
Testicular Anatomy - Vascular Testicular artery
Branch off aortaMajor intra-testicular blood
supply
Cremaster and deferential arteryExtra-testicular
Cremaster a.
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
History
Severe unilateral scrotal pain
Previous episodes, spontaneous resolution
Related to activity, trauma, during sleep
Nausea, vomiting, abdominal pain, fever
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
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.
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
Logistics Linear Array (7-10 MHz) Scan asymptomatic side first
Positioning Frog leg positionDrape for support and elevationGenerous amount of warm gel
Ultrasound – B-Mode Compare echotexture
(straddle view)
Visualize each testicle in two planes
Ultrasound – B-Mode Normal: homogenous symmetric
Early ischemia: enlargement, no Δ echogenicity
Hemorrhage: hyperechoic areas in an
infarcted testis, heterogenous
• Late ischemia/infarct: hypoechoic
Ultrasound: Color Doppler
NormalIntratesticular artery
TorsionArterial flow absentNormal / increased
in detorsion
Ultrasound: Color Doppler
Early TorsionNo flow, echogenicity similar
Late TorsionHeterogenous echotextureIncreased extra testicular
blood flow
Ultrasound: Spectral Doppler
Arterial waveform Venous waveform
Ultrasound: Spectral Doppler
Extratesticular blood flow- High resistance, low flow
Intratesticular blood flow- Low resistance, high flow
Ultrasound – Power Doppler Power doppler
Increased sensitivity in low flow statesMeasures power of doppler signalPrepubertal patient
Ultrasound: other diagnosis Epididymitis Scrotal abscess Torsion of epididymal appendage Intratesticular hematoma
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
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
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
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
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)