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Testicular torsion is a surgical emergency, and clinicians caring
for adolescent males must have a high index of suspicion given the
short window for salvage of the testicle. Common presentation includes
abrupt onset of severe scrotal pain with associated nausea, vomiting,
fever, and abdominal pain.1-3 Symptomatic males
may describe prior transient episodes of scrotal pain consistent
with intermittent torsion/detorsion.1 The
exact etiology of torsion is unknown. However, a well-described
anatomical abnormality called the “bell clapper” deformity can
predispose to testicular torsion (see Figure 75-1).
In this deformity, the tunica vaginalis completely surrounds the
testicle, including the posterior aspect, and the absence of the
normal posterior anchoring allows the testicle to twist freely.
On physical examination, if the adolescent presents early, the testicle
may have a horizontal lie with minimal swelling.1-3 Typically,
the adolescent presents later, and the scrotum is swollen, tender,
erythematous, and often difficult to examine.1-4 The
cremasteric reflex is nearly always absent.1-3 Diagnosis can be made on physical examination
or with the assistance of color Doppler ultrasound, which has a
sensitivity of 89% to 100% and a specificity of
77% to 100%.2,4 Time is of the essence
because testicular viability declines to zero after 24 hours.2-4 Treatment
involves prompt surgical exploration and detorsion. Given the high
incidence of retorsion, as well as torsion of the contralateral
testis, once detorsed, the affected testis and the contralateral
testis are fixed to the scrotum in a procedure called scrotal orchiopexy.2,3
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Both the testis and the epididymitis have appendages (see Figure 75-2) that are remnants of the wolffian
and müllerian ducts, respectively.3 The
typical presentation of appendiceal torsion occurs in boys ages
7 to 12 years and includes pain that may be accompanied by nausea
and vomiting.2 Palpation of the testis reveals
tenderness over the superior or inferior pole of the testes with
or without a palpable mass.5 The cremasteric reflex
is usually present. The classic “blue dot” sign,
if present, represents the infarcted appendage viewed through the
scrotal skin.1,3,5 The diagnosis is usually made
on clinical examination. If torsion of the testis cannot be ruled
out, a color flow Doppler examination is indicated.5 Treatment
is usually supportive, including analgesics, anti-inflammatory agents, and
scrotal elevation.1 If pain persists for longer than
5 days, consultation by a pediatric urologist is recommended.3
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Trauma may be a cause of pain and swelling ...