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SCROTUM

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Scrotal pain is one of the most common urologic emergencies seen in boys. Although many causes of scrotal pain may not require an immediate organ-preserving procedure, some causes can lead to rapid and permanent loss of testicular function without timely intervention. Thus, the clinician must identify patients who need emergent diagnostic and/or therapeutic procedures and those who need observation and reassurance.

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TESTICULAR TORSION

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Consider testicular torsion in males with acute scrotal pain, because torsion is a urologic emergency. The estimated incidence of torsion in U.S. males younger than 18 years is 3.8 per 100,000 children.1 Testicular torsion has a bimodal age presentation, with one peak in the immediate neonatal period and another peak during early puberty. Because the testicle of neonates with true prenatal torsion is not salvageable, many urologists agree that neonates can be taken to the operating room on a semi-elective basis when the infant is a few months of age to decrease the anesthesia risk. However, in neonates who experience postnatal torsion, the salvage rate is likely similar to adolescent testicular torsion, making early surgical detorsion a priority. The clinical distinction between prenatal and postnatal torsion, however, is sometimes difficult to elucidate.2

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Most boys with testicular torsion present between 12 and 18 years of age. Classically, the pain is abrupt in onset and severe and is usually associated with nausea or vomiting. The testicle is extremely painful, and often the patient will walk with a wide-based gait to minimize the contact of the scrotum to the thigh. There may be a preceding history of a sports activity or even minor trauma to the area, which may lead the clinician to a misdiagnosis of traumatic injury. In some cases, the patient may recall episodes of previous scrotal pain that rapidly resolved without intervention, which may represent intermittent torsion with spontaneous detorsion. Patients with intermittent testicular pain should be referred for elective orchiopexy, as such patients with intermittent torsion are at risk for acute complete testicular torsion.3

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Classic physical examination findings of acute testicular torsion include a swollen, tender, high-riding testis, with an abnormal transverse lie. There are often scrotal skin changes. Ipsilateral loss of the cremasteric reflex is often noted, but the presence of a normal cremasteric reflex does not rule out torsion.4

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Doppler US is the diagnostic imaging study of choice,5 with radionuclide imaging a distant second. If the time to obtain diagnostic imaging may lead to delay of surgical intervention, advocate for emergent surgical exploration for highly suspected cases of torsion, rather than waiting for an imaging study to be completed. Time is especially critical if the duration of symptoms is <6 hours, as the salvage rate is excellent in such cases. Beyond 6 hours, the salvage rate becomes progressively worse, and after 48 hours of symptoms, the salvage rate is near zero. Patients presenting with equivocal signs of torsion may benefit from a Doppler US, which can visualize blood flow to the testis. In acute torsion, Doppler demonstrates an enlarged testis with decreased or absent flow compared with the unaffected side. In patients with suspected intermittent torsion who have a normal Doppler US and resolution of pain, counsel the patient and family to seek medical attention immediately should the pain recur, and recommend urologic follow-up as an outpatient.

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Several recent studies have attempted to develop clinical predictors for acute torsion, with the hopes of decreasing time to surgical intervention for true cases of torsion, reducing the rate of negative explorations, and ...

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