WIDI - R6) Severe testicular pain and absent cremasteric reflex

R6) Severe testicular pain and absent cremasteric reflex

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with testicular pain.
Review the DDx considerations in testicular pain.
Identify the spectrum of imaging findings in appropriate modalities for evaluating patients with testicular pain.

History

An 18-year-old male presents to the ED with worsening, severe right testicular pain and swelling radiating to the abdomen that began the day prior. The patient also endorses nausea and vomiting.

Physical Exam

BP: 123/86, HR: 99, RR: 15, Temp: 37C, O2 saturation: 99%. General: Uncomfortable. Abdominal: pain radiating to the right abdomen and right inguinal area. GU: tender right testis with scrotal elevation (high-riding testis) and absent cremasteric reflex. The pain does not improve with elevation of the scrotum.

Labs

None.

Provisional Diagnosis

Select the Dx you believe is most appropriate

Epididymitis

Testicular hematoma

Testicular tumor

Testicular torsion

Inguinal hernia

This patient’s presentation is most concerning for testicular torsion given his age, sudden onset of testicular pain, and absent cremasteric reflex with a negative Prehn sign.

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

This patient requires emergent workup for his condition. Testicular torsion is a medical emergency with irreversible testicular damage occurring after 6-12 hours of torsion due to ischemia and subsequent infarction.

First Imaging Study

What is the first imaging study you will order?

Pelvic CT

Pelvic MRI

Scrotal ultrasound with Doppler

Scrotal ultrasound with Doppler can help evaluate any structural abnormalities and reduced blood flow to the affected testis to confirm the clinical diagnosis of testicular torsion.

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Scrotal ultrasound with Doppler

There is reduced blood flow to a testicle

Yes

The Doppler ultrasound reveals reduced blood flow to a testicle.

The blood flow to which testicle is reduced?

Right

Left

N/A

Based on the scrotal ultrasound with Doppler findings, the blood flow to the right testicle is reduced likely due to torsion involving of the vascular pedicle.

Compared to the left testicle, the right testicle is

Enlarged with heterogeneous echotexture

Enlarged with homogeneous echotexture

Smaller with heterogeneous echotexture

Smaller with homogeneous echotexture

Enlarged testis with heterogeneous echotexture is a late finding that suggests developing testicular necrosis.

View Report

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View the full study if you'd like to take a look yourself.

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Second Imaging Study

What is the next imaging study you will order?

Abdominal CT

MRI

Fluoroscopy

None

No further imaging is needed as the clinical diagnosis of testicular torsion was confirmed with ultrasound.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Epididymitis

Inguinal hernia

Testicular torsion

Testicular hematoma

This patient has testicular torsion based on his clinical history and ultrasound findings,

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

The patient will require immediate exploratory surgery or manual testicular detorsion (if surgery is not immediately available).

Assessment and Plan

Please provide your assessment and plan for this patient

This patient is presenting with testicular torsion of the right testis. He will require an emergent urology consultation for surgical exploration of the scrotum with reduction (untwisting) and orchiopexy if the testicle is viable. Manual testicular detorsion with appropriate analgesia and sedation should be attempted if surgical services are not immediately available.

Lessons Learned:
- Testicular torsion is most common during the neonatal period (first 30 days of life) and puberty.
- Testicular torsion is a medical emergency with irreversible damage occurring after 6-12 hours of torsion due to ischemia and possible infarction.
- Scrotum ultrasound with Doppler serves to confirm the clinical diagnosis of testicular torsion. Positive ultrasound findings include reduced blood flow to the affected testis and enlargement with or without heterogeneous echotexture.

Socioeconomic Factors:
- In a study, patients without private insurance had increased risk of undergoing an orchiectomy versus a testicle sparing salvage procedure.
- Lower socioeconomic groups experience higher rates of delay in testicular torsion treatment due to farther distance from hospitals.

That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.

Contributors:
Sean Kwak, MS2 - Content Contributor
Haoyu Wang - Content Contributor
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator