MEDizzy - A 10-year-old boy presents to the emergency room with pain

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Urology

A 10-year-old boy presents to the emergency room with pain in the left testicle. The pain was acute in onset and began 1 hour ago. On physical examination, he is noted to have a high-riding, firm, and markedly tender left testis. The right testicle is normal. Urinalysis is unremarkable. Which of the following is the most appropriate management of this patient?

ExplanationD. The patient’s presentation is consistent with testicular torsion and he needs to be taken to surgery immediately. During surgery, the affected testicle is rotated to its normal position. If it is viable, orchiopexy is performed on both the affected and the unaffected testes because the unaffected testes has a greater-than-normal chance of torsion in the future. If the affected testicle is nonviable, orchiectomy is performed with orchiopexy of the nonaffected testicle. Manual detorsion can be attempted by external rotation of the testicle toward the thigh, but the patient still needs to be taken to surgery following the initial presentation of testicular torsion. If left untreated, testicular torsion leads to strangulation of the blood supply to the testicle. Testicular torsion usually occurs in adolescent boys 12 to 18 years of age. The underlying pathology is secondary to an abnormally narrowed testicular mesentery with tunica vaginalis surrounding the testis and epididymis in a bell clapper deformity. As the testis twists, it comes to lie in a higher position within the scrotum. Presentation is acute onset of testicular pain and/or swelling. Diagnosis of testicular torsion is mainly made with clinical presentation and examination. A technetium 99m ( 99mTc) pertechnetate scan or Doppler ultrasound may be helpful in making the diagnosis if clinical suspicion of torsion is low; however, operation should not be delayed in order to maximize testicular salvage. This patient’s presentation warrants immediate operation. If treated within the first 4 to 6 hours of onset of symptoms, the chance of saving the testicle is high.