A Spooky Twist

Written by: Dr. Richard Gallardo

Edited by: Dr. Joann Hsu

Case Presentation

14 year old M with no significant PMH presenting for recurrence of left testicular pain and abdominal pain. Initially began suddenly yesterday at which time he presented to the ED and had an US negative for torsion. Pt tried taking Tylenol at home without relief. Also reports no known trauma to the testicles, dysuria, hematuria, nausea, or vomiting. 



Diagnosis… Testicular Torsion!



Testicular Torsion Overview

  • Defined as twisting of the spermatic cord and is considered a SURGICAL EMERGENCY! 

  • Accounts for about 10-15% of acute scrotal disease in children and has orchiectomy rates of about 42% in boys undergoing surgery

  • Of note, the presence of the cremasteric reflex does not confirm the absence of torsion

Presentation follows a bimodal distribution

  • First peak during the neonatal period - extravaginal torsion

    • May occur antenatally or in early postnatal period

    • Torsion of spermatic cord, epididymis, and testicle

  • Second peak is usually seen around puberty - intravaginal torsion

    • Most commonly associated with a bell clapper deformity - a congenital condition in which there is abnormal fixation of the testicle to the inner wall of the scrotum, thus, allowing for increased mobility of the testicle within the tunica vaginalis and predisposing patients to torsion

    • This predisposing anatomic condition is presumed to be bilateral and so patients must have both sides checked. 

Symptoms

  • Sudden, severe pain in the scrotum

  • Scrotal swelling

  • Abdominal pain

  • Nausea

  • Vomiting

  • Testicular position that is high riding or unusual angle

Role of Ultrasound in Diagnosis

  • Sensitivity 88.9-100%; Specificity 97-98.8%

  • Linear probe

    • Provides great balance between penetration and resolution

    • Great for detecting low flow systems

    • Side-by-side comparison

  • Positioning

    • Place towel underneath scrotum for support

    • Drape the patient as modestly as possible, exposing only as much as needed to perform the ultrasound

    • Patient may require frog-leg position

  • Views

    • Buddy view

    • Short and long views, fanning completely through each of the views

    • Color doppler of each testicle to measure blood flow

  • Tips

    • Use enough gel to eliminate gas trapped in the skin folds

    • Do no change settings when moving from one testis to the other to keep the comparison accurate between the unaffected and affected testicle

Initial Imaging

In this image from the patient’s initial visit, we note that there is adequate blood flow noted to bilateral testicles on gross visual assessment.

In this image from the patient’s second visit, we note that there is now no blood flow noted to the patient’s left testicles, highly concerning for torsion in this clinical context.

Short and Long Axis views

Testicular torsion is associated with many ultrasound findings. Below are some that can clue you in to a diagnosis of testicular torsion.

Reactive Hydrocele

Shown here is a hydrocele which is a finding that is sometimes associated with testicular torsion:

Heterogeneity

This is a testicles that appears to have heterogenous echotexture. This is a late finding (typically after 24 hours) and implies necrosis. The hypoechoic regions represent necrosis whereas the hyperechoic regions represent hemorrhage (can occur after reperfusion).

Resistive Index

Testicular torsion results in increased venous pressure and congestion with subsequent decreased arterial blood flow and ischemia. This translates to increased resistance of the vascular system and can be calculated as such. (Peak systolic flow - End diastolic flow) / Peak systolic flow. The image on the left represents a normal resistive index of <0.7. The image on the right represents a high resistive index of >0.7. In this right clinical context, this is suggestive of testicular torsion.  

Whirlpool Sign

This shows what is called the “Whirlpool sign”. This is due to the twisting of the spermatic cord contents. It is the most specific and sensitive finding in both complete and incomplete torsion.

Treatment and Prognosis

  • Rapid diagnosis and treatment with surgical detorsion/orchiopexy

  • “Time is testicle”

    • <6 hours ~ 100% viability 

    • 6-12 hours ~ 50% viability

    • 12-24 hours ~ 20% viability

  • Absent flow with heterogeneity suggests non-viability


Patient Follow-up

  • High concern for torsion based on bedside POCUS

  • Official US showed no blood flow in left testicle

  • Taken to OR for BL orchiopexy, both testicles viable

  • Discharged home same day

Happy scanning!

References

https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0002838X1360369X

https://www.mayoclinic.org/diseases-conditions/testicular-torsion/symptoms-causes/syc-20378270

https://pmc.ncbi.nlm.nih.gov/articles/PMC8112403/

https://www.sciencedirect.com/science/article/pii/S073386270400032X?via%3Dihub

https://radiopaedia.org/articles/testicular-torsion?lang=us

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