Case Discussion: “Don’t Forget the Testis”

By: Muhamad Na’im B. Ab Razak

4^th year medical student, University Sains Malaysia.

15 years old Malay boy with history of imperforated anus and has undergone surgery presented with sudden onset lower abdominal pain that occurs during sleep which is sharp in nature, radiating to the left thigh 3 hour before the admission and associated with one episode of fainting after micturation. FBC shows elevated white blood cell and his blood pressure is low for two readings.

Discussion

Since patient has history of imperforated anus and underwent surgery, there should be high suspiciousness of bowel problems. Elevated white blood cell count may suggest the infection.

However, when patient presenting with acute abdomen, one should always be suspicious of non-abdominal cause of the pain especially if the location of the pain is at the lower abdomen. Therefore, the adjacent organ like uterus, bladder, kidney and testis must be examined.

The examination of the testis reveals elevated left testis, negative translumination test, swelling, tender to palpation and the pain increase upon elevation of left testis. (Differentiate it from epididymitis in which elevation of testis reduce the pain-Prehn sign)

Ultrasound was done however normal. But, based on history and physical investigation, a diagnosis of testicular torsion has been made because ultrasound may shows false negative or false positive result. Identification of Testicular torsion is so important as patient may lose their testis if there is delayed in intervention. There has been a case whereby a patient presented with lower abdominal pain with sign of urinary tract infection was discharge with antibiotic come back 72 hours later with testicular gangrene.

Differential diagnosis includes Epididymitis, orchitis, epididymo-orchitis, Hydrocele, Testis tumor and Idiopathic scrotal edema.

Testicular torsion is uncommon because normal testis is anchored by tunica vaginalis to the posterolateral surface of the testis, hence allows a little mobility of the testis.

Abnormality that may lead to testicular torsion includes inversion of the testis, high investment of the tunica vaginalis causing testis to hang within tunica like a clapper in a bell and separation of epididymis from the body of the testis.

Testicular torsion particularly occurs in age group 10 and 25 years old with the peak age is 14 years old. It is often involves the left testis.

Signs and Symptoms vary with degree of torsion. Usually patient may present with sudden onset of severe unilateral scrotal pain that may occur 1) with activity 2) trauma or 3) during sleep, scrotal swelling, nausea and vomiting, abdominal pain, fever, urinary frequency, horizontal lie of testis, edematous testis, scrotal erethyma, ipsilateral loss of cremastic reflex and pain upon elevation of testis.

Doppler ultrasound may confirm the absence of the blood supply to the affected testis.

In the first hour of presentation, gentle manipulation of testis may be performed. However, one’s should be prepared for the emergency surgery. Exploration of torsion may be performed through scrotal incision. Prevention of re-twisting may be done by suturing the tunica vaginalis and tunica albuniae with absorbable suture material.

Consent for orchidectomy must be taken as gangrenous testis needs to be removed. A proper counseling must be given to the patient including the placement of prosthetic testis.

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Reference

1) Leslie Tackett McQuiston, "Testicular Torsion", eMedicine

http://emedicine.medscape.com/article/438817-overview

2) Norman S. Williams, Christopher J.K. Bulstrode & P. Ronan O’Connel, “Bailey & Love’s Short Practice of surgery”, 25^th edition, Edward Arnold Ltd, 2008.

3) Timothy J Rupp, "Testicular Torsion", eMedicine

http://emedicine.medscape.com/article/778086-overview