Paediatrics

Question 1

Define testicular torsion

Answer 1

A urological emergency caused by the twisting of the testicle on the spermatic cord leading to constriction of the vascular supply and time-sensitive ischaemia and/or necrosis of testicular tissue

Question 2

Describe epidemiology of testicular torsion

Answer 2

• Bimodal - extra vaginal affecting neonates in the perinatal period, and intra-vaginal affecting males at any age (most commonly adolescent)
• In males under 25, annual incidence is 1 in 4000 in the US
• Generally doesnt affect the elderly

Question 3

List risk factors for testicular torsion

Answer 3

• Under 25 (12-18)
• Neonate
• Bell clapper deformity (testicles rotate freely within the tunica vaginalis)
• Trauma/exercise
• Intermittent testicular pain
• Undescended testicle
• Cold weather

Question 4

List symptoms of testicular torsion

Answer 4

• Testicular pain
• Intermittent or acute on-and-off pain
• No pain relief on elevation of the scrotum
• Nausea and vomiting
• Abdominal pain
• Fever and urinary frequency

Question 5

List signs of testicular torsion

Answer 5

• Scrotal swelling or oedema
• Scrotal erythema
• Reactive hydrocele
• High riding testicle
• Horizontal lie
• Absent cremasteric reflex
• Prehns sign (not relieved by lifting testes)

Question 6

List investigations of testicular torsion

Answer 6

• Grey-scale ultrasound (fluid and whirlpool sign)
• Power doppler ultrasound (absent or decreased blood flow in the affected testicle)
• Colour doppler ultrasound (absent or decreased blood flow)
• Spectral doppler (asymmetrical vascular perfusion)
• Urinalysis
• FBC
• CRP
• Scintigraphy (decreased uptake)
• Exploratory surgery

Question 7

Describe treatment of testicular torsion in non-neonates

Answer 7

• Immediate urological consultation for emergency scrotal exploration + morphine + ondansetron
• Fix other side
• Alternatively manual de-torsion with scrotal exploration (open book method) + morphine + ondansetron

Question 8

Describe treatment of testicular torsion in neonates

Answer 8

With torsion at birth
- Initial stabilision, urological consultation and semi-elective scrotal exploration + morphine sulfate and ondansetron)

With normal testes at birth

• Emergency scrotal exploration. Fixing testes (orchidopexy) with 3 stitches, on both sides to prevent recurrence.
• Morphine sulfate and ondansetron

Question 9

List complications of testicular torsion

Answer 9

• Infarction of testicle/ permanent testicular damage/ loss of testicles
• Infertility
• Psychological implication (offer prosthetic device)
• Cosmetic deformity
• Recurrent torsion
• Impaired pubertal development

Question 10

Describe prognosis of testicular torsion

Answer 10

• The longer it takes for diagnosis and definitive repair, the greater the likelihood that the patient will develop tissue necrosis, decreased tissue viability, decreased spermatogenesis, and possible infertility.
• Can recur

Question 11

Describe hydatid of morgagni

Answer 11

• A torsion of the appendix testes
• Will heal itself and fall off.
• Presents similarly to testicular torsion.
• Blue dot sign on testicle may be seen