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An Emergency Case!
Year 4 Medical Student | Hakimah Khani Binti Suhaimi| Nor Aini Binti Mohamad
4/24/12
Chief Complaint
4/24/12
3 hours prior to admission Sudden onset Constant Severe Sharp Right hemiscrotum Radiated to right suprapubic region Gradually became swollen One bout of vomiting
Several prior episodes have occurred in the past, but have always only lasted a few minutes.
No history of trauma
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No urinary symptoms
Age of patient?
Is pain present and what has been its duration? Timing of pain onset gradual vs. sudden? Have there been similar episodes in the past? Is there a history of STDs, urinary tract infections, or recent urethral discharge?
Is there a history of recent scrotal or perineal trauma? Have there been systemic symptoms such as fever, emesis, anorexia or weight loss and lymphadenopathy?
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Physical Examination
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On Examination . . .
On examination, the right testis appears to have assumed a horizontal lie and is considerably higher in the scrotum. The cremasteric reflex is absent. Both the testis and epididymis are tender. The cord can only be palpated high in the scrotum.
Consistency?
Transillumination is negative.
Phrens sign?
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Summar y
Mr P, 17, presented with 3 hours history of sudden, constant, severe pain in right hemiscrotum radiated to suprapubic region assoc. with one episode of vomiting. No history of trauma and no urinary symptoms. Had similar episodes of pain with shorter
duration.
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Possible Diagnoses?
q
Testicular torsion Testicular appendiceal torsion Epididymo-orchitis Orchitis Acute Hematocele Incarcerated inguinal hernia Varicocele
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Investigations
Investigations done on this patient:
Upon urgent referral for urologic assessment, Mr P is immediately taken to the OR for exploration.
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Investigations
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Treatment
Seven hours after the onset of pain, the testis is found to be but ischemic ultimately and dusky in its appearance recovers
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Discussion
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Epidemiology
q
extra-vaginal torsion affecting neonates intra-vaginal torsion affecting males of any age but most commonly adolescent boys.
In males <25 years of age, the annual incidence of torsion is 1 in 4000 in the US
BMJ last updated: Sept
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Risk factors
q
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Pathophysiology
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venous occlusion engorgement arterial occlusion ischemia and infarction The degree of torsion the testicle endures may play a role in the viability of the testicle over time.
If the testes remain torsed >10-12 hours ischaemia and irreversible testicle damage are likely After 12 hours, necrosis most likely has occurred.
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Diagnosis is Critical!
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Take-home Messages
q
Sudden onset of severe scrotal pain demands urgent urological attention to rule out torsion or hemorrhagic tumour
If clinical suspicion for torsion is high, waiting for an ultrasound is not advisable
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Medic ogal!! le !
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References
q
The Scrotal Mass: Ensuring a Correct Diagnosis The Canadian Journal of CME / February 2007
http://www.stacommunications.com/journals/cme/2007/February%202007/0
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Bailey & Loves Short Practice of Surgery 25th Edition Browses Introduction to The Symptoms and Signs of Surgical Disease
Failure to Diagnose Testicular Torsion Clinical Practice: Risk Management / AFP July 2003
Thank you
4/24/12