Take Notes

1. mengapa pada torsio testis terdapat gejala mual dan muntah?

testis diinervasi oleh saraf simpatik yang berasal dari segmen T10-L1, dan parasimpatis berasal dari segmen S2-4,
yang juga mempersarafi bagian pencernaan. sehingga nyeri disertai dengan gejala gastrointertinal berupa mual dan
muntah.

2. bagaimana cara mendiagnosis torsio testis dengan usg doppler?

USG Doppler digunakan untuk menilai kecepatan aliran darah pada arteri testikularis, yang merupakan gold standar
dengan sensitivitas 82-90% dan spesifitas 100%. Pada torsio testis akan terlihat hypoechoic dan pembesaran pada
testis, namun hal ini berkaitan dengan derajat terpuntirnya testis yaitu 180-720, pada derajat yang lebih kecil
mungkin menunjukan hyperecho yang akan menyerupai epididymitis dan orchitis.

3. kapankah harus digunakan USG Doppler? Apakah pada setiap kasus torsio testis?
Pada score twist yang medium risk

4. Td disebutkan bahwa gold standarnya 6 jam dan nilai kesuksesannya 90-100%. Pada
kasus seperti apa 10%nya terjadi infark testis?

Torsion Infarction onset

3 2 hours

1 12-24 hours

<1 >24 hours

5. apa yang dimaksud dengan sindroma/ anomali bell clapper?

Failure of normal posterior anchoring of the gubernaculum, epididymis and testis is called a bell clapper
deformity because it leaves the testis free to swing and rotate within the tunica vaginalis of the scrotum
much like the gong (clapper) inside of a bell. Twisting of the testis on the axis of the spermatic cord is
called spermatic cord torsion. The twisting causes edema of the spermatic cord resulting in obstruction of
the lymphatic, then venous and finally arterial vessels to the testis. When the arterial supply is impaired,
testicular ischemia results. If a boy has had pain and swelling for 8 hours due to spermatic cord torsion,
there is a 50% chance that the testis will be lost. Therefore, prompt diagnosis and treatment are very
important.

6. Perlukah testis yang nekrosis dibuang? mengganggu fertilitas ga?

Testicular torsion with subsequent ischemia destroys the blood-testis barrier and allows the formation of
autoantibodies, which cause a contralateral testicular damage. Furthermore, reflectory vasoconstriction can cause a
contralateral testicular damage.
incidence of apoptosis was increased in the contralateral testes in all patients. Apoptosis occurred predominantly in
spermatocytes, early and late spermatids, and Sertoli's cells. In contrast, spermatogonia, peritubular connective
tissue (fibroblasts and myofibroblasts) and endothelial cells seldom underwent apoptosis. Leydig cells were affected
less often than spermatocytes. The extent of apoptosis and necrotic changes within the twisted testicle directly
correlated with the duration of torsion.

7. apabila pasien torsio testis tidak ingin dilakukan pembedahan bagaimana?

 Dilakukan manual detorsion dan inform consent ke pasien berupa torsio testis ini berulang dan dapat menyebabkan
kemandulan dalam waktu 6 jam, dan disarankan untuk dilakukan pembedahan.

8. apabila manual detorsion telah dilakukan bagaimana kriteria berhasil dan tidak?
Hilangnya nyeri dan dibantu dengan USG Doppler

9. Perlukah dilakukan pemberian anestesi pada manual detorsion?

Tidak perlu, karena dalam manual detorsion dibutuhkan evaluasi nyeri. Namun apabila ada USG Doppler boleh
dilakukan pemberian anestesi IV.

10. manual detorsion berhasil, perlukah dilakukan bedah?

Perlu. Karena merupakan terapi definitive agar tidak terjadi lagi.

11. tindakan bedah apa yang dilakukan?

Orchidopeksi
Orchidektomi

Orchiectomy is performed if the affected testicle appears grossly necrotic or nonviable. Orchiectomy rates
vary widely in the literature, typically ranging from 39% to 71% in most series.33,56,57 Age and prolonged time
to definitive treatment have been identified as risk factors for orchiectomy. 51,52The rate of testicular loss can
approach 100% in cases where the diagnosis is missed, emphasizing the necessity of maintaining a high
index of suspicion for torsion in males presenting with scrotal pain. 52

If the affected testicle is deemed viable, orchiopexy with permanent suture should be performed to
permanently fix the testicle within the scrotum.58

Contralateral orchiopexy should be performed regardless of the viability of the affected testicle. 59The bell-
clapper deformity that increases testicular mobility and, therefore, the risk of torsion, is bilateral in up to 80%
of patients.14 It is assumed to be present contralaterally in all patients with testicular torsion. 26,51,53

12. bagaimana cara memeriksa cremasteric reflex dan mengapa bisa terjadi?
Cara : goresan pada kulit paha sebelah medial dari atas ke bawah
Respon : elevasi testes ipsilateral pada lakilaki diatas 2 tahun
The reflex utilizes sensory and motor fibers from two different nerves. When the inner thigh is stroked,
sensory fibers of the ilioinguinal nerve are stimulated. These activate the motor fibers of the genital
branch of the genitofemoral nerve which causes the cremaster muscle to contract and elevate the testis

13. cremasterik refleks positif atau negative pada apa penyakit apa aja?
The cremasteric reflex may be absent with testicular torsion, upper and lower motor neuron disorders, as
well as a spine injury of L1-L2. It can also occur if the ilioinguinal nerve has accidentally been cut during
a hernia repair.
The cremasteric reflex can be helpful in recognizing testicular emergencies. The presence of the
cremasteric reflex does not eliminate testicular torsion from a differential diagnosis, but it does broaden the
possibilities to include epididymitis or other causes of scrotal and testicular pain. In any event, if testicular
torsion cannot be definitively eliminated in an expeditious manner, a testicular Doppler ultrasound or
exploratory surgical intervention is usually implemented to prevent possible loss of the testicle to necrosis.

14. fungsi dilakukan urinalisis?

2
 Urinalysis should be performed to rule out urinary tract infection in any patient with an acute scrotum. Pyuria
with or without bacteria suggests infection and is consistent with epididymitis. Based on our experience, a
white blood cell count is not helpful and should not be routinely obtained.

15. apakah genetik?

RESULTS:
Eight of 70 boys (11.4%) with torsion had affected family members. Another 2 families were included from a
historical perspective. One relative was affected in 7 families, 2 were affected in 2 and 3 were affected in 1.
First degree relatives were most commonly affected. In 1 family torsion occurred in 3 consecutive
generations. Despite a family history 50% of patients experienced testicular loss. Brothers were affected in
each of the 10 previously reported cases. In 3 families fathers were also affected. There were 3 sets of
monozygotic twins. We noted laterality concordance 5 times and discordance 6 times. Age at torsion in
probands was adolescence except in 2 with neonatal torsion. No clear inheritance mode was found.
CONCLUSIONS:
Familial torsion occurs in about 10% of probands and can affect multiple relatives and generations. A
positive family history may be useful for torsion diagnosis and management. Relatives of affected patients
need education on the signs and symptoms of torsion, and the importance of early presentation to improve
outcome.

16. bisakah dicegah? bagaimana mendiagnosis apabila blm ada torsio tersis? misalnya
papanya ada riwayat torsio testis, anaknya mau ngecek apakah dia punya kelainan
anatomis seperti papanya?
Deformation itself is difficult to detect from radiographic images. However, there are some specific findings in case
of MRI for example an abnormal direction of the longitudinal axis of the testicles and irregular pattern of fluid
collection inside the cavity of tunica vaginalis.
It is difficult to diagnose bell clapper deformity via physical examination because it is cannot be observed with naked
eye. For this purpose you healthcare provide may ask you you to perform some radiographic as well as sonographic
test for clear diagnosis. Lower abdominal ultrasound with special focus to testicular region is beneficial in this regard.
However, sometimes it is necessary to perform MRI if ultrasound does not provide adequate results.

17. Selain pemeriksaan usg Doppler penunjang apa lagi yang bisa digunakan? evi
18. Bagaimana cara membedakan torsio testis dan torsio appendix testis? evi
19. Bagaimana membedakan pembengkakan akibat torsio testis dan hernia? evi
20. Mengapa nyeri tetap ada pada phren sign torsio testis? evi
21. Apakah pada torsio testis dapat terjadi gangguan BAK? evi
22. Berdasarkan epidemiologi torsio testis banyak terjadi pada usia <25 th / 13-16 th,
mengapa lebih sering terjadi pada remaja? evi
23. Mengapa torsio testis ekstravagina lebih sering pada neonates? evi
24. Mengapa torsio lebih sering pada testis sebelah kiri? evi
25. Apakah udt/kriptokidism dapat meningkatkan resiko terjadinya torsio testis? evi
26. Perbedaan torsio testis intra dan ekstra vaginal? evi
27. Bagaimana trauma bisa mencetus torsio testis? evi
28. Jika tindakan pembedahan telah berhasil dilakukan bagaimana dengan fertilitas
pasien? evi
29. Mengapa torsio dapat pula terjadi pada testis kontra lateral? evi
30. Bagaimana membedakan dengan orchitis? evi
31. Bagaimana membedakan dengan epididimitis? evi