Aims and objectives • Target audience: medical students in clinical years, and PAs • Duration: 70 minutes • Cover 2 key urological emergencies • Provide important differential diagnoses • Pathophysiology, clinical features, investigations, management, prognosis • Multi-step SBAs: for a full understanding of the patient journey • Summary and Q&A • Slides and previous recordings: app.bitemedicine.com 2 Case-based discussion: 1 History and examination A 14-year-old male presents to the emergency department with a 3-hour history of sudden-onset, severe pain in his right testicle. This was initially intermittent but is now constant. He has vomited twice. There is no history of trauma. Prehn’s sign is negative and the cremasteric reflex is absent. Observations HR 130, BP 102/70, RR 20, SpO2 94% on air, Temp 37.3 3 Case history History and examination A 14-year old male presents to the emergency department with a 3-hour history of sudden-onset, severe pain in his right testicle. This was initially intermittent but is now constant. He has vomited twice. There is no history of trauma. Prehn’s sign is negative and the cremasteric reflex is absent. Observations HR 130, BP 102/70, RR 20, SpO2 94% on air, Temp 37.3 Q1 Q2 Q3 Q4 What is the most likely diagnosis? Epididymal hypertension Testicular torsion Varicocele Torsion of the testicular appendage Epididymo-orchitis app.bitemedicine.com 4 Explanations Q1 Q2 Q3 Q4 What is the most likely diagnosis? Epididymal hypertension Usually presents with aching testes following arousal without ejaculation; ‘blue balls’ Testicular torsion Severe, unilateral testicular pain and swelling with vomiting in a young male and absent cremasteric reflex Varicocele Usually only a dull ache and associated with a dragging or ‘bag of worms’ sensation Torsion of the testicular appendage Mimics testicular torsion. Not associated with vomiting, ‘blue dot sign’ and cremasteric reflex is present Epididymo-orchitis Gradual onset testicular pain in sexually active men, LUTS, vomiting is rare, Phren’s positive and cremasteric reflex is present app.bitemedicine.com 6 Case-based discussion: 1 History and examination A 14-year old male presents to the emergency department with a 3-hour history of sudden-onset, severe pain in his right testicle. This was initially intermittent but is now constant. He has vomited twice. There is no history of trauma. Prehn’s sign is negative and the cremasteric reflex is absent. Observations HR 130, BP 102/70, RR 20, SpO2 94% on air, Temp 37.3 7 Case-based discussion: 1 History and examination A 14-year old male presents to the emergency department with a 3-hour history of sudden-onset, severe pain in his right testicle. This was initially intermittent but is now constant. He has vomited twice. There is no history of trauma. Prehn’s sign is negative and the cremasteric reflex is absent. Observations HR 130, BP 102/70, RR 20, SpO2 94% on air, Temp 37.3 8 Conditions to cover Today… • Testicular torsion • Priapism 9 10 Introduction and pathophysiology • Twisting of the testicle on its spermatic cord à ischaemia and necrosis à non-viable testis 11 Introduction and pathophysiology Epidemiology and risk factors • Young age: two peaks; one in neonatal period and one in puberty (peak 13-15 years old) • Bell clapper deformity • Cryptorchidism • Trauma: accounts for < 10% of cases 12 Introduction and pathophysiology Normal Bell-clapper deformity Torsion 13 Case history History and examination A 14-year old male presents to the emergency department with a 3-hour history of sudden-onset, severe pain in his right testicle. This was initially intermittent but is now constant. He has vomited twice. There is no history of trauma. Prehn’s sign is negative and the cremasteric reflex is absent. Observations HR 130, BP 102/70, RR 20, SpO2 94% on air, Temp 37.3 Q1 Q2 Q3 Q4 The young man is noted to have a bell clapper deformity. What is the cause of this? Fibrosis of the tunica albuginea Gubernaculum is not firmly attached to the scrotum Failure of the tunica vaginalis to properly fix to scrotum Dysregulation of the NO/cGMP signalling pathway in the penis Abnormal enlargement of the pampiniform venous plexus app.bitemedicine.com 14 Explanations Q1 Q2 Q3 Q4 The young man is noted to have a bell clapper deformity. What is the cause of this? Fibrosis of the tunica albuginea This is the mechanism underlying Peyronie’s disease Gubernaculum is not firmly attached to the scrotum This contributes to cryptorchidism (undescended testes) Failure of the tunica vaginalis to properly fix to the scrotum Lack of proper fixation à high attachment of tunica vaginalis to spermatic cord à ’bell-clapper’ Dysregulation of the NO/cGMP signaling pathway in the penis This is the primary molecular mechanism of recurrent ischemic priapism Abnormal enlargement of the pampiniform venous plexus This describes varicocele formation app.bitemedicine.com 16 Anatomy 17 Introduction and pathophysiology Normal Bell-clapper deformity Torsion 18 Clinical features Symptoms Signs Testicular pain: unilateral, sudden, Swollen, high-riding, tender testicle excruciatingly painful Nausea and vomiting: common Absent cremasteric reflex Lower abdominal pain: referred Prehn’s negative: pain is not relieved on lifting the ipsilateral testicle 19 Cremasteric reflex 20 Prehn’s sign 21 Testicular torsion vs. epididymo-orchitis Testicular torsion Epididymo-orchitis Neonates, adolescent and young men Often sexually active men Sudden onset of scrotal pain Gradual onset of scrotal pain (over days) Tender testis +/- cord Tender along epididymis Nausea and vomiting common Nausea and vomiting are rare LUTS and fever usually absent LUTS and fever may be present Testis may be high-riding or transverse Testis not high-riding, with normal lie Cremasteric reflex absent Cremasteric reflex present Prehn’s sign negative Prehn’s sign positive 22 Case history History and examination A 14-year-old male presents to the emergency department with a 3-hour history of sudden-onset, severe pain in his right testicle. This was initially intermittent but is now constant. He has vomited twice. There is no history of trauma. Prehn’s sign is negative and the cremasteric reflex is absent. Observations HR 130, BP 102/70, RR 20, SpO2 94% on air, Temp 37.3 Q1 Q2 Q3 Q4 What is your next step? FBC and CRP Urinalysis Urgent testicular ultrasound Refer to urology for surgical exploration Urgent abdominal X-ray app.bitemedicine.com 23 Explanations Q1 Q2 Q3 Q4 What is your next step? FBC and CRP Will not add anything if torsion is strongly suspected, and will delay definitive management Urinalysis May be considered if the diagnosis is uncertain but is not required in this case Urgent testicular ultrasound As per NICE, imaging studies would not be performed in this case (see next slide) Refer to urology for urgent surgical exploration Suspected torsion is a urological emergency and delay will result in loss of the testis Urgent abdominal X-ray Not indicated and will not provide any useful information app.bitemedicine.com 25 “In patients with a history and physical examination suggestive of torsion, imaging studies should NOT be performed as they may delay treatment, therefore prolonging the ischaemic time” NICE Guidelines August 2019 app.bitemedicine.com 26 Investigations Primary investigations: • Surgical exploration: should be performed immediately if there is high clinical suspicion; perform within 6 hours to prevent irreversible damage Investigations to consider: if clinical suspicion is high, do not delay surgery • Testicular ultrasound: operator-dependent; ‘whirl-pool’ sign suggests torsion • Urinalysis: may suggest an alternative diagnosis, e.g. leukocytes and nitrites in epididymo-orchitis 27 Case history History and examination A 14-year old male presents to the emergency department with a 3-hour history of sudden-onset, severe pain in his right testicle. This was initially intermittent but is now constant. He has vomited twice. There is no history of trauma. Prehn’s sign is negative and the cremasteric reflex is absent. Intra-operatively, the affected testicle is found to be viable. Q1 Q2 Q3 Q4 What is the most appropriate management of this patient? Bilateral orchiopexy Ipsilateral orchiectomy and contralateral orchiopexy Ipsilateral orchiopexy and contralateral orchiectomy Manual detorsion Ipsilateral orchiectomy app.bitemedicine.com 28 Explanations Q1 Q2 Q3 Q4 What is the most appropriate management option for this patient? Bilateral orchiopexy The affected testicle is untwisted and fixed, as is the contralateral testicle to prevent contralateral torsion Ipsilateral orchiectomy and contralateral orchiopexy Used in the case of a non-viable testicle (e.g. necrotic) Ipsilateral orchiopexy and contralateral orchiectomy Not appropriate Manual detorsion Considered in cases of surgical delay; not appropriate in this case as the patient is in theatre Ipsilateral orchiectomy May be performed if the ipsilateral testicle is non-viable, however the contralateral testicle should be fixed (orchiopexy) app.bitemedicine.com 30 Management Viable testicle • Bilateral orchiopexy: affected testis is untwisted and fixed; contralateral testis always fixed too Non-viable testicle (e.g. necrotic) • Ipsilateral orchiectomy and contralateral orchiopexy: removal of the affected testis; contralateral testis is always fixed In cases of surgical delay • Manual detorsion: a temporary measure only performed if surgery is not available within 6 hours 31 Complications System Complication Urological • Recurrent torsion: may occur despite orchiopexy (very rare) • Subfertility/infertility: orchiectomy results in decreased spermatogenesis 32 Prognosis Within 4-6 hours: testis can be saved in the majority of cases A delay of >10-12 hours: irreversible ischaemia and necrosis ≥24 hours: testis is salvageable in <10% of cases 33 Case-based discussion: 2 History and examination A 30-year-old Afro-Caribbean male presents to the emergency department with a painful, sustained erection for the past 5 hours, without sexual arousal. He has never had an episode like this previously. The penis is painful and rigid.