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Paediatric Surgery
Testicular Torsion
Built from Puri — Pediatric Surgery and Pediatric Urology
What’s inside
11 sections · 67 slides
Overview
- What this deck will teach you
The Acute Scrotum
Setting the scene before we name the emergency
- A boy with a sudden painful scrotum
- Testicular torsion by the numbers
- Causes of acute scrotum in 388 boys (Zvizdic 2021)
- When does torsion strike? A tale of two peaks
Classification
Two mechanisms, defined by where the twist happens
- Clinical classification of testicular torsion
- Two mechanisms of torsion
- Extravaginal torsion - the newborn pattern
- Neonatal extravaginal torsion
- Intravaginal torsion and the 'bell clapper' testis
- Bell clapper deformity versus normal attachment
- What actually triggers a twist?
Pathophysiology
Why a twist becomes dead tissue - and why time is everything
- The mechanics of strangulation
- Salvage rate falls with every hour of torsion
- Reperfusion injury
Clinical Features
Reading the scrotum - and knowing when the story sits in the belly
- Neonatal torsion - what you find at or after birth
- Acute torsion in a newborn
- Torsion in the adolescent
- Which signs actually predict torsion?
- The trap: torsion that hides in the abdomen
Special Forms of Torsion
Undescended, intermittent, and familial torsion
- Torsion of an undescended testis
- Intermittent testicular torsion - the warning shots
- Familial testicular torsion
Differential Diagnosis
The mimics you must not mistake for true torsion
- Torsion of the testicular appendages
- Necrotic appendix testis at surgery
- The five testicular and epididymal appendages
- The appendages worth knowing
- Recognising and managing appendage torsion
- The blue dot sign
- Epididymo-orchitis - the inflammatory mimic
- Epididymo-orchitis - diagnosis and treatment
- Two more mimics: HSP and idiopathic scrotal edema
- Idiopathic scrotal edema
Imaging Studies
When the exam is equivocal, the pictures decide
- Color Doppler ultrasound (CDU) - the first-line test
- Sonographic clues that raise accuracy
- Color Doppler: necrotic versus normal testis
- Newer and alternative modalities
Management
Turning the diagnosis into a decision in the operating room
- The governing principle
- The controversial case: unilateral prenatal torsion
- Neonatal torsion management algorithm
- From algorithm to action
- Operative technique
- Fixing the salvaged (and the solitary) testis
After the Emergency
Prosthesis, complications, fertility, and the law
- Testicular prosthesis
- Complications and medicolegal reality
- Fertility after torsion
- No consensus: surveys of practice
Summary
What to carry away
- Three ideas that anchor the topic
- High-yield takeaways
- A 14-year-old: sudden severe scrotal pain, a high-riding tender testis, no cremasteric reflex. Next step?
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- Pediatric Surgery and Pediatric Urology