Testicular Torsion Surgery
Acute scrotal syndrome, or acute scrotal pain, is characterized by a condition of intense pain and sudden or gradual onset secondary to involvement of the scrotal contents or its covers, frequently associated with swelling and increase in size. It encompasses a series of entities: torsion of the spermatic cord, torsion of testicular appendages, epididymitis-epididymitis and testicular trauma.
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It accounts for around 0.5% of all reasons for consulting an Emergency Department. It may constitute a urological emergency, since it requires ruling out vascular compromise of the scrotal contents that threatens testicular viability.
TESTICULAR TORSION OF THE SPERMATIC CORD
Testicular torsion is produced by the axial rotation of the spermatic cord on itself, to a variable degree (from 180º to 720º), compromising the blood supply of the testicle and epididymis. It is the most common cause of acute scrotal pain between 11 and 18 years of age, although It can manifest at any age.
It represents a surgical emergency, since ischemia of the testicular parenchyma can evolve within 4-6 hours towards irreversible necrosis, with atrophy of the gland and loss of its reproductive and endocrine functions. In this way, the rate Testicular viability reaches 85-100% if the process is resolved in the first 6 hours from the onset of symptoms, reducing to less than 20% after 12 hours.
Etiology
It is due to the combination of a series of predisposing anatomical factors (which determine insufficient fixation of the testicle to the scrotal sac), and circumstances that favor the sudden contraction of the cremaster muscle (intense physical exercise, cold, intercourse, Valsalva maneuver, etc. .), producing testicular ascent during which torsion takes place of the spermatic cord.
Clinic and physical examination
It usually occurs, after minimal effort or trauma, with pain intense and acute onset, located in the affected hemiscrotum, which sometimes radiates towards the suprapubic and inguinal region, even towards the lumbar fossa; this presentation can simulate renal colic or acute appendicitis.
In up to 60% of cases it is accompanied by vegetative symptoms (nausea and vomiting). In many cases it can be collected in the anamnesis previous episodes of self-limited pain, of lesser intensity, corresponding to subacute or incomplete torsions.
There is usually no fever or urinary symptoms. Upon examination, scrotal edema and erythema can be observed, with a very painful testis on palpation, in elevated and horizontal position with respect to the contralateral (Gouverneur sign).
It is accompanied by abolition of the cremasteric reflex. The spermatic cord will appear thickened and painful. Unlike epididymitis orchitis, scrotal elevation towards the inguinal ring does not reduce pain, and even increases it (negative Prehn sign).
Diagnosis
The presence of scrotal pain of sudden onset, intense and affecting the state. Generally, it should lead to suspicion of this entity. In the face of a highly suggestive clinical picture, confirmation through complementary tests should not delay in any way the immediate surgical exploration.
In doubtful cases, color Doppler ultrasound would be indicated, which is the technique of choice, with a sensitivity and specificity close to 100% if the absence of intratesticular flow for one minute is confirmed. However, it may present false negatives in situations of incomplete rotation. The usefulness of testicular scintigraphy with Tc99 pertechnetate is limited, given its lack of availability in Emergency services and the accompanying diagnostic delay.
Treatment
It is surgical and urgent in nature, in order to preserve testicular viability, inversely proportional to the time of evolution. On occasions, and as a temporary measure, You can try manual detorsion under analgesia, which in no case avoids surgical intervention, consisting of definitive fixation (orchidopexy) of the affected testis and the contralateral one. Once necrosis is definitively established, orchiectomy will be performed.
TORSION OF TESTICULAR APPENDICES
Testicular appendages are formed from remnants of embryonic structures of Müllerian origin, and can suffer acute torsion, often self-limited; in 95% of Sometimes the structure involved is the testicular appendage or hydatid of Morgagni, located in the upper testicular pole. Exceptional in people over 18 years of age, it usually occurs in prepubertal adults, with a maximum incidence between 10 and 13 years of age.
Causes pain scrotal of a more or less gradual nature, with reno-ureteral irradiation being less frequent and vegetative symptoms than in testicular cord torsion. Palpation is characteristic selective pain in the upper pole of the testicle, sometimes being able to observe, during the first hours of evolution, a bluish spot («blue drop») through the skin of the scrotum, corresponding to the congestive and cyanotic hydatid; Its presence is considered practically pathognomonic of this entity.
The cremasteric reflex is preserved. Doppler ultrasound will show normal vascular flow, thus allowing testicular torsion to be excluded as the origin of the painting. The treatment of this entity is conservative and symptomatic (rest and analgesia), evolving towards complete resolution after a week due to autoinfarction of the appendix.
EPIDIDYMITIS AND ORCHITIS
It is the most common cause of acute scrotal pain in postpubertal adults. Of In the usual way, the microorganisms reach the gonad by a retrograde route, through the vas deferens, with epididymitis being the primary lesion; although sometimes it can be observed in isolation, as the epididymal inflammatory process progresses it tends to encompass the testicle, giving rise to epididymal orchitis.
More exceptionally, acute orchitis, without involvement of the epididymis, is usually secondary to hematogenous dissemination. (particularly viral), and is clinically superimposable to the previous processes.
Etiology
Chlamydia trachomatis and Neisseria gonorrheae are the most frequent causal agents between 18 and 35 years of age, in direct relation to sexual activity; in During this period, the infection usually coexists with urethritis. In adults over 35-40 years old Escherichia coli and other enterobacteria predominate, followed to a lesser extent by cocci gram-positive and Pseudomonas.
Other agents (viruses, Brucella, Mycobacterium tuberculosis) are more exceptional; However, brucellosis should be taken into account in the differential diagnosis in all young patients with subacute orchitis, little epididymal involvement, and a suggestive epidemiological context.
Most cases of Genital tuberculosis (usually in the form of epididymitis) occurs by dissemination retrograde from a renal or urinary tract focus. Finally, isolated acute orchitis tends to arise during a viremia; The most common is that caused by mumps virus (urlian orchitis), bilateral in up to a third of cases. Can affecting young adults, it usually appears several days after the clinical onset of mumps, and frequently resolves with residual testicular atrophy.
Clinical and physical examination
Pain of progressive onset appears, initially limited to the affected hemiscrotum, accompanied by fever and chills (in more than half of the patients), affectation of the general condition and voiding symptoms (dysuria, frequency and tenesmus), generally secondary to concomitant urinary infection, and absent in case of isolated orchitis without epididymal involvement.
Discharge is not uncommon urethra predominantly in the morning, which suggests coexistence with urethritis (gonococcal or not). TO On physical examination, an edematous and enlarged hemiscrotum appears with local inflammatory signs, in which the epididymis and testicle usually form an indistinguishable mass; It may be accompanied by a reactive hydrocele, which will be revealed by transillumination.
The teste retains its usual position, with preservation of the cremasteric reflex. Characteristically, the pain is relieved by raising the scrotum toward the pubis (sign of Prehn positive). In very advanced cases the collection can abscess and fistulize towards the skin of the scrotum.
Diagnosis
It is eminently clinical. The blood count may show leukocytosis with neutrophilia, accompanied by pyuria and bacteriuria in the urinary sediment; Urine culture is sometimes positive. Exceptionally, tests may be necessary specific, such as Gram staining of urethral exudate and its culture in media special tests (Thayer-Martin) to demonstrate gonococcal infection, or certain studies serological (rose bengal, lues).
In selected circumstances, primarily Regarding the differential diagnosis with testicular torsion, one can resort to performing a scrotal color Doppler ultrasound, which will show increased vascular flow compared to contralateral testis; However, and in the event of reasonable diagnostic doubt, the practice of this The test should in no case delay surgical exploration for more than 6 hours from the beginning of the symptoms, given the risk of loss of testicular viability in case of that the condition is due to testicular torsion. On the other hand, scrotal ultrasound allows us to rule out the formation of an abscess in cases of torpid evolution despite correct antibiotic treatment.
Treatment
Treatment must be established empirically, without the need for Wait for the results of urine cultures. In adults under 35-40 years of age, sexually active, we will resort to a third generation cephalosporin (ceftriaxone 250 mg im in single dose) followed by doxycycline 100 mg/12 h orally for 10-14 days. It will be necessary to treat sexual partners of the last month.
In people over 35-40 years of age we will use a quinolone (ciprofloxacin 500 mg/12 h orally) or cotrimoxazole (160/800 mg/12 h). h orally) for at least four weeks, due to the frequent association with prostatitis.
In very florid cases it may be necessary to resort to the parenteral route (cephalosporin third generation, with eventual association with ampicillin or an aminoglycoside). Bed rest, the use of a testicular support, and the application of local cold are recommended and conventional analgesic treatment.
The remission of pain can be delayed fifteen days, and up to 4-6 weeks the complete disappearance of edema and swelling; Sometimes some residual epididymal induration persists.
Información del autor
- A. B. Carlavilla Martínez; F. J. Castelbón Fernández; 2007; Manual de Diagnóstico y Terapéutica Médica; Hospital Universitario 12 de Octubre; Madrid.
- Enfermeria Buenos Aires.
Última actualización: [02/08/2024]
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