Testicular torsion is one of the few true urologic emergencies It does not always present in the same way Any boy with abdominal pain must undergo a testicular examination, because testicular torsion may present solely with abdominal pain, without any scrotal complaints Testicular masses must be diagnosed promptly for best outcomes Background Primordial germ cells have their origin in the endoderm of the yolk sac By the fifth week of intrauterine life, they have reached the ventromedial portion of the urogenital ridge, the portion destined to form the testes A mesodermal cord, the gubernaculum, becomes attached to the bottom of the testis at the epididymis and runs to the bottom of the scrotum With rapid growth of the trunk, the testes lie adjacent to the internal ring by the third month of gestation The testes remain at this location until the seventh month when, preceded by a fold of peritoneum (the processus vaginalis), the testes move down the inguinal canal and reach their final scrotal position shortly before birth This fact accounts for the higher incidence of undescended testis in premature boys Testicular Torsion Goals of Treatment Torsion of the testis is one of the few true urologic emergencies; time is of the essence The goal in management of testicular torsion is prompt diagnosis (aided by high index of suspicion) and early consultation with a urologist for prompt surgical treatment Clinical Recognition Key symptoms that should raise suspicion for testicular torsion are: (1) acute onset, often waking a boy up from sleep, (2) presence of nausea/emesis, (3) severe pain not improved by any position, and (4) sudden enlargement and redness of the hemiscrotum in a newborn Important signs on physical examination include (1) an enlarged, swollen hemiscrotum, (2) significant tenderness, (3) loss of cremasteric reflex, and (4) horizontal lie of the affected testis Any boy with abdominal pain must undergo a testicular examination, because testicular torsion may present solely with abdominal pain, without any scrotal complaints In newborns, the testis undergoes extravaginal torsion (compared to intravaginal), and may occur prenatally or postnatally Most often the prenatally torsed testis will present as a firm, enlarged mass in the hemiscrotum often with discoloration of the skin On the other hand, if a normal examination is noted at birth, and a follow-up examination reveals an erythematous, tender, enlarged scrotum, the patient must be evaluated emergently and surgical intervention undertaken, as the testis may be salvaged Many debate the need to intervene acutely in the prenatally torsed patients, however asynchronous torsion has been reported, resulting in anorchia Thus, careful balance of the risks and benefits of surgery in the newborn period must be undertaken Triage Considerations Early recognition is essential A patient presenting with scrotal pain should be evaluated immediately Similarly, if a newborn presents with the history of a new finding of testicular swelling, he must be treated as if he had testicular torsion until proven otherwise If symptoms are consistent with testicular torsion, urology should be consulted immediately If there is any question, a scrotal ultrasound must be ordered on an emergent basis Some patients will have intermittent testicular torsion—and in these cases, the pain will resolve spontaneously within 30 to 45 minutes These patients should still be evaluated with a scrotal ultrasound since a torsion may partially untwist with resolution of pain, but still have vascular compromise Clinical Assessment The differential diagnosis of scrotal pain and/or swelling includes epididymitis, torsion of the testis appendix, intermittent torsion, hernia/hydrocele, trauma, cellulitis, or even vasculitis (Henoch–Schönlein purpura) Often an ultrasound is the only way to distinguish these entities In the interest of time, some urologists will take a child to the operating room without an ultrasound; however most of the time an ultrasound is done to confirm diagnosis Upon evaluation, the emergency physician should be able to make the diagnosis, call the consultation, and in the interim, obtain an ultrasound Two similar presentations that are corollaries of testicular torsion are torsion/detorsion, and intermittent torsion If a boy presents with acute onset of pain consistent with torsion, but after 30 minutes to hour (or longer), the pain abruptly resolves, and imaging shows the presence of flow to the testis, it is possible that the testis detorsed The challenge here is that this should still be treated urgently, since (1) the testis may twist again and (2) at times there is an incomplete detorsion so that there is still a 180-degree twist, with return of some blood flow, but the testis is still compromised Alternatively, if the patient’s history is that one or two times prior to the current presentation, he has had the same type of pain, yet the pain resolved within 30 minutes each time, he may be experiencing intermittent torsion This, too, should be treated with surgery to prevent torsion in the future, but this may be done on a semi-elective basis Management The only management for testicular torsion is surgical reduction and fixation While the testis may be able to be “detorsed” in the emergency room for temporary relief of pain, this is not adequate treatment The patient requires exploration in the operating room Depending on the duration of the torsion, the surgeons may find a completely nonviable testis upon evaluation, and an orchiectomy is performed Alternatively, if there appears to be some blood flow to the testis after untwisting and allowing time for blood flow to return, then the testis will be fixed into place in the scrotum The contralateral side will also be fixed in place to prevent torsion on the other side in the future Testicular Mass Background Pediatric (prepubertal) testicular masses account for 1% of all pediatric solid tumors, with the peak age of incidence around years Overall the most common prepubertal testicular masses are teratomas, followed by rhabdomyosarcomas, epidermoid cysts, yolk sac tumors, and germ cell tumors Gonadoblastoma (in dysgenetic gonads), and nontesticular tumors such as lymphoma and leukemia are also possible Goals of Treatment Prompt recognition, diagnosis, and referral for treatment Clinical Recognition Testicular masses are often asymptomatic These may be found as incidental findings during thorough physical examination, may present as scrotal enlargement, or may present concurrent with testicular torsion or other pathologies Triage Considerations Testicular masses require early diagnosis, but treatment will not occur emergently Once diagnosed, the urologist will typically manage the testicular mass within the next to days Clinical Assessment If a testicular mass is palpated on examination, a scrotal ultrasound is warranted If a mass is found incidentally on ultrasound, further workup is also warranted All patients with a scrotal mass concerning for a tumor must undergo blood testing for AFP, bHCG, and LDH In addition, these patients need cross-sectional imaging of the abdomen Management A pediatric urologist must be consulted Once a testicular mass is identified, it will require resection Imaging and patient parameters will determine whether a partial orchiectomy is permissible, or a radical orchiectomy is required Torsion of the Appendix Testis Clinical Recognition A torsed appendix testis may present much like a testicular torsion by report, but the patient appears vastly different Pain is still a presenting complaint but torsion of an appendix less often awakes a patient from sleep, and is not associated with nausea or emesis The swelling is less pronounced, and a key finding on physical examination is focal tenderness at the superior aspect of the testis rather than the inferior testis The “blue dot” sign, in which a bluish hue is visible through the scrotal skin at the superior aspect of the testis, is an often elusive finding Triage Considerations Since the initial presentation may be similar to testicular torsion, a prompt evaluation with history and physical examination is essential to help guide evaluation and management Clinical Assessment The testis may be swollen and red; thus, a scrotal ultrasound is a valid tool for diagnosis This may identify the torsed appendage (though it does not always), but more often, and more importantly, will rule out testicular torsion Management Torsion of a testicular appendage is managed with supportive care The key component of treatment is administration of a nonsteroidal anti-inflammatory ... torsion on the other side in the future Testicular Mass Background Pediatric (prepubertal) testicular masses account for 1% of all pediatric solid tumors, with the peak age of incidence around years... torsion is surgical reduction and fixation While the testis may be able to be “detorsed” in the emergency room for temporary relief of pain, this is not adequate treatment The patient requires... ultrasound; however most of the time an ultrasound is done to confirm diagnosis Upon evaluation, the emergency physician should be able to make the diagnosis, call the consultation, and in the interim,