Pediatric emergency medicine trisk 1174 1174

FIGURE 61.2 Torsion testis Abnormality of testicular fixation—bell-clapper deformity— permits torsion of spermatic vessels with subsequent infarction of the gonad Epid., epididymis Torsion results from an inadequate fixation of the testis to the intrascrotal subcutaneous tissue ( Fig 61.2 ), resulting in the “bell-clapper” deformity The testis, which hangs more freely within the tunica vaginalis in this deformity, may rotate, producing intravaginal torsion of the spermatic cord, venous engorgement of the testis, and subsequent arterial infarction ( Fig 61.3 ) The sudden onset of severe scrotal pain and tenderness, often with radiation to the abdomen, and associated nausea and vomiting is typical They may be associated with sports activity or mild testicular trauma that is perceived by the patient as the cause of pain Prior episodes of similar pain that resolved may suggest intermittent torsion and spontaneous detorsion With torsion, the testis is acutely swollen, diffusely tender, and usually lies higher (“horizontal lie”) in the scrotum than the contralateral testis There may be overlying erythema of the scrotal skin The cremasteric reflex (retraction of the testis with stroking of the inner thigh) is usually absent with testicular torsion, but may be present in early or incomplete torsion The cremasteric reflex may be absent in some boys without torsion, usually less than months of age Since pain