Dr. Vivek M. Rege
Pediatric Surgeon & Pediatric Urologist
B J Wadia Hospital For Children, Hurkisondas Hospital, Wockhardt Hospital, Mumbai
This is one condition that requires a quick decision and urgent surgery. The usual story is that of a boy who comes home from school or from playing with a pain in the scrotal region. The onset may have been while the boy was playing or even more often while sitting. There may be some history of trauma, which may lead to the parents to assume that pain is due to direct trauma only. However, the boy must be thoroughly questioned to find out when did the pain actually start, has it remained the same, increased, or decreased and disappeared. Check if the boy is having any urinary problem like burning or painful micturition prior to the pain. Also, one must check for swelling and redness on one side of the scrotum. Thus a boy presenting
with pain and swelling on one side of the scrotum has to be given immediate therapy since there are 2 possibilities. The first is Testicular torsion that requires urgent surgery to untwist the torsion; the other is epididymo orchitis that requires purely non surgical therapy.
Testicular torsion ? The cause is a congenital anomaly wherein, the testis after descending into the scrotum is not fixed in place and is mobile. The testis is free to rotate along its long axis ? this in turn leads to a twisting of the blood vessels of the testis and cutting off of the blood supply to the testis. As this progresses, the total blood supply of the testis is cut off leading to gangrene or infarction of the testis. This makes the testis atrophy and loose all functions. The twists can be of various degrees i.e. 180 degrees, 360 degrees ? thus it may be one full turn or 2 or more turns. Obviously, more the twists the faster the loss of blood supply. Additionally, the time interval from the occurrence of the torsion and its relief is also very important. If corrected within 6 hours ? still about 10% of testis can loose their functions; this can increase to 90 % if the time interval goes more than 24 hours. This then is the reason for urgent intervention and untwisting of the torsion. This is also the reason for showing the proper doctor as soon as possible.
Epididymo orchitis (EO) ? This is an infective inflammatory condition secondary to urinary infection. Retrograde infection from the urethra via the vas deferens to the epididymis and testis. The infection and subsequent inflammation lead to pain and swelling in the testicular region very similar to that in torsion. The infection could also have come to the epididymis from the normal blood flow. Rarely there may be an abnormal upper urinary tract anomaly and presents as epididymo orchitis.
Differentiating the two is very difficult clinically. However, a detailed history with a proper examination may help if the child allows. Usually, a small child with severe pain will scream just looking at the doctor and examination will not be possible very easily. Some of the things that may help during examination are ? check if there is more swelling posteriorly with thickening of the epididymis, suggestive of EO. At times the pain is not very severe and gradually supporting and lifting the epididymis with the palm of the hand may give relief to the child again a sign of inflammation. Another clinical sign that may help is eliciting the Cremasteric reflex by stroking the medial side of the upper thigh. If this results in a positive reflex, the testis gets pulled upwards due to the contraction of the cremaster muscle, it means that the cremaster can function as it is not twisted. Thus, positive cremasteric reflex, usually rules out torsion. On the other hand absence of the reflex does not necessarily mean only torsion as the inflammation and edema due to the infection can temporarily make the cremaster inactive. Thus there is no active and definitive method of clinically differentiating one from the other.
There is one investigation that may help to a certain extent. A Color Doppler study for the blood supply to the testis will show no blood flow in case of Torsion but excess blood flow in EO. However, this is based on many factors like, the person doing the study (experience). The time from onset when the study is done, after 6-9 hours, there is an excess blood flow around the testicular region and could be mistaken for EO and the boy is conserved with poor result and the testis is atrophic and functionless later in life.
The dilemma in such a case is assuming the cause to be EO, the treatment is medical; however, if the diagnosis is then found to be torsion, the testis is lost permanently. On the other hand, if the child is operated on assuming it is torsion and it turns out to be EO, then the operation would have been unnecessary and unindicated. In this type of a case my philosophy is, when in doubt, assume all cases are torsion of the testis and operate the child to look for the torsion of testis. This operation is undertaken after a full detailed explanation of the pros and cons to the parents of the boy, their consent is taken. The advantages of this approach no torsion will be missed or remain uncorrected after the child is brought to the surgeon for opinion and advice; there is no wastage of valuable time for searching traveling to and from a Sonologist who will be doing the Doppler study and not being definitely sure about the final diagnosis based on the interpretation of the study. It is better to explore and find that the diagnosis is EO rather than conserve, treat medically and later find this was a case of torsion.
In cases of torsion ? the testis is explored, untwisted, and observed. The color, consistency, pulsations are looked for to confirm that the testis is viable. After confirming that the testis is alright, it is reposited into the scrotum and fixed in position with a stitch going through the testis and the skin of the scrotum to prevent a recurrence of the torsion. Even more important, the opposite side testis must always be fixed at the same sitting with a suture. This is done because, the same congenital anomaly that was responsible for torsion on one side, may be present on the opposite side, and fixing the opposite side testis would prevent torsion from occurring on that side in the future. This is very important to remember.
In case of EO, an oral broad spectrum antibiotic is started for the infective pathology, additionally, an anti-inflammatory drug is begun to take care of the inflammation and the edema. Elevation of the scrotum with local cold compresses are also started. This therapy is continued till the swelling and tenderness begin to recede. More important in these cases is to investigate the child for urological defects after the episode settles. A complete urinary tract investigation must include Ultrasound for kidneys, ureters and bladder, a MCU to look for reflux, obstruction of the lower urinary tract, and an IVP to look for anomalies of the upper urinary system like double or ectopic ureters etc.
Last Updated: 27th January 2009