1. Presentation
A male teenager presented to the emergency department with intermittent left testicular pain for 12 hours. At the initial presentation, he was not in severe distress, and an ultrasound was ordered. The sonographer requested the clinician’s presence in the ultrasound suite due to abnormal findings (Fig 1).
Figure 1.
Testicular Doppler ultrasound, transverse view, showing an enlarged left testicle with a small hydrocele and an absence of normal color flow indicative of testicular torsion.
2. Diagnosis
The case ultrasound revealed absent blood flow to the left testicle, consistent with testicular torsion. Although torsion is primarily a clinical diagnosis, ultrasound is recommended for equivocal presentations. Typical sonographic findings include absent or markedly decreased blood flow.1 In cases with preserved perfusion, additional indicators may include altered arterial waveforms, testicular swelling, or the “whirlpool” sign of a twisted spermatic cord.1,2 A heterogeneous echotexture of the testicular parenchyma is a late finding that suggests nonviability.3 When ultrasound findings suggest torsion, do not delay urologic consultation while awaiting radiologist interpretation.
3. Management
Manual detorsion was performed in the ultrasound suite using the “open-book” technique and stopped after approximately 270° of rotation when the patient reported immediate pain relief. Doppler ultrasound confirmed restored perfusion to the left testicle (Fig 2). The patient’s testicle was viable at the time of surgery, a bell-clapper deformity was identified, and bilateral fixation was performed without complications.
Figure 2.
Testicular Doppler ultrasound, transverse view, after manual detorsion. Visible color flow to left testicle was indicative of return of perfusion. The small hydrocele surrounding the enlarged left testicle is redemonstrated.
Manual detorsion should be performed promptly upon diagnosis, with ultrasound guidance enabling real-time verification of reperfusion.4, 5, 6 As manual detorsion is a temporizing measure, definitive management requires surgical exploration to confirm detorsion, assess viability, and perform bilateral orchiopexy.7
Funding and Support
By JACEP Open policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.
Disclaimer
The views expressed in this publication are those of the authors and do not reflect the official policy or position of William Beaumont Army Medical Center, Department of the Army, Defense Health Agency, or the US Government.
Conflict of Interest
All authors have affirmed they have no conflicts of interest to declare.
Footnotes
Supervising Editor: Jeffrey Jarvis, MD, MS
References
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