Manual Testicular Detorsion

imagesTesticular torsion


Signs and symptoms include:


   imagesAcute scrotal pain/swelling or intermittent testicular pain


   imagesTesticular tenderness


   imagesHigh-riding testis with horizontal lie


   imagesAbsent cremasteric reflex on the affected side


   imagesNegative Prehn sign (no relief of pain upon elevation of the testis)


Manual detorsion may serve as a temporizing measure to reperfuse the testis while the patient is awaiting definitive surgical management. A urologist or general surgeon should be consulted immediately when torsion is suspected to prepare for emergency surgery.


CONTRAINDICATIONS



imagesManual detorsion should not delay scrotal exploration and bilateral orchiopexy in the operating room (OR)


imagesSpermatic cord anesthesia should be used only after discussing with the consulting urologist because it may blunt the subjective end point of detorsion efforts (relief of pain)


RISKS/CONSENT ISSUES



imagesPain (sedation and local anesthesia may be used)


imagesLocal bleeding and/or infection if spermatic cord anesthesia is administered


imagesManual detorsion does not replace the absolute need for surgical scrotal exploration/orchiopexy


LANDMARKS



imagesIf considering spermatic cord anesthesia/block, identify the spermatic cord at the external inguinal ring. Alternatively, if severe edema is present, palpate cord at pubic tubercle over pubis.



imagesGeneral Basic Steps


   imagesPatient preparation


   imagesLocal anesthesia (optional)


   imagesDetorsion


   imagesConfirmation


TECHNIQUE



imagesPatient Preparation


   imagesPlace the patient in reclining, supine, or lithotomy position


   imagesConsider light procedural sedation


imagesLocal Anesthesia (optional)


   imagesEnsure that the consulting urologist or general surgeon does not object to providing local anesthesia


imagesSpermatic Cord Block


   imagesSterilize the skin overlying the spermatic cord


   imagesInsert small (30-gauge) needle directly into the spermatic cord (FIGURE 35.1)


   imagesAspirate for blood to ensure the needle is not intravascular


   imagesSlowly inject 10 mL of 1% plain lidocaine (maximum 3 mg/kg)


imagesDetorsion


   imagesThe most common direction for torsion to occur is lateral to medial


   imagesThe initial attempt at detorsion should therefore be medial to lateral (FIGURES 35.2 and 35.3). Imagine you are “opening a book.”


   imagesMultiple rotations of the testicle may be necessary for complete detorsion; the degree of torsion may be guided by the patient’s pain relief


   imagesOne-third of cases are torsed in the opposite direction. If initial detorsion efforts appear ineffective/painful, attempt to detorse laterally to medially.


imagesConfirmation


   imagesRelief of pain


   imagesRestoration of anatomy


   imagesEventual return of cremasteric reflex


   imagesColor Doppler ultrasonogram shows return or improvement of flow


COMPLICATIONS



imagesUnsuccessful manual detorsion


imagesPatient unable to tolerate procedure (consider procedural sedation)


imagesTesticular loss due to prolonged ischemia



images


FIGURE 35.1 Injecting lidocaine at the superficial inguinal ring to achieve a spermatic cord block.

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Manual Testicular Detorsion

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