Here is the situation:
You are in bright and early for an early morning practice. It about an hour and a half before the team’s 8:00am go time on the court. Normal practice prep is on your mind along with some rehabilitation notes you are documenting before the players arrive. One of the players happens to report a little early this morning with a distressed look on his face. You meet him at the treatment table and listen as the player describes an intense testicle pain. The pain is described as nothing he has ever felt before. He reports to your athletic training room with acute onset of unilateral scrotal pain, scrotal swelling, nausea, abdominal pain, fever, urinary frequency. He tells you he woke up with the pain and it has been getting worse over the course of the past 2 hours. Do you recognize the male medical emergency, if not this young man could potentially loose his testicle………
Given the population that Boston Sports Medicine and Performance Group reaches out to and focuses on it is important to examine male emergencies in men’s basketball. A male emergency all athletic trainers working with basketball should be aware of is testicular torsion.
Testicular torsion is a true urologic emergency and must be differentiated from other complaints of testicular pain because a delay in diagnosis and management can lead to loss of the testicle. Though testicular torsion can occur at any age, including the prenatal and perinatal periods, it most commonly occurs in adolescent males; it is the most frequent cause of testicle loss in that population.
The testicle is covered by the tunica vaginalis, a potential space that encompasses the anterior two thirds of the testicle and where fluid from a variety of sources may accumulate. The tunica vaginalis attaches to the posterolateral surface of the testicle and allows for little mobility of the testicle within the scrotum.
In patients who have an inappropriately high attachment of the tunica vaginalis, the testicle can rotate freely on the spermatic cord within the tunica vaginalis (intravaginal testicular torsion). This congenital anomaly, called the bell clapper deformity, can result in the long axis of the testicle being oriented transversely rather than cephalocaudal. This congenital abnormality is present in approximately 12% of males, 40% of whom have the abnormality in the contralateral testicle as well.1 The bell clapper deformity allows the testicle to twist spontaneously on the spermatic cord. Torsion occurs as the testicle rotates between 90° to 180°, causing compromised blood flow to the testicle. Complete torsion usually occurs when the testicle twists 360° or more; incomplete or partial torsion occurs when the twisting is less than this. The twisting of the testicle causes venous occlusion and engorgement as well as arterial ischemia and infarction of the testicle. How tightly the testicle is twisted appears to correlate with how quickly the testicle becomes nonviable from ischemia.
Causes of testicular torsion may include the following:
• Congenital anomaly; bell clapper deformity
• Undescended testicle
• Sexual arousal and/or activity
• Testicular tumor
Emergency Department Care
• Early diagnosis and prompt urologic consultation is essential since time is critical in salvage of the testicle.
• Analgesic pain relief should be administered as testicular torsion is typically very painful.
• Attempt manual detorsion with pain relief as the guide for successful detorsion. The procedure is similar to the "opening of a book" when the physician is standing at the patient's feet.
• Most torsions twist inward and toward the midline; thus, manual detorsion of the testicle involves twisting outward and laterally.
• Consultation with urology is a must since most testicular torsion need surgical intervention.
The unique aspect of being an athletic trainer is that it involves being well educated on all aspects of medical emergencies in the population we provide care. Medical emergencies related to orthopedic and internal medicine. It is all about early recognition to provide efficient and appropriate care.
Dogra V, Bhatt S. Acute painful scrotum. Radiol Clin North Am. Mar 2004;42(2):349-63. [Medline].
Ringdahl E, Teague L. Testicular torsion. Am Fam Physician. Nov 15 2006;74(10):1739-43. [Medline].
Beni-Israel T, Goldman M, Bar Chaim S, Kozer E. Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med. Sep 2010;28(7):786-9. [Medline].
Cattolica EV, Karol JB, Rankin KN, Klein RS. High testicular salvage rate in torsion of the spermatic cord. J Urol. Jul 1982;128(1):66-8. [Medline].
Coley BD. The Acute Pediatric Scrotum. Ultrasound Clinics. 2006;1:485-96. [Full Text].
Hayn MH, Herz DB, Bellinger MF, Schneck FX. Intermittent torsion of the spermatic cord portends an increased risk of acute testicular infarction. J Urol. Oct 2008;180(4 Suppl):1729-32. [Medline].
Creagh TA, McDermott TE, McLean PA, Walsh A. Intermittent torsion of the testis. BMJ. Aug 20-27 1988;297(6647):525-6. [Medline].
Schmitz D, Safranek S. Clinical inquiries. How useful is a physical exam in diagnosing testicular torsion?. J Fam Pract. Aug 2009;58(8):433-4. [Medline].
Brenner JS, Ojo A. Evaluation of scrotal pain or swelling in children and adolescents. UpToDate [web site]. 2006.
Eyre RC. Evaluation of the acute scrotum in adults. UpToDate [web site].
Doehn C, Fornara P, Kausch I, et al. Value of acute-phase proteins in the differential diagnosis of acute scrotum. Eur Urol. Feb 2001;39(2):215-21. [Medline].
Prando D. Torsion of the spermatic cord: the main gray-scale and doppler sonographic signs. Abdom Imaging. Sep-Oct 2009;34(5):648-61. [Medline].
Dogra VS, Bhatt S, Rubens DJ. Sonographic Evaluation of Testicular Torsion. Ultrasound Clinics. 2006;1:55-66.
Yagil Y, Naroditsky I, Milhem J, Leiba R, Leiderman M, Badaan S, et al. Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department. J Ultrasound Med. Jan 2010;29(1):11-21. [Medline].
Turgut AT, Bhatt S, Dogra VS. Acute Painful Scrotum. Ultrasound Clinics. 2008;3:93-107. [Full Text].
Cassar S, Bhatt S, Paltiel HJ, Dogra VS. Role of spectral Doppler sonography in the evaluation of partial testicular torsion. J Ultrasound Med. Nov 2008;27(11):1629-38. [Medline].
Blaivas M, Sierzenski P, Lambert M. Emergency evaluation of patients presenting with acute scrotum using bedside ultrasonography. Acad Emerg Med. Jan 2001;8(1):90-3. [Medline].
Bomann JS, Moore C. Bedside ultrasound of a painful testicle: before and after manual detorsion by an emergency physician. Acad Emerg Med. Apr 2009;16(4):366. [Medline].
Capraro GA, Mader TJ, Coughlin BF, et al. Feasibility of using near-infrared spectroscopy to diagnose testicular torsion: an experimental study in sheep. Ann Emerg Med. Apr 2007;49(4):520-5. [Medline].
Terai A, Yoshimura K, Ichioka K, et al. Dynamic contrast-enhanced subtraction magnetic resonance imaging in diagnostics of testicular torsion. Urology. Jun 2006;67(6):1278-82. [Medline].
Moschouris H, Stamatiou K, Lampropoulou E, Kalikis D, Matsaidonis D. Imaging of the acute scrotum: is there a place for contrast-enhanced ultrasonography?. Int Braz J Urol. Nov-Dec 2009;35(6):692-702; discussion 702-5. [Medline].
Baker LA, Sigman D, Mathews RI, et al. An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion. Pediatrics. Mar 2000;105(3 Pt 1):604-7. [Medline].
Blank BH, Goldsmith G, Schneider RE. Recognizing a testicular emergency. Patient Care. 1997;31(13):117-35.
Brenner JS, Ojo A. Causes of scrotal pain in children and adolescents. UpToDate [web site]. 2006.
Caesar RE, Kaplan GW. Incidence of the bell-clapper deformity in an autopsy series. Urology. Jul 1994;44(1):114-6. [Medline].
Cattolica EV. Preoperative manual detorsion of the torsed spermatic cord. J Urol. May 1985;133(5):803-5. [Medline].
Flanigan RC, DeKernion JB, Persky L. Acute scrotal pain and swelling in children: a surgical emergency. Urology. Jan 1981;17(1):51-3. [Medline].
Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics. Jul 1998;102(1 Pt 1):73-6. [Medline].
McCollough M, Sharieff GQ. Abdominal surgical emergencies in infants and young children. Emerg Med Clin North Am. Nov 2003;21(4):909-35. [Medline].
Schwab R. Acute scrotal pain requires quick thinking and plan of action. Emerg Med Rep. 1992;13(2):11-7.
Wan J, Bloom DA. Genitourinary problems in adolescent males. Adolesc Med. Oct 2003;14(3):717-31, viii. [Medline].
Weber DM, Rosslein R, Fliegel C. Color Doppler sonography in the diagnosis of acute scrotum in boys. Eur J Pediatr Surg. Aug 2000;10(4):235-41. [Medline].