Do not forget to include testicular torsion in differential diagnosis of lower acute abdominal pain in young males

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Abstract

Background

Management and outcomes of pediatric patients with testicular torsion initially presenting as acute abdominal pain were evaluated.

Patients and methods

The case records of 84 children operated on for testicular torsion from January 1999 through May 2012 were retrospectively reviewed. Of the total number of operated patients, 9 presented with abdominal pain but without initial scrotal pain, and only they were included in the study. The diagnosis of testicular torsion was made clinically and confirmed by Doppler ultrasound and scrotal exploration.

Results

The most common presenting symptoms were abdominal pain and vomiting. The patient's scrotum and testicles were not examined during the first evaluation in 6 cases, while in 3 cases the testicles were examined during the first physical examination. At surgery, 4 testes were salvaged, while 5 have been lost because of testicular necrosis. The mean duration of symptoms was 4 h in the group of salvaged testes and 39 h in the orchidectomy group. There were no major complications.

Conclusion

Testicular torsion should always be included in differential diagnosis when evaluating lower abdominal pain in young males. The external genital organs should be examined in every child or adolescent with acute abdominal pain.

Introduction

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 [1], [2], [3], [4], [5]. Annual incidence of testicular torsion is 4.5 in 100,000 males 1–25 years of age [1]. It can occur at any age but usually occurs in young males, with a bimodal incidence in the pediatric population: during the first year of life, and between the ages of 13 and 16 years [2]. Testicular torsion occurs when the testis twists in the scrotum, cutting off its blood supply. This is an extremely painful condition and is the most common cause of a testicle loss [3], [4], [5]. As many as 50% of boys with testicular torsion have had a prior episode of testicular pain [6]. The left testis is more frequently involved. Bilateral cases account for 2% of all torsions [3]. It is a commonly held belief that a testicle torsed for longer than 6 h is outside the timeframe for survival [5]. If treated within 6 h of the presenting pain, there is a good chance of saving the affected testicle, as 90–100% testicles will be saved. If treated within 6–12 h 20–50% testicles will be saved and if treated within 12–24 h 0–10% testicles will be saved [1], [2], [3], [5]. There are many conditions that can mimic testicular torsion. The differential diagnosis of an acute scrotum includes spermatic cord torsion, torsion of testicular appendage, acute epididymitis, trauma, incarcerated hernia, hydrocele, testicular tumors, and idiopathic and scrotal edema [1], [2], [3], [4], [7]. On examination, the patient with testicular torsion usually has a swollen tender testicle that is raised in a red scrotum and the testicle may be lying horizontally in the scrotum. Loss of the cremasteric reflex on the affected side and no pain relief when the testicle is elevated may also be noticed, and the patient may have a fever [1], [4], [5]. Not all testicular torsion cases present as acute onset severe scrotal pain. Some patients initially present only with lower abdominal or inguinal pain, and the pain moves to the scrotum a few hours later after the initial abdominal presentation. If this condition remains unrecognized, within the golden timeframe of 6 h after initial pain, the testicle may be lost. This is the reason why any male patient presenting with lower abdominal pain should have their testicles checked to make sure that they do not have torsion.

Since there are very few data on this topic in the current literature and these are mostly limited to case reports, the purpose of this study was to evaluate the management and outcomes of pediatric patients with testicular torsion initially presenting as acute abdominal pain.

Section snippets

Patients and methods

The case records of 84 children operated on for testicular torsion in the Department of Pediatric Surgery, Split University Hospital Centre, from January 1999 through May 2012, were retrospectively reviewed. The medical records included initial medical history, physical examination, emergency ultrasound, operative findings, and the results of follow-up. The outcomes of all 84 patients were determined and those patients who presented only with abdominal pain were selected for further review. Out

Results

In the selected study period a total number of 84 patients were operated on for testicular torsion. Mean age at the time of the surgery was 12.5 years (range 3 days–17 years). There was no significant difference in age between boys who presented only with abdominal pain and those who presented with testicular pain. Two peak incidences of testicular torsion were found: one during the first year of life, the other between 13 and 15 years of age. Mean duration of symptoms in the group of salvaged

Discussion

The differential diagnosis for a child with abdominal pain is extensive. It includes problems from organs within the abdomen as well as from organs outside of the abdomen. Testicular torsion can present with abdominal pain that mimics appendicitis or some other abdominal conditions, and can lead to significant morbidity if not quickly diagnosed [5]. As a result, it is important to always perform a complete physical examination, including the genitals, when a child presents with abdominal pain

Conclusion

Considering the fact that abdominal pain can be the only presenting symptom of testicular torsion, any male patient presenting with lower abdominal pain should have their testicles checked to make sure that they do not have torsion. Bearing in mind this fact, if the patient comes in time, the testicle can be salvaged.

Conflict of interest statement

Zenon Pogorelić and co-authors have no conflict of interest.

Funding

None.

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