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Testicular Torsion; Plea for Urgent Exploration

Article Information

John L Yovich*

Medical Director, PIVET Medical Centre, Perth, Western Australia 6007, Australia

*Corresponding Authors: Dr. John L Yovich, Medical Director, PIVET Medical Centre, Perth, Western Australia 6007, Australia

Received: 30 January 2020; Accepted: 10 February 2020; Published: 09 March 2020

Citation: John L Yovich. Testicular Torsion; Plea for Urgent Exploration. Archives of Clinical and Medical Case Reports 4 (2020): 196-199.

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Abstract

A case of misdiagnosis of testicular torsion in a 17-year old virginal boy is presented. Orchidectomy of a gangrenous testis was required following an 11 hour uncomfortable flight from London to Mumbai. The wrong diagnosis of epididymitis and a misleading scrotal ultrasound contributed to the delayed surgery and loss of testis.

Keywords

Testicular torsion; Orchidectomy; Scrotal ultrasound; Misdiagnosis; Epididymitis

Testicular torsion articles, Orchidectomy articles, Scrotal ultrasound articles, Misdiagnosis articles, Epididymitis articles

Article Details

1. Case Report

I am moved to write following a recent horrendous experience by a schoolfriend of my grandson. He is an Indian boy from Mumbai, an excellent student at one of England’s prestigious secondary colleges. At age 17 years, the boy had been experiencing testicular pain intermittently over the few weeks prior to the recent Christmas new Year break. He checked online and suspected he might have a testicular torsion. He attended a general practitioner who, after clinical examination, gave re-assurance that there was evidence of epididymitis but not torsion. He was provided with antibiotics and analgesics and was referred across to a major London private hospital where he was seen by doctors including a Consultant Urologist, and had a scrotal ultrasound scan although colour doppler appears not to have been utilised. He was re-assured that testicular torsion was unlikely, and epididymitis would resolve with further antibiotics and analgesics.

Two days later, the boy travelled alone back to Mumbai to be re-united with his family for the festive break. Whilst in the waiting lounge at Heathrow his intra-scrotal pain became exacerbated (1.5 hr) but, keen to be re-united with his family, he boarded the airplane despite his discomfort. During his 9.5 hour airplane flight he endured excruciating pain in his left testicle with associated nausea and consumed repeated analgesics every couple of hours. The next 9 hours was a difficult time for not only the boy, but the neighbouring passengers on this packed flight, as well as the attendant air crew, who all tried their best to help him find a position of comfort. Stoically, the boy travelled uncomfortably to Mumbai where he had wheelchair assistance and an ambulance whisked him away to a nearby hospital. He soon had exploratory scrotal surgery resulting in left orchidectomy for an avascular (black) torted testis. A week later this was followed by a right orchidopexy to secure a dusky testis which showed evidence of having undergone partial torsion. The boy has recovered from his emergency operation and has been completely pain-free following post-operative recovery. His testicular function will be evaluated at a later time.

Whilst the boy has been able to enjoy the festive season with his family and friends (including myself at the event of my grandson’s sixteenth birthday) in Mumbai, he has now returned to his college in England, due to complete the year in preparation for a University placing as he has been accepted into a prominent University in Boston, Massachusetts, USA. His young male friends in the age-range 15 years to 22 years have been quite shaken by this history, particularly those from India who attend secondary and tertiary schooling in the United Kingdom. What they can be informed is that whilst they are indeed in the high-risk age group, their individual risk of unexpected torsion is no greater than 1:4000. None-the-less, if any of them experience testicular pain, they should attend the nearest hospital with an emergency department. The diagnosis of testicular torsion may be clinically obvious hence immediate surgery is required. If it is not clinically certain, scrotal ultrasound with colour doppler can measure any vascular compromise in the testicular artery. Any torsion lasting more than 4-hours is more likely to require orchidectomy, although cases of incomplete, intermittent torsion have been salvaged even after 24 hours.

With respect to scrotal ultrasound, I consider myself a pioneer in this area, having promoted its application as a routine in assessing males in the setting of infertility [1]. However, ultrasound scanning is not a definitive investigation and should not over-ride clinical findings or suspicions when there is discordance. Where there is doubt, scrotal exploration will provide the definitive answer and one can argue that this should have been performed in this case when he was seen at the London hospital, given that the boy is virginal and had no predisposing or associated symptoms to support the diagnosis of epididymitis.

In my personal speciality practice of Reproductive Medicine embracing almost 44 years [2, 3], I have been concerned that males often receive sub-optimal clinical management for unclear reasons, probably related to deficiencies within clinical training programmes [4]. With respect to the potential differential diagnoses in this young, virginal public school-boy, I do not understand why the diagnosis of epididymitis was placed above that of testicular torsion. Publishing this story might help revise the medical education status with respect to protecting and managing the reproductive system for males.

References

  1. Jequier AM, Philips N, Yovich JL. The diagnostic value of a routine genito-urinary ultrasound examination for men attending an infertility clinic. Androl Gynecol: Curr Res 2 (2014): 4.
  2. Yovich JL, Craft IL. Founding Pioneers of IVF: Independent innovative researchers generating livebirths within 4 years of the first birth. Reprod Biol 18 (2018): 324-329.
  3. Yovich JL. Founding Pioneers of IVF Update: Independent innovative researchers generating livebirths within 4 years of the first birth. Reprod Biol (2020).
  4. Yovich JL, Keane KN. Assessing the male in fertility clinics - men undervalued, undermanaged and undertreated. Transl Androl Urol 6 (2017): S624-S628.

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