Case Presentation Testicular torson

8/9/2019 Case Presentation Testicular torson

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BAB I

CASE PRESENTATION

A. PATIENT IDENTITY

Name : Mr. M

Age : 63 y.o

Sex : Man

Address : Gegesikwetan

Religion : Moeslem

Marital Status : Married

B. ANAMNESIS

• Main Grievance

Enlargement of the testis

• Historical of Present Disease

he !atient "ame to the hos!ital Ar#awinangun $e"ause there%s an enlargement of his

testis sin"e &' days ago. (nitially) his has a normal*si+ed it getting $igger after day $y day

and after that his testis $e"ome reddish and !us inside the testis.

• Historical of Past Disease

,i!ertension -*

/ia$etes Melitus -*

Ne!hrolitiasis -*

• Historical of Fail! Disease

,i!ertension -*

/ia$etes Melitus -0

he !atient said there was no one of his family mem$er that ha1e a disease like him

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C. MEDICA" E#AMINATION

• Present Stat$s

• General 2ondition : Moderate

• Awareness : 2om!osmantis

• lood 4ressure : &3575

• 4ulse : 88 xminute

• reathing : 9 xminute

• em!erature : 36);


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E&treitas

o Su!erior : Akral warm) Edema **) 2R B 9C

o (nferior : Akral wamt) Edema **

Genitalia :

here%s an in"ision wound whi"h had $een sewin and "o1ered $y $andaged.

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D. IN-ESTIGATIONS

"a,orator! E(aination

'ole ,loo% tan))al // Dese,er /012

• >euko"ytes : &6.855

• ,$ : &&)8 mgd>

• 4latelets : '39.555

• 2 : 9% 3%35C

• >E/ '5 mmhour

P'otos of ra%iolo)!

Res$lt 3

• Not seem !ulmonary

• /oesn%t a!!ear enlargement of the heart

E. RES4ME

F. DIAGNOSIS

orsion testis and se"ondary infe"tion

G. DIFERENTIA" DIAGNOSIS

*

H. MANAGEMENT P"AN

Non*e%ical3

D ed Rest

D 2ar$ohydrate /iet

Me%ical3

o (nfusion R> 95 G min


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o 2efo!era+on 9 x &

o eterola" 9 x &

o Ranitidine 9 x &

I. Pro)nosis

Fuo ad 1itam: Ad onam

Fuo ad fun"tionam: du$ia ad onam

Fuo ad sana"tionam: du$ia ad onam

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BAB II

"ITERAT4RE RE-IE

Anato! an% P'!siolo)! of t'e testis

he testes -singular: testis) "ommonly known as the testi"les) are a !air of o1oid glandular

organs that are "entral to the fun"tion of the male re!rodu"ti1e system. he testes are res!onsi$le

for the !rodu"tion of s!erm "ells and the male sex hormone testosterone. he testes !rodu"e as

many as &9 trillion s!erm in a males lifetime) a$out 55 million of whi"h are released in a single

e#a"ulation.

>o"ated in the hollow sa" of the s"rotum) ea"h testis is a$out &.; to 9 in"hes long along its

long axis and around & in"h in diameter. he testes are "onne"ted to the 1ital organs of the 1entral

$ody "a1ity 1ia the s!ermati" "ords. Ner1es) $lood 1essels) and lym!hati" 1essels tra1el through the

s!ermati" "ords to su!!ort the testes. he 1as deferens also !asses through the s!ermati" "ord

"arrying s!erm out of the testes toward the !rostate and urethra. he "remaster mus"le wra!s

around the exterior of the s!ermati" "ord to lift the testes "loser to the $ody or !ermit them to

des"end.

he testes are wra!!ed $y the tuni"a 1aginalis) an extension of the !eritoneum of the

a$domen) and the tuni"a al$uginea) a tough) !rote"ti1e sheath of dense irregular "onne"ti1e tissue.

Ea"h testis is di1ided $y in1aginations of the tuni"a al$uginea that di1ide it into se1eral hundred

small segments "alled lo$ules. Ea"h lo$ule "ontains se1eral tightly "oiled tu$es "alled seminiferous

tu$ules.

he walls of the seminiferous tu$ules "ontain the germ "ells) Sertoli "ells) and >eydig "ells

that gi1e the testes their fun"tion. Millions of germ "ell in the walls of the seminiferous tu$ules

multi!ly and differentiate to !rodu"e s!ermato"ytes from the onset of !u$erty until death. he

s!ermato"ytes de1elo! into s!ermatids and e1entually s!ermato+oa) or s!erm "ells. he immature

s!erm "ells are su!!orted and !rote"ted $y Sertoli "ells as they tra1el the length of the seminiferous

tu$ules and slowly mature. >eydig "ells at the ends of the seminiferous tu$ules !rodu"e the male

hormone testosterone that !rodu"es the se"ondary sex "hara"teristi"s asso"iated with males.

Ea"h s!erm !rodu"ed $y the testes takes a$out se1enty*two days to mature and its maturity

is o1erseen $y a "om!lex intera"tion of hormones. he s"rotum has a $uilt*in thermostat that kee!s

the testes and s!erm at the "orre"t tem!erature. (t may $e sur!rising that the testes should lie in su"h

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a 1ulnera$le !la"e outside the $ody) $ut it is too hot for them inside. S!ermatogenesis reHuires a

tem!erature that is three to fi1e degrees =ahrenheit $elow $ody tem!erature. (f it $e"omes too "ool

on the outside) the "remaster mus"le will "ontra"t to $ring the testes "loser the $ody for warmth.

Definition of t'e testic$lar torsion

esti"ular torsion) or twisting of the testi"le resulting in a strangulation of the $lood su!!ly)

o""urs in men whose tissue surrounding the testi"le is not well atta"hed to the s"rotum . (t is

im!ortant to em!hasi+e that testi"ular torsion is a ME/(2A> emergen"y. he testi"le will die- infar"t and diminish in si+e - atro!hy if the $lood su!!ly is not restored within a!!roximately

six hours. Restoration of the $lood su!!ly reHuires untwisting the "ord -de*torsion.

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E+i%eiolo)! of t'e testic$lar torsion

orsion is relati1ely rare) o""urring in a!!roximately one in )555 males under the age of

9;. ,owe1er) it "an also o""ur in new$orns and in older men.

Etiolo)! of t'e testic$lar torsion

(n most indi1iduals a testi"le "annot twist $e"ause the surrounding tissue is well atta"hed to

the s"rotum . he term I$ell "la!!erI deformity is often used to des"ri$e a "ongenital "ondition in

those indi1iduals) whose testes hang within the s"rotum and "an IswingI like a $ell "la!!er in a

$ell) allowing for easy twisting. (t must $e em!hasi+ed that $oys and men $orn with the I$ell

"la!!erI deformity ha1e no atta"hments around either testi"le) so that torsion "an !otentially o""ur

on either side. ilateral testi"ular torsion) howe1er) is an ex"eedingly rare e1ent.

Pat'o)enesis

orsion o""urs when an ex"essi1ely mo$ile testis rotates on its "ord stru"tures) im!airing 1enous return) whi"h leads

to 1enous "ongestion and oedema. his results in redu"ed arterial $lood inflow)

with su$seHuent is"haemia and

infar"tion of the testis if left un"orre"ted.

esti"ular torsion may $e di1ided into two main ty!es) de!ending on the anatomi"al details of the axis of torsion.

An intra1aginal torsion -=igure &a) $y far the most freHuent in adoles"ent $oys) o""urs when the axis of rotation is

within the tuni"a 1aginalis. (n "om!arison) an extra1aginal torsion -=igure &$ o""urs due to the tuni"a 1aginalis

ha1ing an a$normally long atta"hment to the testis.

hus the rotation is external to the tuni"a 1aginalis) whi"h itself is also torted. his 1ariety of testi"ular torsion

o""urs mainly in "hildren. Males with a hori+ontal lie to their testes) the so*"alled J$ell*"la!!er deformity% are

more !rone to de1elo!ing testi"ular torsion. his anatomi"al 1ariant arises as a result of the manner in whi"h the

tuni"a 1aginalis is refle"ted on the testis and is $ilateral in nature) thus ex!laining the risk of su$seHuent

"ontralateral torsion in !atients who ha1e ex!erien"ed a testi"ular torsion. esti"ular torsion may also o""ur due to

a long mesor"hium) often asso"iated with "ry!tor"hidism -=igure &".

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Fi)$re 1. Classification of t!+es of testic$lar torsion3 5a6 intrava)inal torsion7 5,6 e(trava)inal torsion7 5c6

torsion %$e to lon) esorc'i$

S!+tos of testic$lar torsion

he hallmark of testi"ular torsion is sudden) se1ere) one*sided testi"ular !ain. orsion "an

o""ur at any time) while sitting or standing) or may awaken an indi1idual from slee!. 4hysi"al

a"ti1ity does not "ause torsion) $ut it may o""ur during s!orts or !hysi"al exer"ise. here is often

asso"iated nausea and 1omiting. Slow*onset testi"ular !ain) o1er se1eral hours or days) "an

re!resent torsion) $ut it is less "ommon. 4ro$lems with urination) su"h as $urning or freHuen"y) are

not normally asso"iated with torsion. orsion is not a !ainless e1ent) ex"e!t !erha!s in the new$orn.

he left side tends to $e more "ommonly affe"ted. orsion in undes"ended testes is also more

"ommon on the left side. (n fa"t) one study re!orted that '3K of all torsions in undes"ended testes

o""urred on the left side. orsion is usually on one side) with only 9K of the !atients de1elo!ing

torsion in $oth testi"les.

Early in the !ro"ess) there may $e no s"rotal swelling. ,owe1er 1ery shortly thereafter)

there will $e swelling and redness of the s"rotal skin. (n nearly half of the !atients s"rotal swelling

is found on surgi"al ex!loration. esti"les that ha1e died -infar"ted) after many hours of torsion)

"ause the greatest s"rotal "hanges. he s"rotum will $e 1ery tender) reddened and swollen. Lften

the indi1idual will not $e a$le to find a "omforta$le !osition.

Dia)nosis

General a$dominal examination

• 4atients with intra*1aginal testi"ular torsion ha1e se1ere testi"ular !ain. Some may also

ex!erien"e a$dominal !ain. A !atient with a history of undes"ended testes who !resents

with sudden a$dominal !ain should $e e1aluated for !ossi$le torsion.

Genital examination

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• here is usually se1ere tenderness to !al!ation of the affe"ted testi"le. he testis may ha1e a

trans1erse lie and may $e higher riding than the unaffe"ted testis. A "remasteri" reflex)

o$tained $y stroking the inner thigh on the affe"ted side with su$seHuent testi"ular rise) may

$e a$sent in "ases of torsion. A more delayed !resentation would re1eal a worsening of the

s"rotal erythema and oedema) and a rea"ti1e hydro"ele may de1elo!.

Not all !atients !resent with all of these findings. esti"ular tenderness alone may exist without

other signs suggesti1e of torsion.

2lini"al relief or im!ro1ement after manual de*torsion of testi"ular torsion is highly suggesti1e

of the diagnosis of torsion.

Re"ent ad1an"es in imaging modalities ha1e im!ro1ed the a$ility to identify "ases of torsionhowe1er) if history and !hysi"al examination suggest testi"ular torsion) immediate surgi"al

"onsultation and ex!loration should take !re"eden"e o1er diagnosti" tests. he !rimary goal is to

determine the need for immediate surgi"al inter1ention as soon as !ossi$le. Ln"e the need for

immediate surgi"al inter1ention is identified) further diagnosti" testing should not delay definiti1e

surgi"al treatment. (f the diagnosis is un"lear) immediate surgi"al "onsultation and ex!loration may

also $e warranted.

@ltrasound examinations are non*in1asi1e and Hui"k) and "an determine the !resen"e of

testi"ular torsion or identify other aetiologies for testi"ular !ain. @ltrasound examinations should $e

!erformed $y a sonogra!her skilled in mani!ulating the eHui!ment and in o$taining and inter!reting

sonogra!hi" results. lood and urine tests "an also $e !erformed $ut should not delay timely

ultrasound examination that may lead to diagnosis of torsion.

o !erform an ultrasound examination on a !atient with testi"ular !ain) analgesia will most

likely $e ne"essary. (nitially grey*s"ale ultrasound is !erformed $ilaterally. Grey*s"ale ultrasound !ro1ides non*s!e"ifi" information) and in most "ases will not suffi"e for diagnosis. 2olour and

!ower /o!!ler studies are also needed to esta$lish the !resen"e or a$sen"e of $lood flow. Grey*

s"ale ultrasound "an identify anatomy) the !resen"e of fluid) s"rotal loo!s of $owel or omental

fat) and the whirl!ool sign. he real*time whirl!ool sign -the swirling a!!earan"e of the s!ermati"

"ord from torsion as the ultrasound !ro$e s"ans downwards !er!endi"ular to the s!ermati" "ord is

a s!e"ifi" sign of !artial or "om!lete testi"ular torsion.

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4ower /o!!ler is then !erformed to determine the !resen"e of $lood flow. 4ower /o!!ler is

dire"tion sensiti1e) making it more likely to !i"k u! $lood flow than "olour /o!!ler. 4ower

/o!!ler is u! to ; times more sensiti1e to $lood flow than regular "olour /o!!ler) making it the

mode of "hoi"e to !i"k u! slow*mo1ing $lood su"h as seen in o1aries and testi"les.

2olour /o!!ler is a "olour*$ased dis!lay of $lood flow. essels within the s"rotum that tra1el

towards the transdu"er are assigned one "olour and 1essels flowing away from the transdu"er

another "olour. his mode is sensiti1e to dire"tion of $lood flow. (dentifi"ation of homogeneous)

symmetri"al 1as"ular !erfusion of the unaffe"ted testis "om!ared with "om!lete or !artial de"reased

!erfusion of the affe"ted testi"le leads to a diagnosis of torsion. Normal or in"reased intra*testi"ular $lood flow may suggest an inflammatory diagnosis or de*torsion.

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S!e"tral analysis is a modality on ultrasound that assesses wa1eform of flow through a 1essel.

S!e"tral analysis "an $e used in "om$ination with "olour /o!!ler ultrasound or 4ower /o!!ler

ultrasound to determine !ulsatile flow) arterial or 1enous.

Serial ultrasound examinations "an $e !erformed using the a$o1e*mentioned modalities)

!arti"ularly in !atients with !ersistent testi"ular !ain and a normal ultrasound examination.

=indings may in"lude inter1al "hanges re1ealing de"reasing $lood flow) whi"h suggests torsion) or

normal flow) whi"h would suggest alternati1e diagnoses. =urther testing to rule out testi"ular

torsion "an $e done with s"intigra!hy -nu"lear s"anning) whi"h has almost &55K sensiti1ity for

identifying !atients with torsion howe1er) it takes longer and is less readily a1aila$le than /o!!ler

ultrasound. S"intigra!hy !ro1ides information a$out anatomy and 1as"ular !erfusion that "an $e

used to distinguish testi"ular torsion from other non*surgi"al "auses of an a"ute s"rotum) !re1enting

unne"essary surgery or "onfirming the diagnosis of testi"ular torsion in !atients with a negati1e or

eHui1o"al sonogram.

4rior to serial examinations and nu"lear s"anning) urologi"al "onsultation should take !la"e

$e"ause surgi"al ex!loration may $e the $est o!tion to rule out a"ute testi"ular torsion.

Lther diagnosti" tests are !erformed to rule out other "auses of testi"ular !ain or to "onfirm the

diagnosis in a !atient with a delayed !resentation when immediate ex!loration is unne"essary. ests

might in"lude =2) 2R4) or urinalysis to suggest the !resen"e of e!ididymitis or or"hitis) =ourniers

gangrene) or s"rotal a$s"ess. (t is im!ortant to know that the urinalysis may $e negati1e in "ases of

e!ididymitis or or"hitis and !ositi1e in the setting of testi"ular torsion.

Diferential Dia)nosis

he hydatid of Morgagni is a "ommon testi"ular a!!endage em$ryologi"ally deri1ed from the MOllerian

-!aramesone!hri" du"t) whereas the ex!loration and diathermy to the a!!endage. his offers a mu"h more ra!id

resolution of the !ain.

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E+i%i%!itis. (n adult men) e!ididymitis is more "ommon than torsion) $ut the latter must $e "onsidered as

delayed diagnosis may result in testi"ular loss. he !atient ty!i"ally !resents with ra!idly !rogressi1e s"rotal !ain

and swelling) whi"h radiates u! the s!ermati" "ord and to the lower a$domen. he o1erlying skin may $e

erythematous and the inflammatory !ro"ess may gi1e rise to a rea"ti1e se"ondary hydro"ele. A midstream urine

"ulture should $e routinely !erformed to identify a urinary tra"t infe"tion. (f the !atient "om!lains of urethral

dis"harge) a Gram stain should $e sent) whi"h may re1eal the !resen"e of intra"ellular di!lo"o""i -Neisseria

gonorrhoeae. (f only white "ells are seen) the most likely diagnosis is non* gono"o""al urethritis.

(f e!ididymo*or"hitis does not resol1e within two weeks) the !atient should $e referred for urgent urologi"al

assessment for sus!e"ted testi"ular "an"er. Men o1er the age of ;5 years in whom a diagnosis of e!ididymitis is

sus!e"ted and !ro1en should $e referred for routine urologi"al re1iew to ex"lude any !redis!osing fa"tors to

urinary tra"t infe"tion) su"h as $ladder outflow o$stru"tion or stru"tural a$normalities.

Treatent of testic$lar torsion

@ltimately) all indi1iduals with torsion reHuire surgery. he testi"le "an at times $e manually

untwisted in the emergen"y room) $ut whether this is su""essful or not) surgery is ne"essary. At

surgery) the affe"ted testi"le will $e untwisted and then sutures !la"ed around $oth testi"les to

!re1ent future torsion. Most often this is !erformed through the s"rotum) although an inguinal

a!!roa"h may $e used. @nfortunately) there are indi1iduals whose testi"les "annot $e sa1ed)

$e"ause it has already infar"ted or died. his is determined at surgery. hese indi1iduals will

undergo remo1al of the affe"ted testi"le at the time of surgery and then !la"ement of sutures around

the remaining o!!osite testi"le to !re1ent future torsion. (rre1ersi$le "hanges and !ossi$le damage

starts o""urring after 6 hours. Lne study found that nearly ';K of !atients need the testis to $e

remo1ed or"hide"tomy if surgery is delayed for more than &9 hours.

he testi"les of new$orns with torsion "an rarely $e sal1aged $y untwisting) $e"ause they

are almost always infar"ted. Neonatal torsion is) therefore) not the same sort of surgi"al emergen"y

as torsion in older $oys and men. Ln the other hand) there ha1e $een instan"es of the other non*

in1ol1ed testi"le twisting shortly after $irth) lea1ing the $a$y with no testi"les. (n addition) there

ha1e $een great im!ro1ements in !ediatri" anesthesia and !osto!erati1e "are of e1en the smallest

new$orns. Many !ediatri" urologists will therefore take a new$orn to surgery within the first few

hours or days of life to remo1e the affe"ted testi"le and to !la"e sutures around the o!!osite testi"le

to !re1ent future torsion.

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Pro)nosis

he testi"le may "ontinue to fun"tion !ro!erly if the "ondition is found early and treated

right away. he "han"es that the testi"le will need to $e remo1ed in"rease if $lood flow is redu"ed

for more than 6 hours. ,owe1er) the testi"le may lose its a$ility to fun"tion if torsion has lasted

fewer than 6 hours

Co+lications

Atro!hi" of the testis) re"urrent torsion and se"ondary infe"tion.

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BAB III

REFERENCES

&. 2am!$ell Palls) @rology &5th

edition) 95&&.

9. htt!:www.urologyhealth.orgurologytesti"ulartorsion.A!ril.95&

3. htt!:www.dokter$edahherryyudha."om95&959testi"ulartorsion.fe$ruary

&;

http://www.urologyhealth.org/urology/index.cfm?article=34http://www.dokterbedahherryyudha.com/2012/02/nephrolithiasis.htmlhttp://www.urologyhealth.org/urology/index.cfm?article=34http://www.dokterbedahherryyudha.com/2012/02/nephrolithiasis.html


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&6

Case Presentation Testicular torson

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