Case study: C. M is a 13-year-old Caucasian male who presents to the center with a complaint of sudden left testicular pain that occurred two hours ago while he was playing basketball. His medical condition is described as an acute, continuous pain radiating to his left groin. The patient describes his testicular pain as similar to being punched. He asserts that nothing aggravates or exacerbates his symptoms. On his way to the center, the patient claims to have vomited once. He denies any trauma, fever, blood in his urination, or pain treatment. He states that his pain is a 9 out of 10. During the physical examination, the patient appears acutely distressed and restless. He also has tachycardia and is mildly diaphoretic. The genitourinary exam reveals his left testicle appears higher than the right and tender to touch; his left hemiscrotum is swollen and erythematous; and his left cremasteric reflex is absent. The patient is negative for Prehn’s sign.

Carson Mayer Case Study-Plan of Care

Primary Diagnosis

The patient described in the case study has a positive diagnosis of testicular torsion. Testicular torsion is an acute condition that results from spontaneous twisting of the spermatic code and the consequential impediment of testicular blood flow. This condition is non-common, usually occurring in males 25 years and below. It is characterized by sudden onset acute pain and swelling of the testicular area. A positive diagnosis of testicular torsion should be made upon assessment using the testicular workup for ischemia and suspected (TWIST) score. This assessment tool assigns scores to various listed components, and the summative score is said to be predictive of testicular torsion or non-torsion. These components include the presence of testicular swelling and hardness assigned a score of 2 apiece, absence of cremasteric reflex, high riding testis, and nausea and vomiting, each assigned a score of 1. A summative score of 0 is often predictive of non-torsion, while testicular torsion will be very likely when a score of 6 or 7 is attained

Whereas this tool gives a high indication of the likelihood of testicular torsion, a positive diagnosis does not depend solely on the findings from this tool. Patient history, including risk factors such as trauma, undescended testicles, and prior intermittent torsion, considerably aids the diagnosis (Keays & Rosenberg, 2019). The patient described in the case study presented with acute testicular pain. History and physical examination revealed a swollen left hemiscrotum, absent left cremasteric reflex, high-riding left testicles, and vomiting. This gives a TWIST score of 5, which is highly predictive of testicular torsion.

Differential Diagnosis

The differential diagnosis for this patient was an inguinal hernia, torsion of the testicular appendage, and testicular neoplasm, among others. Torsion of testicular appendage refers to the twisting of tissue above the testicle. It often presents with pain that worsens over time. This condition is common in younger males, often preadolescent males. Scrotal swelling, soreness, and redness are almost always present. The presence of vomiting in the patient, absent cremasteric reflex, and high riding testis are often consistent with testicular torsion and not torsion of the testicular appendage (Fujita, Tambo, Okegawa, Higashihara & Nutahara, 2017). This formed the exclusion criteria for torsion of testicular torsion of the appendages. 

Inguinal hernia results from the protrusion of a tissue sample through the abdominal muscle. It also presents with pain that is made worse by cough reflexes and bending, as well as a bulge in the area of protrusion. If the scrotum is involved, pain and swelling in the testicular area may be apparent (Kulacoglu & Köckerling, 2019). Inguinal hernia is, however, excluded from this diagnosis by history that reveals that nothing aggravates the symptoms. The pain is also continuous and irradiating to the left groin. Testicular neoplasm, on the other hand, defines cancers of the testicles. It often presents with pain and swelling of the testicles. It is, however, excluded from this diagnosis due to the acute onset of the pain in the patient presented in the case study, as opposed to testicular neoplastic pain, which is often gradual (Coursey Moreno et al., 2015). No other symptoms presented by the patient or history were predictive of a testicular neoplasm.

Whereas the TWIST assessment tool and the patient history reveal high predictability towards diagnosing testicular torsion, diagnostic tests may be required to accurately confirm the diagnosis. A positive diagnosis of testicular torsion often requires a scrotal ultrasound as well as a Doppler ultrasonography. Doppler ultrasonography forms the hallmark for testicular torsion diagnosis. This diagnostic test reveals the presence or absence of blood flow to the testicles. A positive diagnosis is made when testicular blood flow is absent (Yin & Trainor, 2016). This test alienates testicular torsion from other differentials. Scrotal ultrasound may as well be helpful as it produces images that can be examined independently by a specialist.

Consults

Testicular torsion is a medical emergency that requires surgical intervention. Referral to a urologist is thus required. Interventions done may include orchiopexy or manual detorsion. Manual detorsion involves using the hands to untwist the spermatic code, while orchiopexy is a complex surgical procedure that requires general anesthesia (Yin & Trainor, 2016). The goal is often to restore blood flow to the testicles to prevent testicular hypoxia and ischemia. In the referral notes, the pain onset should be indicated to inform the urgency of the required medical interventi