"Preserving fertility: A Tale of Timely Intervention and Awarness"

Tuesday early morning at 0100 hours: 9 years old John has woken up because of right testis pain. He waited for some time before he decided to wake his parents up at around 0200 hours due to aggravating pain. His father, Christopher, have a full busy schedule on that day and left this matter to his wife Martha. At around 0240 hours; after the failure of home remedies to relieve the son’s pain, mom wakes up her husband & they headed to the nearest hospital seeking medical advice.

 Dr. Noshina Sadaf (Emergency Physician) covering the Emergency shift at that time received the case at 0334 hours. Upon history taking, he finds out that similar episodes have happened before; The child had the same issue before which was the main reason behind the family delay to come to the hospital, assuming it’s just another episode of pain that will self-resolve shortly.

Dr. Noshina Sadaf (Emergency Physician) diagnosis is Acute Scrotum. She suspected testicular torsion & asked without delay for blood & urine tests and urine culture, she called radiology team for urgent scrotal Doppler ultrasound and called the on-call Urologist & Operation theater team to inform about the suspected case of torsion. 

The Radiologist performed the Doppler ultrasound with the urology team in the presence of child’s family and confirmed the testicular torsion. The family clearly saw the ultrasound signs of torsion and the difference between the right avascular and normal left testis. The decision was made for urgent intervention to save the right testis.

Anesthetist saw patient John in the Emergency within minutes after the Emergency team informed him. At about 0500 hours; operation scrotal exploration was started under general anesthesia, Avascular right testis was detected with a dark bluish color; 360-degree torsion found; detorsion done; blood supply restored and both testes fixed.

RAISING AWARENESS

Q: What’s testicular torsion?

Torsion of the spermatic cord is a true surgical emergency of the highest order. Irreversible ischemic injury to the testicular parenchyma may begin as soon as 4 hours after occlusion of the cord.

Q: At what age can it happen?

Can accrue at any age; even before birth! with peak between 12 & 16 years old.

Q: Why does it happen?

The cremaster is a muscle that enters the scrotum in a spiral way, the cremaster reflex is a defense mechanism that pulls the testes up away from possible trauma or harm. In some kids with abnormally mobile testis (testis than hangs freely without strong fixation in scrotum) the reflex will pull up the testis while twisting it at the same time, the reflex can be so strong that can pull it all the way up to inguinal area, making it difficult for the testis to go back to normal position.

Q: Is there a specific time or direct cause that can trigger torsion?

Yes, it’s common for torsion to happen after an active day for the child like sports; bicycle riding and other physical activities. Most cases of torsion usually happen late night- early morning hours.

Q: What shall I do if my child complains of testicular pain?

The best thing to do is to immediately bring your child to the nearest hospital and seek the medical advice. There is a 4-hour window to save the testis once missed, the testis will have irreversible damage. Urine test, scrotal ultrasound and physical exam will differentiate between testicular torsion and epididymitis which are both common in children.

Q: Should the doctor fix the other normal testis during the operation?

Yes, it should be. Torsion happened due to poor fixation of testis in scrotal sac, a condition that’s usually bilateral. It means, if one testis had an incident of torsion, the other has similar risk. The question is, we don’t know when it will happen.

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