Testicular

Torsion
Pembimbing: dr. Hartolo, Sp.B

Hashina Zulfa
Thesar Waldi
Devina Rossita H
Identitas Pasien
● Nama : EP
● Usia : 20 tahun
● Tanggal lahir : 29 Mei 1999
● Jenis Kelamin : Laki-laki
● Alamat : Delanggu
● Status : Belum kawin
● Tanggal masuk RS : 10/08/2019
Keluhan Utama
Bengkak testis kiri
Anamnesis
● RPS: 3HSMRS pasien mengeluhkan bengkak pada testis kiri saat pagi hari
bangun dari tidur. Keluhan disertai nyeri. Demam (-), riw trauma (-), mual dan
muntah (-). HMRS pasien mengeluhkan testis kiri semakin bengkak dan terasa
nyeri memberat. Keluhan sering berkemih (-), nyeri saat berkemih (-)
● RPD: Keluhan serupa (-), riwayat keluhan genital bawaan (-), alergi
makanan/obat/asma (-), riwayat operasi (-)
● RPK: Keluhan serupa (-), riwayat kelainan kongenital atau penyakit bawaan (-),
alergi makanan/obat/asma (-)
Pemeriksaan Fisik
Kesan umum : baik, compos mentis E4V5M6
Tanda Vital
● TD : 146/91 mmHg
● N : 111 kpm, isi dan tegangan kuat, reguler
● T : 36.6*C
● RR : 18 kpm, tipe thoracoabdominal
● SpO2: 99%
● VAS : 4
Status gizi :
● BB : 78 kg
● TB : 170 cm
● BMI : 26,9 kg/cm2 (obese 1)
Pemeriksaan Fisik
● Kulit : sianosis (-), jaundice (-), pucat(-)
● Kepala: normocephal
○ Mata: konjungtiva pucat (-/-), sklera ikterik (-/-), mata cowong (-/-)
○ Hidung: sekret (-), deformitas (-)
○ Telinga: sekret (-), deformitas (-)
○ Mulut/lidah: atrofi (-), hiperemis (-)
● Leher: lnn tidak teraba, JVP normal
● Thorax
○ Ins: bentuk dada normal, simetris (+) retraksi (-)
○ Pal: Nyeri tekan (-/-), taktil fremitus (+/+)N
○ Per: sonor
○ Aus: SDV (+/+), wh (-/-), rh (-/-)
Pemeriksaan Fisik
● Jantung
○ Ins: IC tidak tampak
○ Pal: IC teraba di SIC 5 LMCS
○ Per: cardiomegaly (-)
○ Aus: S1 S2 regular, murmur (-)
● Abdomen
○ Ins: distensi (-), deformitas (-)
○ Aus: bising usus (+) menurun
○ Per: hipertimpani
○ Pal: supel, NT (+) epigastrik, defans muskular (-), hepatomegaly (-), splenomegaly (-)
● Ekstremitas: akral hangat, WPK <2dtk, edema (-)
● Status Lokalis:
- Inspeksi → ukuran testis kiri lebih besar, testis edema/bengkak (-/+), hiperemis (-/+),
jejas/ luka pada skrotum (-/-), skrotum kiri tampah lebih tinggi
- Palpasi → testis kiri teraba hangat, tenderness (-/+) reflex cremaster (+/-), Prehn sign (-),
Deming sign (+), Angel sign (+)
 Nama Hasil Nilai Rujukan
Pemeriksaan

DARAH LENGKAP

Lekosit 14 10^3/uL 4.8-10.8

Eritrosit 6 10^6/uL 4.7-6.2

Pemeriksaan Hemoglobin 18.30 g/dL 14-18

Penunjang Hematokrit 53.1 % 37-52

MCV 88.5 fL 80-99

Lab darah (14/8/19) MCH 30.5pg 27-31

MCHC 34.5 g/dl 33-37

Trombosit 325 x10^3/µL 150-450

RDW 13.2 % 10-15

 Neutrofil 74.3 % 50-70

Limfosit 23.7 % 20-40

MXD 2% 1-12

FAAL GINJAL

Pemeriksaan Ureum 19.7 mg/dl 19-44

Penunjang Creatinin 0.69 mg/dl 0.7-1.1

BUN 9.2 mg/dl 7-18

Lab darah (14/8/19) FAAL HATI

SGOT 16.9 U/L 7-45

SGPT 10.1 U/L 7-41

 PAKET ELEKTROLIT

Natrium 139 mmol/dl 136-145

Kalium 3.26 mmol/dl 3.5-5.1

Kloridal 102 mmol/dl 98-107

Pemeriksaan
SERO IMUNOLOGI

HBsAg Negatif Negatif

Penunjang Anti HCV Negatif Negatif

Anti HIV Non Reaktif Non Reaktif

Lab darah (14/8/19)
HEMATOLOGI

APTT 27.2 detik 20-40

PT 13.6 detik 11-17

Ratio (PT) 0.97

INR (PT) 0.96 detik 1-1.52

 Pemeriksaan
Penunjang
USG Doppler Testis CITO
(14/8/19)
Kesan:
● Torsio testicle sinistra dengan
bagian nekrosis di sebagian
besar (+⅔ bagian) testicle
sinistra
● Tanda ischemia juga didapatkan
pada epididymis sinistra
● Hydrocele testicle sinistra (+)
● Testicle dextra dan epididymis
dextra baik
Diagnosis
Torsio testis sinistra
Tatalaksana
Inj cefotaxim 1 gram/8 jam

Inj ketorolac 30 mg/12 jam

Pro eksplorasi testis sinistra s/d orchidectomy sinistra CITO

Premedikasi: inj ranitidin 1 A dan inj metoclopramide 1 A

Laporan Operasi
1. Pasien supine dalam stadium anestesi
2. Dilakukan insisi pada raphe scrotum
3. Diperdalam lapis demi lapis
4. Tampak testis S torsio 360 derajat → hitam → di detorsi
5. Dihangatkan selama 10 menit → tetap hitam
6. Diputuskan orchidectomy S dengan prolene
7. Testis D dilakukan orchidopexy D dengan prolene 2.0
8. Tutup luka operasi lapis demi lapis
9. Operasi selesai
Diagnosis Pre Op: torsio testis S
Diagnosis Post Op: post orchidectomy S dan orchidopexy D a/i torsio testis S
Instruksi Post Operasi
Awasi KU/VS

Inj pycin 750 mg/12 jam

Inj ketorolac 30 mg/8 jam

Inj asam tranexamat 500 mg/8 jam

Pembahasan
General Approach of Acute Scrotal Pain
● Nyeri akut skrotum umum disebabkan → epididimitis
akut (epididimo-orchitis) dan torsio testis
● Penyebab lain Founiere’s gangrene (necrotizing
fasciitis of the perineum)
● Evaluasi onset nyeri, lokasi, dan penyerta seperti
demam dan LUTS (disuria, frekuensi, urgensi)
General Approach of Acute Scrotal Pain
Diffuse scrotal pain -->testicular torsion, acute epididymo-orchitis, and Fournier’s
gangrene.
If febrile (+) → rule out Fournier’s gangrene, (characterized by diffuse scrotal, groin, and
lower abdominal pain, tenderness, and swelling) and necessitates urgent surgical
evaluation → testing the cremasteric reflex

●If the cremasteric reflex (-) → testicular torsion, with other findings : a high-riding testis,
bell clapper deformity, and testicular swelling. If the findings are less clear → scrotal
ultrasound → testicular torsion should be referred urgently for urologic evaluation.
●If the cremasteric reflex is (+) → acute epididymo-orchitis or orchitis
❏ In acute epididymo-orchitis → pain, swelling, and tenderness of the testis with
some localization posteriorly. Fever and LUTS may be present → Perform
urinalysis, urine culture, and urine studies for Neisseria gonorrhoeae and
Chlamydia trachomatis → antibiotic therapy empirically
❏ Acute orchitis from mumps → diffuse testicular swelling and tenderness,
supportive findings presence of constitutional symptoms and parotitis --> serologic
testing

Localized scrotal pain

●If symptoms are localized to the posterior aspect of the testis → acute epididymitis can
be made.
●If symptoms are localized to the upper pole of the testis → testicular appendiceal torsion,
other supportive finding is blue dot sign
Testicular Torsion
● Testicular torsion results from
inadequate fixation of the lower pole
of the testis to the tunica vaginalis
● Fixation is absent or insufficiently broad-
based → testis may torse (twist) on the
spermatic cord → ischemia from
reduced arterial inflow and venous
outflow obstruction
● Occur after an inciting event (eg, trauma)
or spontaneously
Testicular Torsion Types

A) Intravaginal torsion;
B) Extravaginal torsion;
C) Torsion due to long mesorchium.

Dewasa Neonatus
Clinical Features
Acute onset of moderate to severe testicular pain with profound diffuse tenderness
and swelling with negative cremasteric reflex

Nausea and vomiting may be associated

Particularly in children: awakening with scrotal pain in the middle of the night or in the
morning (likely related to cremasteric contraction with nocturnal sexual stimulation
during the rapid eye movement sleep cycle)

Asymmetrically high-riding testis with its long axis oriented transversely instead of
longitudinally related to shortening of the spermatic cord from the torsion ("bell clapper
deformity")
Sign/ test Application Positive finding Negative Testicula
finding r Torsion

Blue dot sign Inspect testicular 2-3 mm blue nodule No nodule -

surface in torsion of
testicular appendix

Brunzel sign Inspect testicular lie Horizontal lie Vertical lie +

Cremasteric Stroke supero Elevation of testis No elevation -

reflex medial thigh

Deming sign Inspect testicular Abnormally elevated Normal +

position/elevation

Ger sign Inspect scrotum Pitting at testicular No pitting +

base

Prehn sign Elevate testicle Pain relief No pain relief -

Diagnosis
The diagnosis of testicular torsion can be made presumptively on the basis of
history and physical examination but can be confirmed by scrotal ultrasound

If access to scrotal ultrasonography is unavailable or if the ultrasound cannot

exclude testicular torsion, surgical exploration is advised
Management
● Urgent surgical exploration with intraoperative detorsion and fixation of the
testes
● Surgical intervention is not immediately available → manual detorsion

1. Surgery
● Detorsion and fixation of both the involved testis and the contralateral
uninvolved testis should be performed since inadequate gubernacular
fixation is usually a bilateral defect
● Extended periods of ischemia (>6 hours) may cause infarction of the testis
with liquefaction requiring orchiectomy
Management
2. Manual Detorsion
● Surgery is not available within two hours
● Surgical exploration is necessary even after successful manual detorsion
because orchiopexy should be performed to prevent recurrence and
residual torsion may be present that can be further relieved
● Testis usually rotates medially during torsion and can be detorsed by
rotating it outward toward the thigh.
● The degree of twisting of the testis may range from 180 to 720 degrees →
requiring multiple rounds of detorsion
● Analgesics are not given because of concern of asking continued torsion
Management
● Successful detorsion is
suggested by
○ Relief of pain
○ Conversion of the transverse lie
of the testis to a longitudinal
orientation
○ Lower position of the testis in
the scrotum
○ Return of normal arterial
pulsations on color Doppler
ultrasound
Irreversible ischemic changes occur 4–6 h after ischemic scrotum, and that 80% of patients need
orchiectomy due to necrosis after 24 h if the testis is not detorsioned.

MD was first described in 1893. It was performed to restore blood flow and give rapid pain relief. The
efficiency of the procedure has been investigated by various authors. The author also reported that
retorsion was not evident in any of the patients, the ischemic testis was saved, and an emergency
procedure became an elective procedure.

MD is a non-invasive procedure, may be applied as soon as the diagnosis is made, decreases the
duration of ischemia when compared to emergency scrotal exploration, and the long-term results of this
study have shown that it is safe when applied together with elective orchiopexy
References
Eyre, R. (2019). UpToDate. [online] Evaluation of acute scrotal pain in adults.
Available at: https://www.uptodate.com/ [Accessed 21 Aug. 2019].
Terimakasih