A 16-year-old boy is brought to the emergency department due to severe right groin pain that has worsened over the past 12 hours. During the last month, the patient has had several episodes of mild scrotal pain while walking between classes at school. He has no history of traumatic injury and is sexually active. Medical history is unremarkable except for an inguinal hernia repaired a year ago. Temperature is 36.9 C (98.4 F), blood pressure is 116/78 mm Hg, and pulse is 86/min. On examination, the right hemiscrotum is swollen and tender. The bisected gross specimen from an orchiectomy is shown in the image below. Which of the following is the most likely mechanism of this patient's acute testicular pain?

Question

A 16-year-old boy is brought to the emergency department due to severe right groin pain that has worsened over the past 12 hours.  During the last month, the patient has had several episodes of mild scrotal pain while walking between classes at school.  He has no history of traumatic injury and is sexually active.  Medical history is unremarkable except for an inguinal hernia repaired a year ago.  Temperature is 36.9 C (98.4 F), blood pressure is 116/78 mm Hg, and pulse is 86/min.  On examination, the right hemiscrotum is swollen and tender.  The bisected gross specimen from an orchiectomy is shown in the image below.  Which of the following is the most likely mechanism of this patient's acute testicular pain?

Quizplus · Accepted Answer

11ec160b_3591_0309_9249_195f59d18e09_MD0001_00 This patient with severe groin pain and unilateral scrotal swelling has evidence of hemorrhagic infarction (ie, venous congestion with extravasation of blood) of the testicle, consistent with testicular torsion. Testicular torsion is caused by spermatic cord twisting, which most commonly occurs in patients with inadequate fixation of the lower pole of the testis to the tunica vaginalis. This anatomic defect (ie, bell clapper deformity) allows for increased mobility of the testis, which can turn freely within the scrotum. As the testis and cord rotate, the pampiniform plexus becomes compressed, leading to reduced venous outflow and hemorrhagic infarction of the testicle. Diminished testicular perfusion can rapidly progress to ischemia and necrosis. The classic presentation is an acute onset of severe scrotal pain and swelling with an elevated, high-riding testis and an absent cremasteric reflex. Groin or lower abdominal pain may be the initial presentation in some, and there may be a history of milder, self-resolving episodes caused by intermittent torsion, as seen in this patient. Emergency surgical detorsion (ideally within 4-6 hr of symptom onset) is required to salvage the testis, but orchiectomy may be necessary if the testicle is necrotic or blood flow cannot be restored. (Choice A) An abnormal fluid collection between the parietal and viscera tunica vaginalis describes a hydrocele, which causes scrotal swelling but not acute pain. (Choice C) Clonal proliferation of testicular germ cells is seen with a germ cell tumor (eg, seminoma), which most often presents as a nontender testicular mass. (Choice D) Infection (eg, epididymitis, epididymoorchitis) due to bacterial migration from the urinary tract can cause scrotal pain and swelling, but additional symptoms (eg, fever, dysuria) are often present, and a history of sporadic painful episodes is not typical. Moreover, testicular edema occurs due to inflammation, not hemorrhagic infarction. (Choice E) Postoperative clotting of the pampiniform plexus (ie, thrombotic varicocele) is a rare surgical complication that causes acute scrotal pain and swelling. However, this patient's inguinal hernia repair was a year ago, making postsurgical complication unlikely. Educational objective: Testicular torsion is characterized by spermatic cord twisting due to an anatomic defect that allows increased testicular mobility. The presentation includes severe scrotal pain and swelling due to venous compression and hemorrhagic infarction of the testis. __________ References: Testicular torsion: diagnosis, evaluation, and management. (http://www.ncbi.nlm.nih.gov/pubmed/24364548)

A 16-Year-Old Boy Is Brought to the Emergency Department Due