460 CHAPTER 10 Trauma to the urinary tract

Torsion of the testis and testicular appendages

Definition

Testicular torsion is a twist of the spermatic cord, resulting in strangulation of the blood supply to the testis and epididymis. Testicular torsion occurs most frequently between the ages of 10 and 30 (peak incidence 13–15 years of age), but any age group may be affected.

History and examination

There is a sudden onset of severe pain in the hemiscrotum, sometimes waking the patient from sleep. It may radiate to the groin, flank, or epigastrium (reflecting its origin from the dorsal abdominal wall of the embryo and its nerve supply from T10/11) and is often associated with nausea.

There is sometimes a history of minor trauma to the testis. Some patients report previous episodes with spontaneous resolution of the pain (suggesting previous torsion with spontaneous detorsion).

The patient is often writhing on the exam table, unable to find a comfortable position. The torsed testis is usually moderately swollen and very tender to the touch. It may be high riding compared to the contralateral testis and may lie in a horizontal position due to twisting of the cord.

The cremasteric reflex is nearly always absent in the event of true testicular torsion—if a prompt bilateral reflex elevation of the testes is noted when lightly scratching the inner thigh (cremasteric reflex), the diagnosis is unlikely. Elevation of the scrotum and supporting may relieve the pain of epididymitis but not in torsion.

Differential diagnosis and investigations

Common diagnoses that may masquerade as torsion include epididymoorchitis, torsion of a testicular appendage, and causes of flank pain with radiation into the groin and testis (e.g., a ureteric stone). The diagnosis of epididymitis should be made intraoperatively in an adolescent with an acute scrotum.

Radiographic studies are generally used to confirm the absence of torsion. If torsion is suspected clinically, arrangements should immediately be made for surgical exploration and detorsion.

Color Doppler ultrasound (reduced arterial blood flow in the testicular artery) and radionuclide scanning (decreased radioisotope uptake) can be used to diagnose testicular torsion. In many hospitals these tests are not readily available and the diagnosis is based on symptoms and signs.

Surgical management

Scrotal exploration should be undertaken as a matter of urgency since delay in relieving the twisted testis results in permanent ischemic damage to the testis, causing atrophy, loss of hormone and sperm production, and, as the testis undergoes necrosis and the blood–testis barrier breaks down, an autoimmune reaction against the contralateral testis (sympathetic orchidopathy).

TORSION OF THE TESTIS AND TESTICULAR APPENDAGES 461

Bilateral testicular fixation should always be performed since the bellclapper abnormality that predisposes to torsion often occurs bilaterally. A soft, braided, permanent suture is recommended with fixation at two or three sites.

Manual detorsion may be attempted in the emergency room while awaiting surgery. Occasionally, the induction of anesthesia will reduce spasm and promote spontaneous detorsion—in both of these instances, bilateral orchiopexy should still be performed to prevent recurrence.

Infarction of testicular appendages

The appendix testis (remnant of the Müllerian duct) and the appendix epididymis (remnant of a cranial mesonephric tubule of the Wolffian duct) can undergo infarction, causing pain that mimics a testicular torsion. The “blue dot” sign is the typical physical finding for appendix testis infarction. At scrotal exploration they are easily removed with scissors or electrocautery.

If these diagnoses are confirmed radiographically, analgesics may be given and surgical exploration is unnecessary.

462 CHAPTER 10 Trauma to the urinary tract

Paraphimosis

Definition and presentation

Paraphimosis is when the uncircumcised foreskin is retracted under the glans penis and the foreskin becomes edematous, and cannot be pulled back over the glans into its normal anatomical position. It occurs most commonly in teenagers or young men and also in elderly men (who have had the foreskin retracted during catheterization, but where it has not been returned to its normal position).

Paraphimosis is usually painful. The foreskin is edematous and a small area of ulceration of the foreskin may have developed.

Treatment

The best initial maneuver for manually reducing paraphimosis is to forcefully squeeze the edematous prepuce for several minutes. Then the skin may be manipulated distally with the fingers of both hands as the glans is pressed down with the thumbs.

If this fails, the traditional surgical treatment is a dorsal slit under general anesthetic or ring block. A longitudinal incision is made in the tight band of constricting tissue and the foreskin pulled back over the glans. Close the incision transversely with chromic sutures to widen the circumference of the foreskin and prevent recurrences. Many patients subsequently require elective circumcision.

MALIGNANT URETERAL OBSTRUCTION 463

Malignant ureteral obstruction

Locally advanced prostate cancer, bladder or ureteral cancer may cause unilateral or bilateral ureteral obstruction. Locally advanced nonurological malignancies can also obstruct the ureters (e.g., cervical cancer, rectal cancer, lymphoma).

Unilateral obstruction

This is often asymptomatic and an incidental ultrasound finding that requires no specific treatment in the presence of a normal contralateral kidney in a patient with limited life expectancy.

Occasionally, flank pain and systemic symptoms may develop due to infection of the obstructed upper urinary tract. In this circumstance, drainage by nephrostomy or stenting is required.

Bilateral ureteric obstruction

This is a urological emergency. The patient either presents with symptoms and signs of renal failure or is anuric without a palpable bladder. A mass will probably be palpable on rectal examination.

Investigations

Renal ultrasound will demonstrate bilateral hydronephrosis and an empty bladder. Noncontrasted CT will confirm the presence of dilated ureters down to a mass at the bladder base.

Immediate treatment of bilateral ureteric obstruction

After treating any life-threatening hyperkalemia, options include bilateral percutaneous nephrostomy or ureteric stenting. Serum coagulation studies are required prior to nephrostomy insertion. Insertion of retrograde ureteric stents in this setting is usually unsuccessful because tumor involving the trigone obscures the location of the ureteric orifices.

More successful is antegrade ureteric stenting following nephrostomy insertion, both of which are performed under IV sedation. The double-J silicone or polyurethane ureteric stents require periodic (4–6 monthly) changes to prevent calcification or blockage.

In the case of prostate cancer, rapid reduction in testosterone through hormone therapy should be started if not previously used.