Working Diagnosis:
Left testicular torsion

Treatment:
Manual reduction was attempted with outward rotation of testis. Successful detorsion was achieved with significant improvement in acute symptoms and objective findings (lengthening of cord). Ice packs were applied to the scrotum to further decrease pain and risk of ischemic insult.

Outcome:
Patient reported 90% improvement in symptoms following reduction. After icing, he was able to walk lightly without symptoms. He elected not to complete the race and waited on the mountain until transportation was available.

Author's Comments:
Given that treatment and subsequent resolution of pain was within one hour of symptom onset, risk of ischemia or infarction was extremely low. Despite manual reduction, urologic follow-up is recommended as soon as possible after an episode of testicular torsion. After either surgical or manual detorsion, return to play is mainly dictated by tolerance to activity without exacerbation of pain. Scrotal supports may also be prescribed post-surgery or after manual detorsion, and ice packs have traditionally been used to decrease pain and ischemic risk after detorsion. (1)

This patient’s removal of compression shorts/liner during his last month of training is of special interest. With increased motion and rotation of the spermatic cord during high-impact activity or vigorous exercise, loose-fitting shorts could be a risk factor for testicular torsion. A literature search failed to find specific case studies or reviews evaluating a definitive link. In this case, the patient had taken part in numerous similar activities without complication, all while wearing compression-style underwear. This absence of compression was the only significant change in his regimen prior to injury. Further research is needed to explore the possibility of underwear style as an independent risk factor for testicular torsion during vigorous activities. Significant findings could influence primary care recommendations for prevention of testicular torsion in the athletic population.

Editor's Comments:
There is no literature on supportive undergarments' potential association with decreased incidence of testicular torsion, but this case suggests a possible link. This would be a very difficult association to prove or disprove.

Each year, testicular torsion affects one in 4,000 males under the age of 25. Complications of torsion include loss of testes, which may lead to impaired fertility. All prepubertal and young adult males with acute scrotal pain should be considered to have testicular torsion until proven otherwise. The most sensitive finding in testicular torsion is absence of the ipsilateral cremasteric reflex. When readily available, Doppler ultrasonography or scintigraphy can confirm the diagnosis in patients with a questionable diagnosis or who have been in pain for longer than 6 hours. Any patient exhibiting a history and physical exam suspicious for torsion should have surgery/manual reduction; diagnostic imaging should not delay intervention during the initial 6 hours of symptoms. After manual detorsion, return of blood flow should be documented and subsequent elective orchiopexy is recommended. Risk factors for testicular torsion include congenital malformation of the processus vaginalis, increased testicular volume, testicle tumor, testicles with a horizontal lie, a history of cryptorchidism, and a spermatic cord with a long intrascrotal portion. (2-10)

References:
1. Buttaravoli, Philip M., and Stephen M. Leffler. Minor Emergencies. 3rd ed. Philadelphia, PA; Elsevier/Saunders, 2012
2. Ringdahl E, Teague L. Testicular Torsion. Am Fam Physician. 2006;74:1739-43.
3. Caesar RE, Kaplan GW. The incidence of the cremasteric reflex in normal boys. J Urol. 1994;152(2 pt 2)779–80.
4. Rabinowitz R. The importance of the cremasteric reflex in acute scrotal swelling in children. J Urol. 1984;132:89–90.
5. Galejs LE. Diagnosis and treatment of the acute scrotum. Am Fam Physician. 1999;59:817–24.
6. Nussbaum Blask AR, Bulas D, Shalaby-Rana E, Rushton G, Shao C, Majd M. Color Doppler sonography and scintigraphy of the testis: a prospective, comparative analysis in children with acute scrotal pain. Pediatr Emerg Care. 2002;18:67–71.
7. Kravchick S, Cytron S, Leibovici O, Linov L, London D, Altshuler A, et al. Color Doppler sonography: its real role in the evaluation of children with highly suspected testicular torsion. Eur Radiol. 2001;11:1000–5.
8. Wu HC, Sun SS, Kao A, Chuang FJ, Lin CC, Lee CC. Comparison of radionuclide imaging and ultrasonography in the differentiation of acute testicular torsion and inflammatory testicular disease. Clin Nucl Med. 2002;27:490–3.
9. Cornel EB, Karthaus HF. Manual derotation of the twisted spermatic cord. BJU Int. 1999;83:672–4.
10. Arce JD, Cortes M, Vargas JC. Sonographic diagnosis of acute spermatic cord torsion. Rotation of the cord: a key to the diagnosis. Pediatr Radiol. 2002;32:485–91.

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