Pain May Present in Variable Ways
The statement that the acute scrotum is always characterized by scrotal pain applies only to a degree. Unfortunately the authors did not mention that scrotal pain by no means dominates the initial consultation for testicular torsion since many patients report pain in the inguinal region/lower abdomen and not the scrotum. If the genitals are not examined lower abdominal pain may be misinterpreted as appendicitis or gastroenteritis, and watchful waiting therefore be practiced, with the result that the testicle will be lost.
In 13 of 37 cases of unrecognized testicular torsion, the genitals were not examined. Torsion leads to scrotal edema, which was misinterpreted as epididymitis in 12 of the 37 cases. This results in the risk of misdiagnosis.
The mention of color Doppler sonography to prevent such misdiagnosis is helpful only to a degree. In the emergency setting, the initial contact with a doctor may be with a doctor in further training who does not have the experience to perform color Doppler sonography. Many hospitals do not have a urology department and initial treatment is provided by doctors from other specialties, who do not know how to perform color Doppler sonography of the scrotum. This is also the case for emergency outpatients, who are seen by doctors from all specialties. Only few of the 37 patients were seen by a urologist or pediatric surgeon on initial presentation.
In cases of undefined pain in the inguinal region/lower abdomen, testicular torsion should be considered and the genitals should be investigated. Older age does not exclude testicular torsion; three of the 37 patients were older than 40. Prior orchidopexy does not exclude torsion and should not lead to a false sense of security.
Dr. med. Christoph von Zastrow
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