Management

Management

The management of the case should be determined primarily on clinical grounds. While Doppler ultrasound scanning ( Figure 86.6 ) can confirm the absence of the blood supply to the a ff ected testis, false-positive results can be seen so it is not routinely recommended. If there is any doubt as to the diagnosis, then urgent scrotal exploration is indicated. The typical window of opportunity for surgical intervention and testicular salvage is 6 hours from onset of pain. Therefore, early urological surgery consultation upon presentation may be critical even in the absence of confirmatory testing. Giovanni Battista Morgagni , 1682–1771, Professor of Anatomy , University of Padua, Padua, Italy , is associated with a number of eponymous structures, in cluding the aortic sinus, the appendix testis, the anal columns and the sternocostal triangles. He is regarded as the ‘father of morbid anatomy’. Christian Johann Doppler , 1803–1853, Professor of Experimental Physics, Vienna, Austria, enunciated the ‘Doppler principle’ in 1842. verse or midline scrotal incision. If the testis is viable when the cord is untwisted, it should be prevented from twisting again by fixation with three non-absorbable sutures between the tunica albuginea of the testis and the scrotal raphe. The use of absorbab le sutures risks the possibility of recurrent torsion at some time in the future. The other testis should also be fixed because the anatomical predisposition is likely to be bilateral. If there is clinical doubt as to testicular viability after detorsion of the testis, then it should be wrapped in a warm swab and observed over a few minutes. If a small incision in the tunica albuginea demonstrates bright red arterial bleeding then the testis may survive. An infarcted testis should be removed – the patient can be counselled later about a prosthetic replacement. In cases where there is a history of pain for several days, the a ff ected testis will be dead. It is not possible to recover such a testis and, although little is gained (other than pain relief) by immediate exploration, it is necessary to fix the contralateral testis. - - - ). Summary box 86.3 Testicular torsion /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF -

Figure 86.6 Doppler ultrasound scanning of a torted right testis showing the absence of blood /f_l ow and heterogeneous architecture indicating late necrosis (courtesy of Dr Davide Prezzi). If the diagnosis of testicular torsion is possible, then surgical exploration is indicated Prompt exploration, untwisting and /f_i xation is the only way to save the torted testis The patient should be counselled and consented for orchidectomy before exploration The anatomical abnormality is bilateral and the contralateral testis should also be /f_i xed Non-absorbable sutures should be used for the /f_i xation of each testis

Figure 86.7 (a) Large varicocele in a pendulous scrotum. Note the left inguinal hernia. Davide Prezzi).