Prior to my motion calling for comprehensive sex ed. reform, I was contacted by Dr. Peter Metcalfe, a Pediatric Urologist at the Stollery. For several years, Dr. Metcalfe has been trying to get something into the sex education curriculum related to one of his most common emergencies. The condition is known as testicular torsion which predominantly affects adolescent boys. Essentially, the testicle twists on itself. If the youth is not in the OR within the critical time frame of in 4-6 hours, it has a high chance of dying and the testicle being removed. As noted by Dr. Metcalfe, “I operated on 3 last Monday night / Tuesday AM, and likely only saved one. Unfortunately, nearly all of the families involved have no idea this was possible, so I feel we need to improve our knowledge dissemination”.
As we continue to wait on sex ed reform, I wish to share this information via my blog to improve awareness on this important matter. As boys tend to suffer in silence in attempts to avoid “embarrassing” conversations with mom/dad it is important that we relay this information so boys fully understand the importance of seeking immediate medical help.
I have attached a Journal Article published by Dr. Metcalfe et al. to provide you with further information.
Testicular Pain:Might be embarrassing, but certainly is worth attention!
As a pediatric urologist, I often hear families say that “Oh…, I didn’t know that could happen”! Most of the time, it probably doesn’t matter, but when it comes to testicular pain, a bit of knowledge may make the difference between saving and losing a testicle.
The sudden onset of testicular pain can be due to several causes, but of utmost importance is testicular torsion. Testicles hang loosely in the scrotum via the spermatic cord (Figure a), which makes them susceptible to spinning or twisting (testicular torsion) (Figure b). This is significant, as the torsion cuts off the blood supply to the testicle and if not corrected in 4-6 hours, may result in the death of the testicle. Therefore, it is paramount that this is corrected with minimal delay.
Far too commonly in my practice, however, teenagers will present to the emergency room well beyond this time frame, as neither they, not their caregivers, were aware of the potential consequences. A recent research article in the UK confirmed that 95% of parents felt that more public awareness is required. Unfortunately, this lack of knowledge results in a dead testicle that needs to be removed, instead of one that is easily saved(Ubee, Hopkinson, & Srirangam, 2014).
It is my goal to increase the general awareness of this issue, with the hope of preventing this unwanted outcome. Unfortunately, teenage boys, and their families, are often very reluctant to talk about their “privates” with others. Hopefully, by introducing this topic into the school system, we may be able to reach this vulnerable population, and prevent unnecessary embarrassment, barriers to discussion, and delays to treatment.
Testicular (or scrotal) pain can be divided in to three general groups: a) Chronic pain (orchalgia) which is not common in the teenager, and is defined as a constant pain present for more than three months; b) Acute scrotal pain not due to torsion; c) testicular torsion. Most (approximately 80%) of episodes of a sudden onset of testicular pain are not due to a testicular torsion, but it is imperative to rule this out.
Although not common, about 80-100 patients present to the Stollery Children’s Hospital emergency department per year with a complaint of testicular pain. Of these, about 10% have a testicular torsion and need immediate surgical intervention. The other 90% are due to generalized inflammation (not infectious) or of an unknown (benign) etiology. Unfortunately, the average time (in our patients) from the onset of symptoms to presentation to the hospital was almost 20 hours(Liang, Metcalfe, Sevcik, & Noga, 2013).
The peak age groups at risk are the 12-16 year old, due to the (newly) increased testicular size. Before puberty, testicles are much less likely to undergo torsion, as they are too small to generate sufficient force or their testicular cords are not long enough to place the testicle at risk.
As most would guess, the presentation can be very painful, and likely hard to ignore! The onset of symptoms can be while the teen is at rest, during activity, or after trauma. The pain is typically a sudden onset of a dull ache (not unlike being kicked!) and often associated with nausea. Very often the boy is not able to attend or continue classes, but is generally not “screaming” in pain. Occasionally, the pain may come and go, which may be a partial or intermittent torsion. In the torsed testicle, the testicle can have rotated from 270-720 degrees!
If this pain occurs, and lasts for at least one hour, medical attention must be sought immediately. The goal would be to get the patient to the operating room within 4-6 hours, from the onset of symptoms, as we then have a very high chance of saving the testicle. If surgery is delayed, certainly if greater than 12 hours, the chance of untwisting the testicle, restoring its blood supply, and salvaging the testicle is very low. In these cases, we often have to remove the entire testicle.
Often, the patient’s history is sufficient to warrant bringing him straight to the operating room, but if the diagnosis is in question, the physician may decide to do an ultrasound. This is very accurate in determining the presence or absence of blood flow, pathognomonic for a torsion. If the ultrasound demonstrates good blood flow to the testicle, the pain is either due to another cause, or the testicle has untwisted itself.
In summary, the sudden onset of testicular pain can have significant physical and emotional consequences. Unfortunately, the emotional aspect can result in a delay to diagnosis and treatment. Hopefully this article will improve awareness of this potentially devastating problem, and we are able to see our patients sooner and save more testicles!
