SPERMATIC CORD TORSION (TESTICULAR TORSION): PALPATE THE CORD

Most people use the term “testicular torsion,” but throughout history it has also been called “spermatic cord torsion.” Many urologists prefer this term. One introduced it as “acute spermatic cord torsion, more commonly and not so exactly named testicular torsion (TT)…”(Drlik M. J Ped Urol 2013)

The reason spermatic cord torsion is a better term is that it accurately identifies the pathologic organ. By neglecting to call it by its right name, we don’t necessarily realize that we can palpate the actual pathology in this disease.

That is why it took until 2011 for an article to assess the sensitivity and specificity of palpation of the spermatic cord knot.(Al-Terki A. Spermatic Cord Knot: A Clinical Finding in Patients with Spermatic Cord Torsion. Adv Urol 2011) With a reported 86% sensitivity and 100% specificity in 46 patients, this is worth our attention.

The knot of spermatic cord torsion may be located in the inguinal canal in neonates, but it is usually in the scrotum in adolescents and adults. We should palpate the spermatic cord in the acute scrotum. If the results of this first article are replicated, this may turn out to be the most important part of the physical examination of the acute scrotum.

Take Home Points:

-“Spermatic cord torsion” is a more accurate term than testicular torsion

-Spermatic cord torsion can often be felt as a knot on physical examination

References:

Spermatic cord knot: a clinical finding in patients with spermatic cord torsion. Al-Terki A…Adv Urol. 2011

Article located for free at:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3235495/

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THE PEDIATRIC EXAMINATION PART 3: LOCALIZATION BY PROXY

In the last 2 posts we discussed techniques for winning rapport and trust with children and for using distraction and play. We discussed a case of a 16 month old with scalp tenderness. In that case none of these techniques worked. So what do you do next?

Parent’s Arms

Most children between the ages of 1 and 3 will become more calm when examined in the arms of their mother or father. The child calms down, and clings to the mother and sometimes that is enough for examination.

Examination By Proxy

If all else fails you can deputize the mother to do the localizing examination. In this case she tries but the child still cries. You decide to leave the room to let her calm down and you ask the mother try to better define the area that is tender. You suggest a gentle scalp massage starting away from any areas of pain.

Come Back Later

Once the limbic system is aroused and heated it takes a few minutes to cool off. Come back later to reassess the child. Of course, treating pain is important for enabling a good examination.

You come back and she thinks it is the left ear. You expect external otitis but see nothing. Then you look at the scalp in that area and see bulging and redness behind the ear. You order a CT scan and find mastoiditis with abscess formation.

Take Home Points:

-Examine the child in the parent’s arms if needed for calmness

-In the uncooperative child, try localization by proxy