Acute scrotum in elderly; is it torsion !

Testicular torsion occurs most frequently in a preadulthood age. In geriatric people, it is very rare and should not be an exclusion criterion for the diagnosis. Lack of awareness about testicular torsion in elderly people may end up with delayed or misdiagnosis. In this article, we report a case of testicular torsion in 62 years old Saudi man.

Introduction

Testicular torsion occurs most frequently in a preadulthood age. In geriatric people, it is very rare and should not be an exclusion criterion for the diagnosis. Lack of awareness about testicular torsion in elderly people may end up with delayed or misdiagnosis. In this article, we report a case of testicular torsion in 62 years old Saudi man.

Case report

A 62-year-old male not diabetic nor hypertensive presented to the emergency department with a 4-day history of left-sided testicular pain radiated to the left groin. Symptoms were of gradual onset, getting significantly worse after 2 days despite antibiotics and analgesics prescribed by his general practitioner. There was no history of trauma, pyrexia or voiding symptoms. No previous similar pain attacks.

Examination revealed an acutely tender left groin and left testicle, markedly enlarged, and erythematous left hemi- scrotum. All blood tests were normal and urine dipstick test was negative.

The patient referred for an urgent ultrasound, which revealed no vascularity within the left testicle (Fig. 1). The patient taken for scrotal exploration under general anesthesia. This revealed a 360° rotated spermatic cord intravaginally with left discolored testicle and black gangrenous epididymis (Fig. 2). A left orchiectomy performed along with right-sided testicular fixation. The patient had an uneventful post-operative course, and discharged home the following day.

Fig. 1

The ultrasound image of our patient demonstrated a heterogeneous left testis with multiple areas of low echogenicity, and absent color doppler flow.

Fig. 2

Intraoperative finding: dusky looking and congested left testis.

Discussion

Testicular torsion referred as wrapping of the spermatic cord followed by blood supply loss of the unilateral testis. It is urological emergency, and early intervention is critically vital for testicular salvage, and fertility preservation.

In geriatric population, torsion is a rare cause of testicular pain. However, there are many causes of pain in adults above 40 years which include hydrocele, epididymo-orchitis, trauma or neoplasm, and most of them have been treated medically.

In general, acute scrotal pain in elderly usually is treated as epididymitis, and because of that, most of them are presenting late and misdiagnosed, which is ultimately result in atrophied testis or orchiectomy.

Cumming et al. report that salvage of the affected testis was worse in adult compared to younger patients, the affecting factor was the time of presentation which was more delay in adult patients, in addition to spermatic cord twisting in adult presented with testicular torsion (585°) was worse than younger group (431°).

In elderly people presenting with acute scrotal pain, Doppler ultrasound became as a first line investigation with 100% of sensitivity and negative predictive value for testicular torsion.

Conclusion

Our case is demonstrate that testicular torsion can happen at any age. Although it is rare in geriatric population, consideration of testicular torsion is must in the differential diagnosis of acute scrotal pain, especially in patients without signs of urinary tract infection.

Doppler ultrasound is helpful in the diagnosis, but it should not delay the surgical exploration.