Testicular torsion in geriatric 82-year old man.

The leading cause of scrotal pain in the geriatric population is epididymitis. Testicular torsion is rare in adult men. This case report of an 82-year old man with acute scrotum represents the second oldest patient reported in published studies. Due to the long delay between the onset of clinical symptoms and surgical exploration, the testicular infarction with necrosis and orchiectomy ultimately occurred. The diagnosis of testicular torsion in the geriatric population is often delayed and lacks awareness for the diagnosis.

Introduction

Testicular torsion is rarely seen in the geriatric population, and it is often treated as an epididymitis, which is the leading cause of scrotal pain in adulthood. This case highlights the awareness for the diagnosis of testicular torsion in older men and shows that long delay between onset of symptoms and surgical exploration results in testicular infarction and orchiectomy.

Case presentation

An 82-year old male was seen in our emergency department with a 5-day history of sudden right-sided scrotal pain and swelling. The family doctor suspected a herniated disc, and a magnetic resonance imaging (MRI) of the lumbar spine and pelvis was performed. The MRI showed a pronounced epididymo-orchitis, so that he was introduced to us. C-reactive protein (CRP) -elevation and leukocytosis were seen in the blood test as a sign of an infection. Urinalysis showed no white cells or bacteria. The patient had no history of trauma, fever, irritative voiding symptoms or an episode of similar pain before. Multiple spermatoceles on the right were known. The examination showed an enlarged and completely hardened right testis and erythematous hemi-scrotum of the right. The ultrasound presented the right testicular parenchyma loosened up, enlarged epididymis, testis with no blood flow without a sign of a tumor. A parenteral antibiosis was started with piperacillin-tazobactam, and a scrotal exploration was performed. Inspection of the right testis revealed a markedly enlarged, necrotic testis with a 540° intravaginal torsion of the spermatic cord. Right scrotal orchiectomy was performed. The pathologic examination showed testicular infarction and necrosis, no evidence of malignancy [Figure 1, Fig. 2]. The postoperative course was uneventful.

Figure 1

Intraoperative finding: Torsion of the right testis with necrosis.

Fig. 2

Intraoperative finding: Opened Testis.

Discussion

Testicular torsion frequently occurs in children and is a rare cause of scrotal pain in the geriatric population. Since it is often treated as an epididymitis, scrotal exploration is often delayed.

The cause of torsion in adulthood is unclear. The disruption of the spermatic cord axis by spermatoceles is discussed as an increased risk of a torsion. Cummings et al. showed that the salvage of the affected testis was worse in adults compared to younger patients. As affecting factors, they postulate the more delayed medical consultation in adults and the more pronounced twisting of the spermatic cord. Doppler ultrasound seems to have the best sensitivity and negative predictive value for torsion and should be used as a first-line investigation.

Conclusion

Testicular torsion is a rare differential diagnosis in older men, but should be taken into consideration in patients presenting scrotal pain. The Doppler ultrasound should be used, and in clinical suspicion, surgical exploration is recommended. The diagnosis of testicular torsion in the geriatric population is often delayed and should be given more awareness.

Declaration of competing interest

None.