Case Report
Testicular Torsion Appearance and Diagnosis on Computed Tomography of the Abdomen and Pelvis: Case Report Graham S. Stephenson, MD Mark I. Langdorf, MD, MHPE
University of California, Irvine, Department of Emergency Medicine, Orange, California
Section Editor: Christopher San Miguel, MD Submission History: Submitted November 6, 2021; Revision received January 23, 2022; Accepted February 4, 2022 Electronically published April 21, 2022 Full text available through open access at http://escholarship.org/uc/uciem_cpcem DOI: 10.5811/cpcem.2022.2.55315
Introduction: Testicular torsion, or the twisting of the spermatic cord compromising blood flow to the testis, is a urologic emergency with the potential to cause infertility in male patients. The diagnosis may be clinical or confirmed using imaging, with ultrasound being the modality of choice. Case Report: We present a case of right lower quadrant pain with radiation to the groin and right scrotum in a young male. A computed tomography of the abdomen and pelvis was ordered to assess for appendicitis, which showed a “whirl” sign on the inferior periphery of the images near the scrotum. The finding was not appreciated during the emergency department visit and the patient was discharged home. He returned 48 hours later due to continued pain and was ultimately diagnosed with testicular torsion via ultrasound and surgical pathology. Conclusion: This is the first reported case to our knowledge identifying “whirl” sign for the diagnosis of testicular torsion. This finding was not appreciated by multiple clinicians during the initial patient presentation, highlighting the uncommon nature of the finding. [Clin Pract Cases Emerg Med. 2022;6(2):117-120.] Keywords: testicular torsion; whirl sign; abdominal pain.
INTRODUCTION The internal and external spermatic arteries travel through the spermatic cord to supply blood to the testicles. Testicular torsion, or the twisting of the testes on the spermatic cord, impedes this supply and is a urologic emergency. Failure to promptly reduce torsion may result in infertility from ischemic loss of germ cells or the generation of anti-sperm antibodies.1 Although most common in neonates and pre-pubertal males, torsion may occur at any age with nearly 40% outside typical demographics.2 In the United States, testicular torsion occurs 5.9 times per 100,000 males ages 1–17 years, and 1.3 per 100,000 over the age of 18.3 A concerning physical exam is sufficient to make the diagnosis of testicular torsion. Presenting symptoms include a firm and tender testicle, abnormal testicle lie (horizontal or high riding), loss of the cremasteric reflex, nausea and vomiting, and lower abdominal pain.4 Symptoms often present after physical activity or minor trauma, although younger patients may be startled from sleep due to nocturnal Volume 6, no. 2: May 2022
cremasteric contraction. Testicular torsion during adolescence will frequently occur within the tunica vaginalis, causing a “bell clapper” deformity where the affected testicle has an abnormal transverse lie in the standing patient.5 When clinical exam is equivocal, imaging is highly sensitive and can confirm the diagnosis. Ultrasound with color Doppler is the test of choice with sensitivity and specificity of 82% and 100%, respectively.6,7,8 Ultrasound findings concerning for torsion include direct visualization of twisted cord with a “whirl” sign, diminished blood flow on Doppler, abnormal echo texture of the affected side, reactive hydrocele, or scrotal wall thickening and hyperemia. Objectively, computed tomography (CT) is an inferior imaging modality for evaluation of suspected testicular torsion with data for efficacy limited to small-scale experimental perfusion studies.9,10 We present a case of right-sided testicular torsion where a CT of the abdomen and pelvis was obtained for suspicion of acute appendicitis. The visible “whirl” sign at the periphery of the abdominopelvic CT, representing the twisted spermatic cord, was
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Clinical Practice and Cases in Emergency Medicine
