Confirmed testicular torsion in a 67 year old

Abstract

INTRODUCTION

Torsion amongst the elderly population is rarely described. This case presents the oldest surgically confirmed case of testicular torsion, in a 67-year-old male, within the UK.

CASE REPORT

A 67-year-old male presented to the emergency department with a 10-day history of left-sided testicular pain. Symptoms were of gradual onset, and were initially treated with antibiotics from his general practitioner. There was no history of trauma, injury, pyrexia or voiding symptoms. Urine dipstick test was negative.

Examination revealed an acutely tender left groin and left testicle with a markedly enlarged, erythematous left hemi-scrotum. Antibiotics were changed to doxycycline from ciprofloxacin, and the patient was referred for an urgent ultrasound which was performed the following day. Full blood count revealed white cell count of 8.2×10⁹/L with a C-reactive protein (CRP) of 48 mg/L. All other blood tests were normal.

An ultrasound scan revealed no vascularity within the left testicle. The patient was taken for scrotal exploration under general anaesthetic. This revealed a torted left testicle with no pus present. A left orchidectomy was performed along with right-sided testicular fixation. The patient had an uneventful post-operative course, and was discharged home the following day.

DISCUSSION

Torsion as a cause for testicular pain in elderly men is rare. It is believed to be due to an anatomical bell-clapper deformity of the testicle [1] and with this genetic disposition, 65%, of cases usually present <18 years of age [2]. However, other possible causes of torsion have been recognised such as trauma and increased-testicular volume [3]. In adults above the age of 40, likely diagnoses include epididymo-orchitis, epididymitis, neoplasm or hydrocele. Many of the patients in this age range do not require imaging, and are sent home on antibiotics. Clinical differentiation with epididymo-orchitis can be difficult in any age range. Clinical signs such as fever, elevated CRP and positive urine dipstick test for leukocytes and nitrites [4] are suggestive of epididymo-orchitis/orchitis. Therefore in the absence of this, alternative diagnosis should be explored more thoroughly at an early opportunity.

As studies suggest that testicular viability in a true torsion is reliant on time to presentation and subsequent definitive surgery, early diagnosis is paramount in order to reduce consequential loss of organ, cosmetic effects and minimize the possibility of reduced fertility [5]. Testicular infarction is as high as 80% 10 h after the onset of pain [6], and therefore ultrasound with Doppler should not be used in the likelihood of torsion if this delays surgical intervention. Despite this, as it has been shown to offer an overall accuracy of 97% [7], it is becoming increasingly used in acute presentations of acute scrotal pain where clinical suspicion is low.

CONCLUSION

This case study demonstrates that testicular torsion can occur at any age, and clinical suspicion should always be high in patients presenting with testicular pain and negative urine dipstick regardless of age. Although risk in this subgroup is low, the identification of a potentially reversible testicular abnormality should be of high priority.

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