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You are called to see a 10-year-old boy with a 4-hour history of acute right scrotal pain with no history of trauma or urinary symptoms. He has nausea and vomiting. He is haemodynamically stable and has a history of mild asthma.
On examination he has a mildly erythematous swollen right scrotum and is distressed with pain. When the patient allows examination, you are able to get above the swelling but when examining the testis the patient cries. The testis is mildly swollen and lying in a horizontal position.
1. What is the most likely diagnosis?
2. What test would you carry out to confirm this diagnosis?
You should not perform an ultrasound scan in this patient. Diagnosis is only confirmed with surgical exploration.
3. What is the pathological basis of this disorder?
Bell-clapper deformity of the testis, allowing a twist around an axis which are the vessels to the testis and compromised blood supply to the testis.
4. What might happen next to this boy if he is not treated?
As it is already 4 hours since the pain started, if not treated immediately the testicle will have irreversible ischaemia.
5. What treatment will you offer this patient?
Scrotal exploration. Because of the patient’s age, informed consent must be obtained from the guardian for surgical exploration of the scrotum. The consent should include ‘Right scrotal exploration +/– orchidopexy +/– orchidectomy and +/– left orchidopexy’. The patient and family should be informed of the possibility of reduced fertility if the right testis is not viable and orchidectomy is performed. This case takes priority in the operating theatre.