So, we've had a couple of cases presented here, but how exactly do you do a testicular exam you ask? Well, lets discuss it...
Testicular ultrasound was not included in the 2008 revision of the ACEP Emergency Ultrasound Policy Statement, but it may make it into the next revision. Testicular ultrasound is pretty easy to perform and can rule out testicular torsion rapidly which can expedite a trip to the OR in these patients. Time is Testicle, remember?
Perform your normal history and physical exam, attempt to manually detorse the testicle if needed. Consult the Urologist (order a ultrasound, if they request it), then perform your bedside ultrasound. This way, the Urologist is already on their way down to the ED and, hopefully, you can provide some useful info when they get down there.
Have your patient lying supine in bed, lay a towel down on thier legs at the groin level and have them place thier scrotum on the towel. Then place another towel over their penis pointed toward thier umbilicus. Now the scrotum is isolated between the two towels.
Using a linear high frequency probe, scan through the affected testicle in the longitudinal position. The testicle should appear as a oval or egg-shaped structure that is medium grey speckled with black. You may see a hyperechoic or white linear structure in the midline which is the mediastinum teste.
Scan through the testicle in a longitudinal plane from medial to lateral. Then turn your probe 90 degrees to the patient's right to view the testicle in a transverse plane. In this plane, the testicle should appear as a circular medium grey speckled tissue.
Scan through the testicle in the transverse plan, cranial to caudal. Using color flow doppler, identify the small vessels in the testicle.
Now place the spectral doppler gates over one of the vessels you seen on color flow. This will create a spectral doppler tracing which will either illustrate an artial waveform or a venous waveform.
You need to document both to rule out torsion. If you are unable to document flow, then torsion is highly likely.
Seems pretty simple doesn't it? Try it out the next time you are ruling out torsion and see how it can expedite patient care!