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BACKGROUND: Testicular torsions in elderly individuals are rare occurrences that are often managed surgically.
METHODS: We present the first reported case of a successful manual detorsion in a 70-year-old male patient, resulting in clinical and radiological improvement.
UNASSIGNED: In this case report we discuss the role of manual detorsion alone in elderly without the need for surgery.
CONCLUSIONS: Observation of our patient for 24 h post-detorsion ensured stability before discharge.

BACKGROUND: Cryptorchidism and testicular torsion (TT) are relatively common conditions in clinical practice; however, sparse information about cryptorchid TT is available in the current literature.
METHODS: We retrospectively reviewed the clinical characteristics, treatment modalities, and long-term outcomes of pediatric patients treated for acute cryptorchid TT.
RESULTS: We found eight patients with unilateral acute cryptorchid TT with a prevalence of 8.9% (8/90) among all TT cases. The left testis was affected in six patients. The median age of patients at the time of the surgery was 65 months (interquartile range (IQR) 4-136 months). The median duration of symptoms was 16 h (IQR 9-25 h), while the median time to treatment was 60 min (IQR 59-63 min). The most common symptoms were pain (abdominal and inguinal) and inguinal mass with no palpable testis in the ipsilateral hemiscrotum. Preoperative color Doppler ultrasonography revealed absent or decreased testicular blood flow in the affected testes in 7/8 of patients. Various degrees of testicular torsion (median 540°, min 360°, max 1260°) were found during surgery. A necrotic testis that led to orchidectomy was found in 4/8 of patients. The median follow-up period was 42.6 months (IQR 12.5-71.2 months), revealing only one patient with testicular atrophy. The final testicular salvage rate was 35%.
CONCLUSIONS: Greater awareness among caregivers and primary care physicians about acute cryptorchid TT is required to improve their timely diagnosis and treatment. A physical examination of the external genitalia and inguinal regions should be mandatory to attain a proper diagnosis and treatment without delay.

Studies have demonstrated the high sensitivity and specificity of pediatric emergency department (PED) point of care ultrasound (POCUS) in the evaluation of testicular torsion. Rarely, testicular torsion may present with intact blood flow. Here, we present a case series of four children with testicular torsion confirmed intraoperatively, who had intact blood flow on POCUS. Markers of testicular torsion can include surrounding hydrocele, heterogenous echotexture, absent venous or high resistance arterial flow, or a torsed cord complex. POCUS practitioners should be familiar with these findings, and the presence of any one or more of these findings should prompt urgent urology consultation to avoid missed torsion.

UNASSIGNED: To explore the factors affecting the success of testicular torsion manual reduction and the safety of subsequent conservative treatment after successful reduction.
UNASSIGNED: Clinical data of 66 patients with testicular torsion treated in our emergency department from February 2017 to February 2022 were retrospectively collected. Manual reduction without anesthesia was performed in 19 patients. Patients with successful manual reduction chose different subsequent treatments according to the wishes of themselves and their guardians, including continuing conservative treatment and surgical exploration. Relevant clinical data were collected and analyzed.
UNASSIGNED: Manual reduction was successful in 11 patients (11/19). Seven of them chose to continue conservative treatment, and four underwent surgical exploration immediately. Among the 7 patients who were treated conservatively, 3 underwent surgical treatment due to scrotal discomfort or testicular torsion at different stages, and the remaining 4 patients showed no recurrence of torsion during follow-up. Compared with other patients, patients with successful manual reduction had the shorter duration of pain (p < 0.05). The time from visiting our hospital to surgery in patients who attempted manual reduction was slightly shorter than those who underwent surgery directly (p > 0.05). The testes of these 11 patients were all successfully preserved.
UNASSIGNED: The short duration of pain may contribute to the success of manual reduction, and manual reduction did not increase the preparation time before surgery. Due to the unpredictable risk of recurrence, immediate surgical treatment is still recommended, or postponed elective surgical treatment should be offered in the next days or weeks.

UNASSIGNED: Symmetrical peripheral gangrene (SPG) is very rare condition associated with symmetrical ischemia and gangrene affecting two or more distal extremities. It is almost always associated with septicemia and has a high mortality rate. The rarity of this condition and lack of prospective trials makes its recognition and management difficult. Care providers should maintain a high index of suspicion for SPG in patients with sepsis who develop cyanosis and ischemia of extremities. Doing early culture and sensitivity studies is key in guiding apropriate antibiotic treatment.
UNASSIGNED: Symmetrical peripheral gangrene (SPG) is very rare condition associated with symmetrical ischemia and gangrene affecting two or more distal extremities. It can occur at any age and may affect either sex. It is almost always associated with septicemia and has a high mortality rate (up to 35%). The rarity of this condition and lack of prospective trials makes its recognition and management difficulty. Only a few case reports have been in literature since its discovery in 1981. A 14 year old boy was referred to our tertiary facility due to postoperative wound sepsis. He had undergone right scrotal exploration and orchidectomy due to right testicular torsion. His initial symptoms were abrupt onset of scrotal pain and swelling which he developed while playing. Physical examination findings on admission were severe pallor of mucous membranes, fever and diaphoresis and mild respiratory distress. He also had a gangrenous perineal area involving the penis and cyanosed tips of fingers and toes bilaterally. He had a normal ankle branchial index of 0.9. His preliminary laboratory investigations revealed a marked neutrophilia, anemia, thrombocytopenia, and elevated D-Dimers. Initial resuscitative interventions included oxygen therapy, blood transfusion with whole blood and platelets, empirical antibiotics, analgesics, and surgical debridement of the perineal in theater. A diagnosis of severe sepsis complicated with disseminated intravascular coagulation (DIC) was made. The cyanosis on extremities spread proximally during the patient\'s course of treatment to full blown gangrene. At the time when clinical and biochemical remission of the infection was attained, the gangrene had demarcated at below elbow in both upper limbs and below knees in both lower limbs. An arterial angiogram was done and revealed normal flow in all proximal and distal branches of the aorta with no occlusion. A multidisciplinary agreement to conduct quadrilateral amputations plus penile amputation was made between urologists, vascular and orthopedic surgeons. The exact pathogenesis of how SPG occurs is not well understood. The underlying mechanism includes a low flow state with DIC. Ischemic changes usually begin in the peripheries and extend proximally. Ischemic changes are not preceded by peripheral vascular occlusive disease. SPG should be suspected when a patient present with marked coldness, pain in the distal extremities, cyanosis, and pallor. Early recognition helps to arrest the progression of ischemic changes before overt gangrene occur and improves the qaulity of life.

Vaso-occlusive phenomena in sickle cell disease lead to ischemia and possible infarction of the affected organ. We report a case of a 20-year-old Saudi male known to have homozygous sickle cell hemoglobinopathy who was admitted to our institution with abdominal pain. One day post admission, the patient developed left testicular pain. Ultrasound showed decreased echogenicity, and Doppler examination showed absent blood flow in the left testicle. Left radical orchidectomy was done, and histopathological assessment revealed ischemic necrosis with sickled red blood cells (RBCs). A few studies have been reported worldwide suggesting that a vaso-occlusive event is the mainstay mechanism in such cases. This is the first case reported in the Eastern Province of Saudi Arabia.

Germ cell tumors (GCTs) are the most common testicular malignancies in men. GCT typically presents as a painless nodule or swelling of the testicles with an atypical presentation such as heaviness or dull ache of the scrotum and/or the lower abdomen. Herein, we report a rare case of a testicular tumor presenting as an acute scrotum. This is a case of a 25-year-old male with no significant medical history; he presented to the emergency department with an acute scrotum for less than one day that was highly suspicious for testicular torsion. Surgical exploration and histopathology investigation revealed that this was a case of mixed GCTs.

Testicular torsion is a condition characterized by the twisting of the testis and spermatic cord within the scrotum, resulting in the obstruction of venous return and subsequent swelling. If left untreated, the torsion can progress to block the arterial blood supply, leading to ischemia. Prolonged ischemia can result in testicular necrosis and decreased fertility. Recognizing the urgency of this condition, timely diagnosis and management are crucial. In this clinical case, a 16-year-old male presented with left-sided scrotal pain following a minor trauma. Despite prompt medical attention, the delay in seeking treatment resulted in irreversible testicular necrosis. The case emphasizes the urgency of diagnosing and managing testicular torsion to prevent serious consequences such as testicular loss and reduced fertility. It serves as a poignant reminder for healthcare professionals to remain vigilant in recognizing this urological emergency and advocating for timely intervention to optimize patient outcomes.

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