To understand this next patient, you need to do me a favor. Ball your hand into a fist. Now, rotate your fist either way as far as you can. When you can't rotate any farther and your forearm muscles feel tense and strained, imagine that you are Stretch Armstrong and continue rotating your fist for a full rotation. Pretty amazing, yes? Now, do the impossible and imagine another full rotation. And then another.
This is exactly what happened to Javier's testicle. Javier, a handsome but frantic eight year-old, had presented to our ER around 10 a.m. just a few weeks back. He had been born with an undescended testicle and had been closely followed by our pediatric urologist, who most recently had seen him just a month prior. Because his testicle had finally decided to spontaneously show up for this life, Javier's doctor was debating whether to surgically anchor his testicle down to keep it in place. Yep, a suture from his testicle to his scrotum.
Unfortunately, on the morning Javier had presented to our ER, he had awoken at 2 a.m. with sudden and severe left-sided groin pain. He was comfortable lying perfectly still, but the minute he moved or someone approached him to palpate his groin area, he was beside himself. You couldn't help but feel sorry for the poor kid who, despite his pain, was trying his best to be courageous.
After some morphine and a brief exam, in which he wouldn't even let me get close enough to thoroughly examine his genitalia, we proceeded with a very quick workup to figure out where his pain originated from. His urinalysis came back clean, just as I expected. Good blood work. The test that I most needed was an ultrasound of his affected testicle. To complete this test, because he was in such intense pain, we needed to give Javier an additional generous dose of morphine. The ultrasound tech was then able to manipulate Javier's scrotum to view his left testicle.
Sure enough, the ultrasound revealed that he has no blood flow to his testicle--a diagnosis of "torsion" of the testicle. So, from above, your fist = Javier's testicle. All the vessels that lead to and from his testicle had been twisted and rotated to the point that they closed off and were no longer delivering significant blood to the testicle.
Javier was in danger of losing his boyhood. Cringe-worthy stuff, I must say. I'd cry, too. I could only hope someone would be kind enough to load me up on morphine. And lots of it.
Javier, by this time, had been in pain for approximately nine hours. Time was "of-the-essence," so to speak, to save his testicle (after 6-8 hours, we begin to seriously worry). There are several manipulations one can sometimes attempt in the ER to save the testicle but, again, I couldn't get near Javier's testicle to really palpate it, let alone manipulate it. I was very close to giving Javier some anesthesia in our ER in an attempt to urgently "unrotate" his testicle. Thankfully, though, his pediatric urologist was close-by (from our earlier alert to her) and arrived in just minutes to take Javier to the OR. The race was on to save his testicle.
After establishing the diagnosis, I had a chance to go spend some time with Javier and his family. Javier and his uncle were well-versed in English, but his father wasn't. Fortunately, his uncle did a fantastic job of translating and by the end of our conversation, Javier's father had given permission to surgically repair Javier's testicle.
Poor Javier, though, was crying inconsolably now, probably as much from the fear of the unknown as from the pain of his testicle. More morphine, please.
I should have saved my drawings explaining the testicular torsion from that day. If I may say so, they were beautiful. Stunning, actually...NOT. They were a complete mess, like most of my attempts at drawing are. I should probably spend more time at home practicing how to draw a realistic testicle, so I'll be ready the next time. I would just need to be very careful about where I leave these practice drawings lying around. And who knows, maybe with a little practice I'll become the male version of Georgia O'Keefe!
What explanation Javier and his family understood best, though, was my fist and my attempt to rotate it. They understood that this "was not good" for the testicle. Bad, actually. To reinforce the seriousness of the situation, I brought a medical book into the room and was able to show them a legitimate picture of the testicle and how it had rotated on itself.
I have great news to share with you, though. Javier still has two functioning testicles! Oh, he sure does! Yes, yes--of course I'll wait for the cheers to die down. After the pediatric urologist made her scrotal incision, she was able to unrotate Javier's testicle and it immediately "pinked-up," meaning blood-flow had been reestablished. She later shared that his testicle probably survived this long because of two reasons; 1) his testicle rotated only a couple times, and loosely at that, and 2) the rotations probably didn't completely cut off his blood supply and a trickle flow of blood may have sustained the testicle. Lucky ball! She tacked it down so that this would hopefully not happen again to brave Javier. Yep, a suture from his testicle to his scrotum (did I mention this already?).
Regardless, I'm just happy that Javier can still face his world with two functioning balls. Let's face it--there is a reason we call them "jewels," and, as any guy will testify, it's better to face the world with two of them instead of one.
If things hadn't worked out for Javier, though, he would still have had one functioning testicle and worse things than that exist. I'm just glad that, in a few years, he won't have to go pick out a life-like prosthesis. Hmmm--decisions, decisions. A steel ball? Wooden? Saline-filled? I personally would go for the steel ball, after living through residency. Come to think of it, though, imagine what a chick-magnet a ten-pound prosthetic testicle could have been for Javier, regardless of what it was made of!
Initially, I thought we had helped Javier win The Amazing Race, saving his testicle and all. But after thinking the prosthesis thing through, maybe not.
Hats off to Javier for being a brave little boy. As always, thanks for reading. The last round of comments were very cool. Next post will be Wednesday, January 20.