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Mhm. Water one start on done. Yeah. Ok. Yeah, Kerry will start in a minute. Ok. Right. Yes. Ok. Good. Ok. I see, Doctor Majola had just joined it's uh five o'clock. So um let's start. Uh Good afternoon everyone. Um We welcome you to uh today's uh Zoom Academic meeting of the Department of pediatric Surgery uh where uh Doctor Ka both are, our medical officer is going to talk about acute scrotum. He has been mentored to prepare the talk by Doctor Nhleko Majola who is a consultant pediatric surgeon with special interest in pediatric urology. And we are fortunate to have uh Doctor Justin Howlett who uh has kindly agreed to um uh to be an invited guest for this talk. Doctor Howlett is a consultant urologist at the Red Cross Children's Hospital at school Hospital in Cape Town. He is a senior lecturer, urology at the University of Cape Town. His special interest is in pediatric urology and minimally invasive urology. He has written a chapter on the Pelvi ric junction obstruction in the African Textbook of Pediatric Surgery. He has already published and has ongoing research on PCNL and congenital mega. So Justin official welcome uh, for you, uh, from the Department of Pediatric Surgery, East London and, and, uh, we thank you for your time. Thank you very much. Looking forward to the talk. Ok. Uh, so, uh, can you, I'll stop sharing my screen and then you can start sharing. Thank you. Uh, sorry, one second. Oh, uh, I support. Ok. Ok. Ok. Yeah, good. Ok. You can, you can start your talk. K Thank you. Good afternoon, everyone. Thank you for the opportunity. Um No, we cannot hear you. My topic for today will be um acute scrotum and to test this afternoon. Um Can you hear me better now? Prov uh it is better. You need to just talk slowly and clearly car. Ok. Ok. Um Please excuse my video. I'm just holding the phone quite close to my face. No one wants to see that. Um So I'll start off my talk by talking about a patient. Uh ll 11 year old male. He was referred to our pediatric surgery outpatient department from Gray Hospital where he was treated with Augmentin. After presenting with a five day history of scrotal swelling, the swelling was on the left side was accompanied by pain. There was no noted. This was the first episode of pain like this and he reported the pain to be at the inferior surface of the string on examination. His left hemiscrotum was large and more tender than the right. His right testis was soft and not tender and his left testis was hard and also not tender. The patient was assessed to have a missed torsion testis and was taken to theater where orchidectomy was done in this case serves us to reiterate the importance of this topic. Now, just for some anatomy, the testis are the two oval shaped organs in the male reproductive system. They produce sperm as well as to testosterone. They encased in the tunica vaginalis and tunica albinea. The albinea is the fibrous layer that protects the testis and then all of this is inside the tunica vaginalis. Epididymis connects the um testis to the vus and the vus transport sperm from the epididymis to the ejaculatory ducts. There's a testicular artery and a testicular vein and together all of these structures make up the spermatic cord. As for the nerve supply. The scrotum is anteriorly um supplied by the renal and genital femoral nerves and posteriorly by the perennial branches of the pedal nerve. Excuse me, on presentation, a patient that presents with acute scrotum pain is always an emergency until it's proven. Otherwise, the onset can be acute or gradual. And in a review of 50 patients with intermittent testicular torsion, 26% reported nausea and vomiting and 21% reported um pain that awakened them from sleep. The pain may present with or without swelling at any age but tends to peak at three years and before three years and after 10 years of age. So, looking at this graph, it was composed, taking information of 100 and 39 patients in a study that was conducted in 2009 to 2010. You can note that distribution of the testicular torsion is initially quite in the younger Children and then it picks up again in the older Children. Also, you can note if you look at the epididymal orchitis, initially, we only have one case, two cases and then all of a sudden it gets much more, we'll get into that a little bit later. So when one of these patients presents to you, it's good to approach the examination and the look feel and light method. So first start off by looking at the color and the size of the scrotum, is it swollen? Is it not swollen? Something else you will look for is a blue dot sign which I'll get you a little bit later as well as a bowel clapper deformity. You can feel for the position of the tests for the orientation and the size bearing in mind that the right tends to be slightly larger than the left and the left tends to be slightly lower. If you see something called the Brunel sign, which is a secondary high position of a testis with a horizontal line together with a friend sign, which is persistent pain, despite support, these two together are very suggestive of torsion testis. Also, while examining your patients, you must check the cremaster cremasteric reflex if it's absent or present. And then also don't forget to do an inguinal and abdominal examination. As you can see in the picture in the bottom right hand corner, this is transillumination that is done for a patient with a hydrocele. So these are some of the differentials you would consider if you look at those first three mentioned testicular torsion, torture, appendix, testis and epididymitis, epididymal architis. These three conditions alone account for 85% of cases of acute scrotum. Other things to consider are trauma and renal hernias which aren't covered in the store as well as other things like tumors, epidermal cysts, viral orchitis and all of these pin canaries. So talking about testicular torsion, a twist of the spermatic cord causing ischemia. That's testicular torsion sources vary. But according to pediatric surgery for Africa, approximately 720 degrees of rotation is required for ischemic damage. However, complete testicular torsion by definition involves a full 360 degree rotation. This is according to the acute scrotum in Children and adolescents. So, IC torsion accounts for 10 to 40% of um the cases of acute scrotum that we see. It affects one in 4000 males less than 25 years old and it's more neonates um than in the adolescent years for now. The cause is still unknown. It may be trauma related. It may be related to anatomical discrepancies differences. Um But let me just talk about that in this slide that so firstly, if you look at slide, the first picture with photos A and B A is uh extravaginal twist proximal to the tunica vaginalis. This happens due to lack of fixation and tends to happen in. However, twist B is intravaginal and this is the more common one and the twist is at the site within the tunica vaginalis. So something that can predispose to this is illustrated in the next picture, if you look at where the tunica vaginalis is attached normally. And then on the next slide, it's something called a bell pla deformity. This is an inappropriately high attachment of the tunica vaginalis, which leads to the testis being able to rotate freely on the spermatic cord within the tunica vaginalis leading to torsion. So when a patient presents with torsion, normally, they'll present with a history of a sudden onset unilateral pain in the testis. Again, the left is more commonly affected than the right because of that lower ha it's often associated with nausea and vomiting as we saw about 1/5 or a quarter of patients. And it may have a history of intermittent testicular pain. Preceding this on physical examination. You can see that that testis can be retracted upwards towards the green region as a transverse lie and an anteriorly located epididymis, it can be enlarged and it often there's a absent ipsilateral premier reflex. So the testers tend to rotate away from the midline such as opening a book. So one can try and detort them by rotating them towards the midline. If this is effective, they will be relieved. This um shows the duration of torsion as compared to the testicular salvage rate. So if we start off initially there at less than six hours, we can see that that is very favorable. And as soon as we get to 6 to 12 hours, there's quite a decrease um in the percentage of salvage rate. And once we get over 24 hours, we only have a less than 10% chance of testicular salvage. Moving on to our next topic, which is the torted appendix testis. Excuse me. This can be one of two things. It can either be a twist in the testicular appendage. This is a malarian duct remnant or it can be a twist in the appendix epididymis. So if you look at this bottom corner, that's the appendix epididymis, the wolffian duct remnant. And that's the appendix testis. This accounts for about 30 to 45% of the cases of acute scrotum that we see. It's more in pre pre butter period. Excuse me. And these patients present with a blue dot sign, which if you look here on the top right hand corner, that is pretty much what it looks like. A blue dot that shines through the skin which is indicative of one of these appendages that has started and become ischemic. The next topic is epididymitis. This is inflammation of the epididymis secondary to infection and accounts for about 30 to 50% of cases of acute scrotum that we see. This may be associated with reflux of urine or even ST is. But keep the age of your patient in mind if it's a child, rather think of something like a urinary tract related incident. Think E coli treat with azithromycin if it's supposed to be patient and they are sexually active. Think of gonorrhea and chlamydia treat with cefTRIAXone intramuscularly and then azithromycin rarely, schistosomiasis may also cause this which is treated with praziquantel. But that seems not to be as common as for trauma. Most commonly, these patients present with hematoma and a clear history of the trauma. The ultrasound um may be useful in these patients to see if there's any rupture of the tunica alb guinea. And the reason this is important is it's an indicator for operative repair. If it is ruptured, it could potentially cause autoimmune injury to the opposing testis. Some of the investigations we would do. Your diagnosis can be made on clinical grounds and never have a patient that has presented with a short history of acute pain. Wait for um, exploration rather than while getting some investigations unless it's a patient that has a longstanding history or you're not sure or it's not a clear cut diagnosis. Urine dipsticks are useful if you're suspecting something like epidermitis, perhaps due to urine reflux and then the color Doppler ultrasound as all ultrasounds is operator dependent but has been shown to have a sensitivity and specificity of generally estimated 89 to 100% of showing absence of blood flow or reduced blood flow and thus helping in the diagnosis of testicular torsion. Remember time is testis. So if you have a patient in which you clinically suspect torsion testis, you can attempt the torsion earlier at presentation. If the patient is relieved, then it was effective and the testis can be fixed later, but it still needs to be fixed. Ideally, you will want to explore within six hours. But as you saw from that initial graph, we can still explore up to 24 hours later. And even then you can still do an ultrasound to check if there is any blood flow. If the test is is salvageable as for if it's not a query torsion, testis, conservative management, bed rest analgesia and antibiotics as I mentioned earlier. But when you need to do exploration, this is just a brief overview. View of how the operation gets done. It's also quite a different procedure and units as compared to older Children, a midline scrotal incision is made, the involved testis is brought out and its inspected, any twist that you can see are reduced and the testis is observed for any improvements in car while waiting for the color to change. The other tests must also be fixed if the color does not improve and the onset of symptoms were, was more than 24 hours later, then the testis can be excised. However, if your color does improve, um the testis needs to be fixed. This is done by a three point fixation of the tunica vaginalis which is incised and sutured with a nonabsorbable suture. So, what do I tell the parents of my patients? Well, um you start off by mentioning that there are three most likely causes the three that account for 85% of cases of acute scrotum. You say that either the testicle has twisted on its pedicle, its stalk or a small tag on the testis has twisted or there might be infection and inflammation of the testis. You can tell the mom that if you suspect infection, you may need further investigation such as a urine dipstick or that if you suspect torsion, you may need to operate and do an exploration. So tell them not to let the child eat at that time. Depending on your findings. Usually these patients are discharged within 24 hours. Also mention to the mom and the dad that necrosis and the patient depending on the age necrosis is likely if it's been longer than eight hours and almost certain if it's been longer than 24 hours as for fertility, which parents tend to be very concerned about. We do not have all the answers. However, studies have shown that the rate of pregnancy and the time to pregnancy in couples where the man has had previous testicular torsion was the same as in the general population. So in summary, a painful scrotum is torsion test is until proven. Otherwise, it's a diagnosis that is easily missed. It requires prompt treatment. History and examination can be used to guide your investigations, especially duration of the pain, how severe it is any nausea or vomiting and do not forget to follow up these patients at 12 to 13 years of age and consider an implant for them. These are just some of the references and thank you very much. Ok. Ka that was a super excellent presentation. Um I'm very happy and I'm very proud of you um uh attendees. If you think it was too short, please blame me. But uh I think Ard has uh has uh just shown uh his efforts and obviously, uh a lot of efforts by Doctor MAOA who has guided him in the right direction so well done. Uh Carrie. Uh So we have plenty of time and now I invite uh Doctor Justin Howlett to uh to make his comments, please. Justin, you can come in. Congratulations on an excellent talk. Um It's easy to make a subject more complicated than it is, but it's difficult to simplify it and you did that excellently. Um I just perhaps wanted to ask a question um and maybe raise the subject because I think that, you know, uh testa torsion in kind of the pediatric and adolescent population is, it's fairly clear what to do. But the scenario that's a little more tricky is neonatal torsion. I'm not sure in your reading. What do you recommend if you have a, a child, a a newborn child with neonatal torsion, how would you approach such a patient? Um So I did read around this a bit doctor. How, how this, um it seems that there are two trains of for a more traditional one and a newer one. It seems previously what other, what was thought is that there's already torsion and that the status has demised and that it can be taken out at a later stage. However, normally men go through life with two testers, they have one and they have one backup in case something happens. So what can happen in these Children is if they were to have another torsion before this one is um removed and the opposite one is fixed, then they will have a much bigger loss, losing both testers, the hormonal problems and fertility problems associated with this. I did read about a study in which I believe 30 patients were taken to um theater for exploration that were just after delivery as long as there was no contraindications for anesthesia in there. And of the 30 patients that were diagnosed with torsion right after delivery, taken to theater and exploration was done, they managed to salvage two testers. So and still not sure what the idea is. I'm not sure how possible this is in our setting to get a patient to theater within the first six hours after delivery. But it seems that early exploration and early fixation, especially of the opposite test is, is very important in the management of these patients. Yeah, I think you hit the narrow on the head there. It's, it's not clear uh from the literature what the best approach is. Um, I'll be interested to hear the other thoughts of, uh, the participants, uh, what you would recommend. Um, hi doctor. Uh, you can please come in and give your opinion. Hi. Hi, good afternoon, everyone. Uh, very good talk to, uh, talk her well done. Uh, with the, the scenario that Justin just posted is uh as cos just, um, sit because this test is we view them as the to has occurred already intra. So you're not really sure, um, as to the rate of salvage of these test and most of them are usually um unsalvageable, um, when you take them to theater. So my view or my sort of uh way of managing these patients if there's no clinical, um uh, if there's no problem. Sorry, we have lost you per anesthesia, obviously. Um, if you, ok, you on the, on the to test, that will be my approach. Are you on your cell phone? We lost you for a couple of sentences. Oh, yes, I'm on my cell phone, sorry? Ok. Ok. No, we got the gist of it. Um So, so uh a anything more about this issue? Otherwise I'll invite Yoda and sell to commit one after the other, can I? Yeah. No, you go ahead. Ok. Uh uh Hello, please make your comment. Um Thanks for uh thanks God for that presentation. I think it's just important to just note either in torsion, we, the typical presentation would be a child with a solid mass in the testes. So, other than just worrying about intrauterine or prenatal torsion, it's important, I think to be um wary and exclude uh malignancy, obviously, it might not be high up on the list, but it's important to do that. And um, um, and we kind of have time in a sense because it's very, as, as he is saying that it's a very small portion of population of patients that have a pickup whereby you can actually salvage your test. So I'm sorry to interrupt you. Uh But I think if you can just comment about uh what scenario Justin presented to Kerry and then we'll come back uh to the comments in general. So if you can pick up where left because, uh because of uh time constraint, I tried to compress scary stuff. Uh So, so, um, it's about the neonatal torsion. What is your opinion? Advice about neonatal testicular torsion in particular I II think for, for, for those ones that um the pickup rate is very low um for for these patients. So it's it's a bit tricky to actually find. And as her was saying, the pickup rate is low and the salvage rate of these testes is also equally low. So it's always about an index of suspicion because as um with any neonatal pathology, the kids don't complain about testicular pain, you will just have to clinically make an assessment and hence why a huge portion of them would be delayed or missed completely. So I think that's, that's the essence of the story is that you have to have a high index of suspicion. Um Otherwise you'll definitely miss all of them. Thank you. Thank you. Thank you. We'll come back to the general comments in a short while. Uh Yes, soda. Please give your uh opinion about this specific scenario, please. Yoda. Ok, thanks. Um I don't have anything else to add really. Um I haven't seen one. but yeah, I would explore if I suspected it. So I would as a matter of urgency um to plexi the other side. Yes. Thank you. I just in sorry, I didn't introduce my two other colleagues, you know, uh Moola personally because he spent uh three months in last year with you guys. But uh the two other uh commenters were uh Yashoda man who is our other uh consultant pediatric surgeon and doctor Maa who is also a consultant pediatric surgeon. It's a, it's a difficult scenario II, my thinking on the matter is perhaps to individualize it to the patient. Um you know, in a patient who's had AAA, in which I think is about 75. Um That patient, I think you could um manage conservatively and get the parents to examine the contra happy change. And if the child gets to one month, then the risk of the other test is having AAA torsion is then much, much lower. Uh If there's no bell cap form, uh you know, the last thing you want is the other testicle to taught. But having said that the uh the, the, the um the salvage rates are low number one and the, the child is normally asymptomatic. There may be other medical conditions. So, um I think one can tailor it but certainly if there is a postnatal um torsion, then I would explore that patient uh because you could salvage it and you want, you, you would want to uh protect the other side. Uh But it is a difficult one because the literature is split on it whether to manage it conservatively, um uh and get them through to one month or whether to explore. And I suppose that's where um imaging may be of value. Um But uh it's, it's one that I think one has to individualize um from patient to patient. Yeah. Uh Can I just make a comment recently? I think it's about a couple of months ago we had uh a newborn who was born at our hospital and was referred fairly soon. But even by that time, uh the testes was necrotic uh on the color Doppler, uh which was done. So obviously the child went for orchidectomy on that side and we fixed the, the testes on the other side. Um Yeah, so Justin, please make, yeah, sorry, sorry, Justin. I didn't hear your comment. I think that's the safest approach is to explore. Um Yes, yes. Uh Ju Justin, please make uh uh comments about uh the, the rest of the topic. Whatever you wish to comment about, it's, it's quite a big topic and especially because you do adult urology as well. You, you follow these patients up uh through adolescence into adulthood. So I think whatever you, you wish to comment about this topic in general of acute scrotum, please. I think the other thing that is maybe not, um or something to maybe discuss is a testicular prosthesis. Certainly in the Western Cape. Uh we don't have pediatric testicular prosthesis. We only have adult size and the thinking there is a cost issue uh in that, you know, if you put a pediatric prosthesis in, you're going to need a second operation later for an upsize. So, um if a child had, uh then, you know, once they're adolescent, then they could have a, a prosthesis. Um So occasionally, uh we will put a prosthesis in uh at the time of um uh orchidectomy uh, but sometimes certainly it will be delayed down the line. Um, and I think that's a reasonable approach. Um, I'm not sure what your views on uh, prosthesis are. Um, it's a, a small detail, I suppose. Um No, II will just, uh, first Justin, we have been following the same, um, same pattern. Um, we, we pediatric surgeons, we uh by rules sort of default, we look after Children up to 12 years of age. So, so uh we don't insert prostheses on our own. But uh we emphasize uh on the parents that when the child is at least about 1314 years of age, they need to come back to the hospital where our urology colleagues will put a prosthesis of the appropriate size which doesn't need to be changed um uh subsequently. So I think we follow uh the same, same approach. Um So just uh uh any other comments uh Justin about the topic overall, it's quite a vast topic. It is one another thing that maybe just to be aware of um in a child that has epididymitis or recurrent epidermitis. Um One of the things to do is a uh ultrasound of the kidneys, ureter and bladder. It's very rare, but one can get an ectopic ureter uh implanting into the um epididymis if you've got a, a duplex system. So, um you know, often it is a viral epidermitis if they are a bit younger and it settles down. Uh But certainly, if it might, just one should think a bit more broadly, even if it's not a, a AAA ectopic ureter one should consider, you know, um, abnormal anatomy, you know why they are getting an infection. Uh, is there a missed valve, etcetera? So, I think certainly if you have an epididymitis and it's a bacterial one, or even you suspecting a bacterial one, then I would do an ultrasound of the kidneys, ureter and bladder to see why is this child getting epiderma because they really shouldn't. No ve very, very good advice, Justin. Uh That's what we have also been following uh that uh uh confirmed bacterial epididymitis with like the standard one organism, et cetera. It doesn't happen without a reason. So, uh what our teaching has been to look for the upper tract abnormality and rule it out and we do exactly the same as you advised. We start with the ultrasound first and obviously, if there is any suggestion on the ultrasound, then we proceed further with the maturative cystourethrogram, et cetera. So, so thank you for reminding that. Um I will just invite uh Doctor Majola back uh to comment and Doctor Majola uh your advice uh in general about the topic of acute scrotum. Um A and, and anything further, please, um Am I loud enough cough? Yes. Yes, very good. Yes, please go ahead. Yeah. So basically a an a acute scrotum is an emergency until proven otherwise. And we think more torsion uh first uh before other conditions, but it has um elaborated. So, torsion, uh you need to do something within 24 hours to fix, uh to try and, and fix or to prevent uh any necrosis of the process of the test, the appendicular torsion. Those can be managed conservatively with analgesia. And obviously, if there's an infection as those are managed with um antibiotics and then had mentioned as well with newborns, it sometimes if they get referred, they usually referred because of the mass in the scrotum. So it is important as well to try and find other causes of that. Uh Yes, in a newborn, which could be a, a cancer, which could be a meconium, uh which is uh tracked down into the tunica vaginalis and causing a mass or a mi intrauterine to. So it's important to figure out first what the cause of that mass is because as, as everyone has, it's very rare that you might get a postnatal uh torsion, but it can happen. Ok. No, th thank you. I think uh uh please, I I'm taking the liberty of uh emphasizing it again. Uh acute scrotum is one of the emergencies in pediatric surgery. So, if a child comes early, which is uncommon but not impossible in our setup, especially in private set up, Children do come early. So as Kat said, we unfortunately do not have um expertise of ultrasound and color Doppler uh around the clock, uh even in private set up. So, so the best plan of action, I suspect uh torsion testis is to take the child to theater as soon as possible and, and explore the testing and, and uh, and either confirm or rule out uh testicle torsion. And, um, and his uh manual detortion under uh under sedation, et cetera is, is uh described in the textbooks. I have never attempted it myself. I'll invite Doctor Howlett to comment on this. Um So I in my personal, like my hands, I would rather take the child to theater explore and then decide. And I think for the juniors, it is important to remember that you need to take consent for orchidectomy in any child with acute scrotum, including a child with obstructed inguinal hernia, which has been there for a while and it is tense and tender because it can get necrotic even in a child with strangulated inguinoscrotal hernia. And so we don't sleep over a patient with acute scrotum. It needs to go to theater as soon as possible. And um I think the rest, everything has been said by, by uh other um consultants. Um Kirsty is saying, maybe car can briefly explain why we operate to remove, um, remove the ischemic testes when it is a late presentation. Ok. Carry, can you see an answer? Then after that, I will invite Doctor Maa and then Doctor Mohan again. Yes, bro. Sorry about that. So the main thing is even if it is a test is that as is necrotic, we want to remove it so that during that surgery, we can fix the other tests so that we do not run the risk of losing the other tests. Um, it's very rare that it happens in two. in that it happens in one patient, both sides. They were saying something like 2% or something. It was very low. The numbers. Um Then the other thing is I'm not sure if when it does have necrosis, I don't think it can affect the same as when we have trauma and rupture. Um I'm not sure why else it is so important. Pro sorry. Mm No. OK. I think the answer that um they may be looking for is you, you can get antisperm antibodies to the contralateral testis and then render the patient infertile. There is some debate as to the um you know, the importance or the um prevalence of getting antisperm antibodies from torsion. Certainly that's something to consider. And as you say that that together with fixing the contralateral testis um would be your main reasons. Yeah, that I think that uh uh that, that, that explains it. Uh So uh Kirsty, uh did you get your answer? I don't know whether Kirsty can hear us. OK. Yes. Yes, you got your answer. OK. Um uh Justin, if you can just comment, uh do you attempt manual detorsion, especially in Children in Children, uh, very rarely. Um, because you're gonna have to sedate the child. Yeah. Um, so it's not practical, you know. Um, in that case it's, it's, it's best to take the child to theater. Um, if there is, you know, a, a delay in theater, if you can't get the child to theater, one could attempt it. Uh, it, it doesn't always work. You, you sometimes can't, the ones that are twisted again and again. Um, and it, it's a little bit cruel. So, II think in Children in general terms, I would stick with what you are practicing there that, you know, try and get management to open another theater and take the patient to theater rather than uh uh fiddling in adults. One can, um, sometimes be luckier. Obviously, it's normally early and um, and if the pain is relieved instantly, once you de ta it, um then you still have to take the patient to theater fairly soon because it can read talk quite quickly. Um, but it's something that can buy you time doesn't always work something to, to think about something else. Maybe just to mention, it's, it's not used very commonly, but it's something that you may um be able to help you in, in really those difficult cases. Is it an intermittent torsion? Is it something else? Uh The clinical findings are not quite correlating. Um It is, is a nuclear medicine study. And so with the technetium scan, one can then see if this is a torsion. I agree if there's, if there's any doubt, take a patient to the theater, but sometimes in those really blurry cases, um, it can give you reassurance that there's good flow in both testicles or, or there is ischemia. Um So that's obviously even less uh widely available in color Doppler, but it's something for the very unusual, uh, unclear cases can help. Yes, I think you just, I want to ask you one more question. Um I in girls, uh the general tendency of a torted ovary is to try and conserve the ovary. Uh I mean, in the olden days, like when we started our practice here in 95 we sort of used to take out the ovary, but then we were cautioned and sort of later around 2000 or so. Uh even late nineties, we were advised that ovary. If after detorsion, it looks ok. It's not frankly necrotic. You rather preserve it, at least for the estrogen, the hormonal function. Why is it, is it the same for the tases or is it, it is different? Why is it different for the tases? Well, I think that the lading cells are more um uh resistant to ischemia. Um but having said that uh whereas the cells are more sensitive to ischemia. So I think that the, the, you know, the reality is, is that perhaps ovarian failure has got more implications for a woman than testicular failure for a man and I don't think that there is strong data to suggest that uh if you've had AAA torsion and orchidectomy rather than uh trying to pexy a sort of borderline uh testicle that you will then um become more hypogonadal later on in life. Um So, so I think that that is probably not necessary. Um But certainly if it is borderline, um you know, wrap it in some warm swab, go and fix the other testicle. Have another look. If you're really unsure, you can do a fasciotomy and you'll see if it's necrotic or not. Uh But II think leaving a necrotic test is behind is not, not a good idea if the patient is still going to have pain. So uh unless it's, it's um uh you, yeah. II don't think that leaving it behind would be, would be a good idea or would preserve hormonal function. I think it's more dependent on your um luteinizing hormone and the contra will, will it will produce enough testosterone to get the man to at least 60. I would, I would imagine. Yes. OK. No, thank you. Thank you, Justin. Uh So you can come back again and uh please comment about the overall topic. Uh Yes, I II think the, the just the gist of it is um it uh testicular torsion is just an emergency and the sooner you deal with it the better. Um and rather earn the side of exploration, it's fine. If you're exploring and you find that the testis is normal. Um, it's unfortunate that you had to operate, but, um, then you would have saved the whole testes, um, versus wasting time and doing, um, frivolous investigations of ultrasound, which may delay. So I think once you suspect it, um, go ahead and explore if you're capable of exploring, um, and try not and try to avoid any delay. Um, I think that's all. Thanks. Well, well said, hello, thank you. So, uh Yoda, please uh come back and and comment about uh the topic in general. Ok. Yes. Hi, pro. Um Yeah, I just uh I think everything is being said, but um I would also say, you know, you can still give the testes a chance and I think Justin already uh mentioned, uh you can do a fasciotomy which we always used to um uh advise us to do to give it a, a chance to re um confused. And then the other thing about the Epididymitis, I would actually do an MC uh because of the reflux into the ejaculatory ducts. So I think Mr Vma published something about it being more common than we think in Children. So I would do the ultrasound of the urinary tract, but I'll also do an MC. Yes. Uh Thank you, Yashoda. Uh Yeah, just, just one second, Justin uh Yashoda comes from Durban and so she trained under pro and Mister Wema and I also seem to remember this publication from Mis Mister. So Justin, please comment. No. Um I just wanted to ask you sure, what would you do for Jack Lary duct reflux? Uh So he described um actually using a bulking agent in the Verum. That's one of the things he described. And I think in some patients they had to do a vasectomy. Yes. On that side. Yeah. Yes. Uh II remember that pa that, that paper from Mister. But that's, that's uh very interesting. Yes. Yes. Yeah. Oh, now, I always remember to do the M CG because it's always uh you know, dr it into us. So um I would do the ultrasound. Obviously, you would check for abnormalities in the tract. But also this um uh this rare finding of uh urethral ejaculatory duct reflux. Yes. Yes. Uh That, that, that's, that's wonderful. I uh yeah, knowing Mister Wema, he, he uh he's fond of such things that he has uh sort of taught us uh that uh things which are rare in Western books may not necessarily be rare in Africa because uh our, our patients don't read Western books. Um uh So I think uh Justin your, your final comments, your final sort of key note, uh take home message for our juniors and there are some attendees from Port Elizabeth, also from Johannesburg and also I see Rux joining from Red Cross. So, so please uh give your final comments, Justin before we close. Well, thank you. Very much for having me. I think it was an excellent presentation and I think that um sometimes these things are very clear cut and you know what to do, but keep an open mind. There are some uh scenarios where um you know, not everything that is testicular pain is torsion. So keep an open mind about your differential diagnosis. But don't let that stop you from managing the appropriate the patient appropriately and emergently. Ok. No, that was really an excellent meeting and we are almost finishing in about 48 minutes. So nothing better than that. So II thank uh cared for hard work, excellent presentation. I also thank Doctor Majola for mentoring him nicely. I uh thank uh Justin for really his, his uh time and his precious advice which we really appreciate and obviously doctors Ma uh Mataya manic for their input and all the attendees for, for attending our meeting. So just say thank you and we will rope you in again sometime next year. Thank you very much for having me. Ok? Thank you everybody. Have a good afternoon. Bye-bye.