Testicular torsion

Written by Soraya Sritangos

Last Reviewed: August 2019

Review Due: August 2020

 

DEFINITION1

‘twisting of the testis on the spermatic cord resulting in compromisation of blood supply to the ipsilateral testis. It is a urological emergency requiring early diagnosis and treatment to preserve testis viability and fertility’

 

AETIOLOGY

Bell-clapper deformity

        The most common anatomical defect which predisposes to testicular torsion 

Trauma 

Sex/Exercise

Testicular Tumour

Cryptorchidism 

Idiopathic

SIGNS AND SYMPTOMS1,2

Classic presentation: acute severe unilateral scrotal pain and scrotal swelling.

 

Common findings:

Absence of cremasteric reflex

Abnormal testicular lie- High-riding and/or horizontal lie

Elevation of scrotum does not relieve  pain

History of trauma/physical activity

History of previous episode(s)- recurrent self-limiting (spontaneous torsion and detorsion)

 

Other features include:

Scrotal erythema and oedema

Nausea and vomiting

Abdominal pain

Fever (uncommon)

 

**Suspect testicular torsion in all males ( <30 years old) with acute scrotal pain and swelling**

 

PATHOPHYSIOLOGY1,2

Intravaginal Torsion: most common, twisting of the spermatic cord and the blood supply to the testis within the tunica vaginalis, resulting in venous occlusion, ischemia and infarction of the testis of the affected side.

 

Bell Clapper deformity:  a congenital defect where there is an abnormal attachment of the tunica vaginalis to the testis,  allowing the testis to rotate freely within the tunica vaginalis and can result in an abnormal horizontal-lie position of the testis within the scrotum, which predisposes to torsion. Bilateral torsion in 40% of cases.

 

Torsion can be partial or complete (⩾360°). The duration and degree of torsion influence the viability of the testis. Torsion more than 6 hours decreases the chance of testicular salvage, and if ⩾ 24 hours there is a high risk of testicular necrosis.


Extravaginal torsion: occurs in neonates, as the tunica vaginalis has not fully developed yet.

 

Investigations3

No useful laboratory tests

 

Urgent surgical exploration is required

Doppler Ultrasound scan -  lack of blood flow to testis, only if diagnostic uncertainty. Surgery should not be delayed for ultrasound

Prognosis 1,2

 

TREATMENT3

  • Emergency Surgical Detorsion (within 4 - 8 hours of onset) + bilateral scrotal orchidopexy - definitive treatment

    • ± Orchidectomy - if unsalvageable

  • Manual Detorsion- may be attempted but often difficult due to pain; not a substitute for surgical exploration.

    • Success detorsion is confirmed by Doppler Ultrasound and complete resolution of symptoms

    • + bilateral scrotal orchidopexy

 

EPIDEMIOLOGY1,2

Primarily a paediatric condition. Most commonly affects adolescents aged 12 -18, but can affect men of any age.

Left testis is more commonly affected, rarely bilateral.

 

 
 
 

Testicular salvageability is dependent on time between onset of symptoms and detorsion:

< 6 hours : 90 - 100% salvageability

> 12 hours: < 50%

> 24 hours: < 10%

REFERENCES

  1. Kaplan G. Testicular Torsion BMJ Best Practice 2018 

  2. Ogunyem, O. Testicular Torsion. Medscape 2018

  3. Scrotal Pain and Swelling. NICE Clinical Knowledge Summary 2019

 
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