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Testicular Torsion

Adedamola Ayo Omole, MD
William Pearce, MD

BASICS

DESCRIPTION

  • Twisting of testis and spermatic cord, resulting in acute ischemia and loss of testis if unrecognized
  • Intravaginal torsion: occurs within tunica vaginalis, only involves testis and spermatic cord. Most commonly seen in practice.
  • Extravaginal torsion: involves twisting of testis, cord, and processus vaginalis as a unit; typically seen in neonates

Geriatric Considerations

  • Rare in this age group

Pediatric Considerations

- Peak incidence at age 14 years

EPIDEMIOLOGY

  • Incidence: ~1/4,000 males before age 25 years
  • Occurs from newborn period to 7th decade
  • 65% of cases occur in 2nd decade, with peak at age 14 years; rare beyond the age of 30 years
  • Second peak in neonates (in utero torsion usually occurs around week 32 of gestation)

ETIOLOGY AND PATHOPHYSIOLOGY

  • Initial incomplete twisting of spermatic cord causes venous obstruction and edema of testis, leading to congestion and then to ischemia.
  • Complete twisting of the spermatic cord causes arterial occlusion, in addition to the above, leading to rapid ischemia.
  • Congenital bell clapper deformity, which is bilateral in at least 2/5th of cases: A high mesorchium (the posterolateral attachment of the testis to the tunica vaginalis) allows more room for the testis to twist within the tunica vaginalis and is associated with intravaginal testicular torsion.
  • No clear anatomic defect is associated with extravaginal testicular torsion: In neonates, the tunica vaginalis is not yet well attached to scrotal wall, allowing torsion of entire testis including tunica vaginalis.
  • Usually spontaneous and idiopathic
  • 20% of patients have a history of trauma.
  • 1/3 have had prior episodic testicular pain.
  • Contraction of cremaster muscle or dartos may play a role and is stimulated by trauma, exercise, cold, and sexual stimulation.
  • Increased incidence may be due to increasing weight and size of testis during pubertal development.
  • Possible alterations in testosterone levels during nocturnal sex response cycle; possible elevated testosterone levels in neonates
  • Testis must have inadequate, incomplete, or absent
  • Torsion may occur in either clockwise or counterclockwise direction.
  • Genetics: Unknown. Familial testicular torsion, although previously rarely reported, may involve as many as 10% of patients.

RISK FACTORS

  • May be more common in colder months
  • Paraplegia
  • Previous contralateral testicular torsion

DIAGNOSIS

Testicular torsion is a clinical diagnosis. A good history and physicals are the most important and helpful tools in evaluating and managing testicular torsion. If H&P are highly suggestive of testicular torsion, imaging studies may be skipped and immediate urologic consult should be done, as time is of the utmost essence (1).

HISTORY

  • Acute onset of unrelenting pain, often during period of inactivity
  • Onset of pain usually sudden but may start gradually with subsequent increase in severity
  • Nausea and vomiting are common: Presence may increase the likelihood of testicular torsion versus other diagnoses
  • Prior history of multiple episodes of testicular pain with spontaneous resolution in an episodic crescendo pattern may indicate intermittent testicular torsion

PHYSICAL EXAM

  • Scrotum is enlarged, red, edematous, and painful unilaterally
  • Testicle is swollen and exquisitely tender
  • "Bell clapper" deformity: an asymmetrically high-riding testis oriented transversely instead of longitudinally occurring due to shortening spermatic cord from the torsion
  • Testis may be high in scrotum with a transverse lie; this is called Brunzel sign
  • Prehn sign: when elevation of the testis does not decrease pain
  • Absent cremasteric reflex on affected side

DIFFERENTIAL DIAGNOSIS

  • Torsion appendix testis (35-67% of acute scrotal pain cases in children)
  • Epididymitis (8-18% of acute scrotal pain cases)
  • Orchitis
  • Incarcerated or strangulated inguinal hernia
  • Acute hydrocele
  • Traumatic hematoma
  • Testicle rupture
  • Idiopathic scrotal edema
  • Acute varicocele
  • Epididymal hypertension (venous congestion of testicle or prostate due to sexual arousal that does not end in orgasm)
  • Testis tumor
  • Henoch-Schönlein purpura
  • Scrotal abscess
  • Leukemic infiltration

DIAGNOSTIC TESTS & INTERPRETATION

  • Doppler US may confirm decreased or absent blood flow to testicle; PPV of 89.4%. A normal testicular US does not rule out testicular torsion.
  • In boys with intermittent, recurrent testicular torsion, both Doppler US and radionuclide scintigraphy may be used.
  • Initial Tests (lab, imaging):
    • Urinalysis to rule out any infection such as epididymitis, orchitis, UTI
  • Diagnostic Procedures/Other:
    • Radionuclide testicular scintigraphy with technetium-99m pertechnetate demonstrates absent/decreased vascularity in torsion and increased vascularity with inflammation (e.g., torsion of appendix testes).
  • Test Interpretation:
    • Venous thrombosis
    • Tissue edema and necrosis
    • Arterial thrombosis
    • Decreased Doppler flow
    • Sensitivity of radionuclide testicular scintigraphy is decreased relative to ultrasonography because hyperemia in the torsed testicle can mimic normal or inflamed testicle.

TREATMENT

Manual Reduction/Detorsion

  • Best performed by an experienced physician
  • May be successful, facilitated by lidocaine 1% (plain) injection at level of external ring
  • Performed by rotating the affected testicle "like opening a book"; 1/3 of torsion, however, is medial-to-lateral on presentation
  • If successful will usually provide immediate relief; may need to rotate anywhere from 180 to 360 degrees, resulting in possible partial untwisting (2)
  • Manual reduction might require sedation, and the entire process may delay definitive surgery
  • Even if successful, must always be followed by surgical exploration, urgently but not emergently

Surgery

  • Surgical exploration via scrotal approach with detorsion, evaluation of testicular viability, orchidopexy of viable testicle, orchiectomy of nonviable testicle
  • In boys with a history of intermittent episodes of testicular pain, scrotal exploration is warranted with testicular fixation

General Measures

  • Early exam is crucial because necrosis of the testicle can occur after 6 to 8 hours

Issues for Referral

  • All patients diagnosed with testicular torsion should receive urgent/emergent referral to urology

Surgery/Other Procedures

  • Operative testicular fixation: At least 3- or 4-point fixation to dartos or tunica vaginalis
  • Excision of window of tunica albuginea with suture to dartos fascia
  • Any testis that is not clearly viable should be removed
  • Testes of questionable viability that are preserved and pexed invariably atrophy
  • Bilateral testicular fixation is recommended, as contralateral testicle frequently has similar abnormality

Complementary & Alternative Medicine

  • No complementary or alternative medicine recommended.
  • Patients should be educated on the acuity of illness, and the need for immediate intervention

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

- Patients can usually be discharged from recovery

ONGOING CARE

Follow-Up Recommendations

  • Postoperative visit at 1 to 2 weeks
  • Yearly visits until puberty may be needed to evaluate for atrophy
  • Counsel high-risk patients during primary care visits on Emergency Room return precautions

Diet

  • Regular diet

Patient Education

  • Possibility of testicular atrophy in salvaged testis with depressed sperm counts
  • Importantly, fertility rates in patients with one testicle remain excellent

PROGNOSIS

  • Testicular salvage:
    • 85-97% if within 6 hours
    • 20% after 12 hours
    • <10% if >24 hours
  • The degree of torsion is related to testicular salvage
  • 80-94% may have depressed spermatogenesis related to duration of ischemic injury (possibly related to autoimmune-mediated injury)
  • Up to 45% of patients undergoing orchidopexy for testicular torsion will develop atrophy of testicle
  • Preoperative manual detorsion is associated with improved surgical salvage in patients with testicular torsion
  • Infertility can be a problem even if the testicle is viable. Autoimmune anti-sperm antibodies may be produced

COMPLICATIONS

  • Possible testicular atrophy
  • Abnormal spermatogenesis
  • Infertility: Fertility rates with one testicle remain excellent
  • Nearly 36% of patients who experience torsion have sperm counts <20 million/mL

REFERENCES

  1. Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013;88(12):835-840.
  2. Bowlin PR, Gatti JM, Murphy JP. Pediatric testicular torsion. Surg Clin North Am. 2017;97(1):161-172. Additional Reading
  3. Jacobsen FM, Rudlang TM, Fode M, et al. The impact of testicular torsion on testicular function. World J Mens Health. 2020;38(3):298-307. Codes
  4. ICD10: N44.03 Torsion of appendix testis, N44.0 Torsion of testis, N44.02 Intravaginal torsion of spermatic cord

Clinical Pearls

  • The diagnosis of testicular torsion is usually made by physical exam.
  • Patients with suspected torsion should be taken to the OR without delay.
  • If the diagnosis is in question, a testicular Doppler US may be done to evaluate blood flow
  • Although testicular necrosis may be present within 6 to 8 hours of torsion, this is highly variable
  • Preoperative manual detorsion is warranted and is associated with improved surgical salvage
  • Infertility can be a problem even if the testicle is viable. Autoimmune anti-sperm antibodies may be produced

End of note