Testicular torsion

Testicular torsion
1. Epididymis 2. Head of epididymis 3. Lobules of epididymis 4. Body of epididymis 5. Tail of epididymis 6. Duct of epididymis 7. Deferent duct (ductus deferens or vas deferens)
Specialty Urology
Symptoms Severe testicular pain, elevated testicle[1]
Complications Infertility[2]
Usual onset Sudden[1]
Types Intravaginal torsion, extravaginal torsion[1]
Risk factors "Bell clapper deformity", testicular tumor, cold temperature[1]
Diagnostic method Based on symptoms[1]
Differential diagnosis Epididymitis, inguinal hernia, torsion of the appendix testicle[2]
Treatment Physically untwisting the testicle, surgery[1]
Prognosis Generally good with rapid treatment[1]
Frequency ~1 in 15,000 per year (under 25 years old)[2][3]

Testicular torsion occurs when the spermatic cord (from which the testicle is suspended) twists, cutting off the testicle's blood supply.[3] The most common symptom in children is rapid onset of severe testicular pain.[1] The testicle may also be higher than usual and vomiting may occur.[1][2] In newborns pain is often absent and instead the scrotum may become discolored or a testicle may disappear from its usual place.[1]

Most of those affected have no obvious prior underlying health problems.[1] Occasionally a tumor or prior trauma may be present.[1][3] Risk factors include a congenital malformation known as a "bell-clapper deformity" wherein the testis is inadequately attached to the scrotum allowing it to move more freely and thus potentially twist.[1] Cold temperatures may also be a risk factor.[1] The diagnosis should usually be made based on the presenting symptoms.[1][2] An ultrasound can be useful when the diagnosis is unclear.[2]

Treatment is by physically untwisting the testicle, if possible, followed by surgery.[1] Pain can be treated with opioids.[1] Outcome depends on time to correction.[1] If done within six hours it is often good, however, if delayed for 12 or more hours the testicle is typically not salvageable.[1] About 40% of people require removal of the testicle.[2]

It is most common just after birth and during puberty.[2] It occurs in about 1 in 4,000 to 1 in 25,000 males under 25 years of age each year.[2][3] Of children with testicular pain of rapid onset, testicular torsion is the cause of about 10% of cases.[2] Complications may include an inability to have children.[2] The condition was first described in 1840 by Louis Delasiauve.[4]

Signs and symptoms

Testicular torsion usually presents with sudden, severe, testicular pain (in groin and lower abdomen) and tenderness.[2] There is often associated nausea and vomiting.[2] The testis may be higher than its normal position and transversely oriented. Mild pyrexia and redness of overlying area may be found. Elevation of the testis may worsen the pain.

Some of the symptoms are similar to epididymitis though epididymitis may be characterized by discoloration and swelling of the testis, often with fever, while the cremasteric reflex is usually present. Testicular torsion, or more probably impending testicular infarction, can also produce a low-grade fever.[5] There is often an absent or decreased cremasteric reflex.[2]

Risk factors

A larger testicle either due to normal variation or a tumor increases the risk of torsion.[3]

A congenital malformation of the processus vaginalis known as the "bell-clapper deformity" accounts for 90% of all cases.[3][6] In this condition, rather than the testes attaching posteriorly to the inner lining of the scrotum by the mesorchium, the mesorchium terminates early and the testis is free floating in the tunica vaginalis.

It may also be caused by trauma; this is fairly rare.[2][7]

Pathophysiology

Torsion is due to a mechanical twisting process. It is also believed that torsion occurring during fetal development can lead to so-called neonatal torsion or vanishing testis, and is one of the causes of an infant being born with monorchism (one testicle).[8]

Intermittent testicular torsion

A variant is a less serious but chronic condition called intermittent testicular torsion (ITT), characterized by the symptoms of torsion but followed by eventual spontaneous detortion and resolution of pain. Nausea or vomiting may also occur.[9]:p.150 Though less pressing, such individuals are at significant risk of complete torsion and possible subsequent orchiectomy and the recommended treatment is elective bilateral orchiopexy. Ninety-seven percent of patients who undergo such surgery experience complete relief from their symptoms.[5]:p.316

Extravaginal testicular torsion

A torsion which occurs outside of the tunica vaginalis, when the testis and gubernaculum can rotate freely, is termed an extravaginal testicular torsion. This type occurs exclusively in newborns. Neonates experiencing such a torsion present with scrotal swelling, discoloration, and a firm, painless mass in the scrotum. Such testes are usually necrotic from birth and must be removed surgically.[5]:p.315

Torsion of the testicular appendix

This type of torsion is the most common cause of acute scrotal pain in boys ages 7–14. Its appearance is similar to that of testicular torsion but the onset of pain is more gradual. Palpation reveals a small firm nodule on the upper portion of the testis which displays a characteristic "blue dot sign". This is the appendix of the testis which has become discolored and is noticeably blue through the skin. Unlike other torsions, however, the cremasteric reflex is still active. Typical treatment involves the use of over-the-counter analgesics and the condition resolves within 2–3 days.[5]:p.316

Diagnosis

The diagnosis should be made on the history and presenting signs and symptoms.[2] With a convincing history and physical exam immediate surgery is recommended[2][3] and doppler ultrasound should only be obtained in low suspicion cases to rule out torsion.[3]

Clinical exam

Prehn's sign, a classic physical exam finding, has not been reliable in distinguishing torsion from other causes of testicular pain such as epididymitis.[10] In cases of true torsion the cremasteric reflex is typically absent (the twisted cords of the testicle make reflexive responses all but impossible). On physical examination, the testis will be swollen, tender, and high-riding, with an abnormal transverse lie.[11] The individual will not usually have a fever, though nausea is common.

Imaging

A doppler ultrasound scan of the scrotum is nearly 90% accurate in diagnosis[2][3] identifying the absence of blood flow in the twisted testicle, which distinguishes torsion from epididymitis.[12]

Radionuclide scanning of the scrotum is the most accurate, imaging technique, but it is not routinely available, particularly with the urgency that might be required.[13] The agent of choice for this purpose is technetium-99m pertechnetate.[14] Initially it provides a radionuclide angiogram, followed by a static image after the radionuclide has perfused the tissue. In the healthy patient, initial images show symmetric flow to the testes, and delayed images show uniformly symmetric activity.[14]

Treatment

With prompt diagnosis and treatment the testicle can often be saved.[3] Typically, when a torsion takes place, the surface of the testicle has rotated towards the midline of the body. Non-surgical correction can sometimes be accomplished by manually rotating the testicle in the opposite direction (i.e., outward, towards the thigh); if this is initially unsuccessful, a forced manual rotation in the other direction may correct the problem.[9]:p.149 The success rate of manual detorsion is not known with confidence.

Testicular torsion is a surgical emergency that requires immediate intervention to restore the flow of blood.[3] If treated either manually or surgically within six hours, there is a high chance (approx. 90%) of saving the testicle. At 12 hours the rate decreases to 50%; at 24 hours it drops to 10%, and after 24 hours the ability to save the testicle approaches 0.[3] About 40% of cases result in loss of the testicle.[2] Common treatment for children is surgically sewing the testicle to the scrotum to prevent future recurrence (orchiopexy).

Epidemiology

Torsion is most frequent among adolescents with about 65% of cases presenting between 12–18 years of age.[15] It occurs in about 1 in 4,000 to 1 per 25,000 males per year before 25 years of age;[2][3][6] but it can occur at any age, including infancy.[9]:p.149

Complication

  • Testicular infarction
  • Scrotal abscess
  • Gangrene of testis
  • Recurrence
  • Chronic epididymitis

See also

  • Ovarian torsion – equivalent condition of the female reproductive system.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Ludvigson, AE; Beaule, LT (June 2016). "Urologic Emergencies". The Surgical clinics of North America. 96 (3): 407–24. doi:10.1016/j.suc.2016.02.001. PMID 27261785.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Sharp, VJ; Kieran, K; Arlen, AM (Dec 15, 2013). "Testicular torsion: diagnosis, evaluation, and management". American Family Physician. 88 (12): 835–40. PMID 24364548. Archived from the original on 2016-11-04.
  3. 1 2 3 4 5 6 7 8 9 10 11 12 13 Wampler SM, Llanes M (September 2010). "Common scrotal and testicular problems". Prim. Care. 37 (3): 613–26, x. doi:10.1016/j.pop.2010.04.009. PMID 20705202.
  4. ↑ Schill, Wolf-Bernhard; Comhaire, Frank H.; Hargreave, Timothy B. (2006). Andrology for the Clinician. Springer Science & Business Media. p. 134. ISBN 9783540337133. Archived from the original on 2017-09-10.
  5. 1 2 3 4 Kavoussi, Parviz K.; Costabile, Raymond A. (2011). "Disorders of scrotal contents: orchitis, epididimytis, testicular tortion, tortion of the appendages, and Fournier's gangrene". In Chapple, Christopher R.; Steers, William D. Practical urology: essential principles and practice. London: Springer-Verlag. ISBN 978-1-84882-033-3. Archived from the original on 2014-07-05.
  6. 1 2 Ringdahl E, Teague L (November 2006). "Testicular torsion". Am Fam Physician. 74 (10): 1739–43. PMID 17137004.
  7. ↑ Shefi, S; Mor, Y; Dotan, ZA; Ramon, J (October 1999). "Traumatic testicular dislocation: a case report and review of published reports". Urology. 54 (4): 744. doi:10.1016/s0090-4295(99)00238-1. PMID 10754145.
  8. ↑ Callewaert PR, Kerrebroeck PV (June 2010). "New insights into perinatal testicular torsion". Eur J Pediatr. 169 (6): 705–12. doi:10.1007/s00431-009-1096-8. PMC 2859224. PMID 19856186.
  9. 1 2 3 Uribe, Juan F. (1 January 2008). Potts, Jeannette M., ed. Genitourinary Pain and Inflammation: Diagnosis and Management. Totowa, New Jersey: Humana. pp. 149–. ISBN 978-1-60327-126-4. Archived from the original on 3 January 2014. Retrieved 8 July 2013.
  10. ↑ Lavallee ME, Cash J (April 2005). "Testicular torsion: evaluation and management". Curr Sports Med Rep. 4 (2): 102–4. doi:10.1097/01.CSMR.0000306081.13064.a2. PMID 15763047.
  11. ↑ Liu DR. Chapter 127. Urologic and Gynecologic Problems and Procedures in Children. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011.
  12. ↑ Arce J, Cortés M, Vargas J (2002). "Sonographic diagnosis of acute spermatic cord torsion. Rotation of the cord: a key to the diagnosis". Pediatr Radiol. 32 (7): 485–91. doi:10.1007/s00247-002-0701-z. PMID 12107581.
  13. ↑ Sexually Transmitted Diseases Treatment Guidelines, 2010 Archived 2012-04-04 at the Wayback Machine. from Centers for Disease Control and Prevention, Recommendations and Reports. December 17, 2010 / Vol. 59 / No. RR-12
  14. 1 2 Medscape > Testicular Torsion Imaging Archived 2012-06-27 at the Wayback Machine. by David Paushter. Updated: May 25, 2011
  15. ↑ Edelsberg JS, Surh YS (August 1988). "The acute scrotum". Emerg. Med. Clin. North Am. 6 (3): 521–46. PMID 3292226.
Classification
External resources
  • Photos of swollen, excised, and detorsed testicles of patient who sought treatment within four hours of onset of pain.
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