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Testicular Torsion

 

Testicular torsion is an urological emergency which often results in the loss of a testicle if not diagnosed and treated quickly. It occurs when the testis twists in the scrotum, cutting off its blood supply. This is an extremely painful condition which most commonly occurs in young males and is the most common cause of a testicle loss. 

 

Facts and Figures

 

Testicular torsion is a fairly common condition amongst adolescent males, although it can occur in males of any age, including newborns. However, it usually occurs in males less than 30, with a peak age of 13-14 years.

In 2003-2004, 2464 cases of testicular torsion were admitted to hospitals in England. The peak age was 15 years, and 41% of these admissions were aged 15-59. No patients were over the age of 75.

(Figures from http://www.patient.co.uk/doctor/Torsion-of-the-Testis.htm, Dec 2010 )

The left testicle is more commonly affected than the right testicle, and in 2% of cases, both testicles are involved.

Torsion is the most common cause of a testicle loss in males. 

 

Testicular Anatomy

 

The scrotum contains two testicles, which hang from the spermatic cord. The testes blood supply comes via the pampiniform plexus, and sperm travels through the vas deferens from the testes to the penis. Both the pampiniform plexus and vas deferens are contained within the spermatic cord. 

 

Although the testicles cannot usually move enough to twist completely in the scrotum, they are able to move slightly. They are stopped from moving freely by the tunica vaginalis, which covers each testicle, and attaches each testicle to the scrotum posterolaterally. 

 

 

Torsion can be classified as partial or complete. In both cases it occurs when the blood supply to the testicle is compromised or cut off.

Complete testicular torsion occurs when the testicle has twisted 360 degrees on the spermatic cord, completely cutting off the blood supply.

Partial testicular torsion is when the testicle twists over 90 degrees compromising the blood supply to the testicle.

The more the testicle is twisted, the more swollen and painful the testicle will be, as necrosis occurs faster. The diagram below shows a left testicular torsion. 

 

Testicular Torsion

Risk Factors

 

  • Congenital (Bell-Clapper Deformity)

This is when the attachment of the tunica vaginalis to the testicle is too high, meaning that the testes can twist on the spermatic cord as it is not held in a fixed position. This is the most common cause of testicular torsion. With this common deformity, the testes will often be in a horizontal lie within the scrotum instead of a vertical lie. The deformity may be unilateral or bilateral.

  • Temperature (Winter Syndrome)

Torsion often occurs in the winter when males are in bed. This is due to the scrotum relaxing in the warmth, allowing the testicle more freedom to move. When the scrotum is suddenly exposed to the cold, it contracts quickly, trapping the testicle in its position. If the testicle had twisted, then a torsion occurs.

  • Size

If one testicle is larger than the other due to any cause (whether pathological or congential) it is more likely to twist on its spermatic cord.

  • Neonatal

Until the testicle descends into the scrotum and attaches to the tunica vaginalis (often days 7-10), it is free to move and more likely to twist causing a torsion.

 

Clinical Presentation: History

 

  • Typically the patient will present with sudden severe pain in their testicle/s (depending on whether the torsion is uni/bilateral).
  • The patient may also complain of lower abdominal pain.
  • The concerned scrotum will be red and swollen.
  • The patient may complain of nausea and vomiting
  • The patient may recall recent episodes of less severe testicular pain that resolved itself. (Suggestive of previous torsion that has corrected itself.)

 

Decreasing/disappearance of pain does not necessarily mean that the torsion has corrected itself - the testis may be undergoing necrosis.

Not all testicular torsion presents as acute onset severe pain. Any male patient presenting with lower abdominal pain should have their testicles checked to make sure that they do not have torsion.

Clinical Presentation: Examination

 

You should perform a testicular examination on these patients if you suspect testicular torsion. On examination, if the patient has torsion, you are likely to see:

  • A swollen tender testicle that is raised in a red scrotum
  • The testicle may be lying horizontally in the scrotum
  • No pain relief when the testicle is elevated (there will be pain relief in epididymitis)
  • Loss of the cremasteric reflex on the affected side
  • The patient may have a fever

 

Remember, this condition is extremely painful and has a very sudden onset. It may not be possible to do a full examination due to the pain. Testicular torsion is a clinical diagnosis, so if you suspect it, then treat it as torsion.

 

    Differential Diagnoses

     

    Due to emergency nature of testicular torsion, it is important to exclude differential diagnoses quickly so that the appropriate treatment can begin.

    • Acute appendicitis
    • Torsion of testicular or epididymal appendage
    • Orchitis
    • Epididymitis
    • Hernias
    • Hydrocele
    • Testicular tumour
    • Idiopathic scrotal infarction/oedema
    • Trauma
    • Mumps
    • Varicocele
    • Spermatocele
    • Fourniere gangrene

     

    Remember: Acute, tender enlargement of the testis is torsion until proven otherwise.

      Investigations

       

      Testicular torsion should normally be a clinical diagnosis due to the speed at which treatment should be commenced in order to save the testicle. However, if you are not certain, then investigations should be undertaken as quickly as possible.

       

      Ultrasound with colour Doppler scans are the best investigations in terms of speed and accuracy to help with the diagnosis of torsion. The Doppler scans show whether the testicle has a patent arterial blood supply.

       

      Dynamic contrast MRI scans can also be used with greater accuracy, but these usually take too long to allow effective treatment after the diagnosis.

       

      Management

       

      1. Medications - review whether the patient needs pain relief +/- anti-emetics

      2. Manual Detorsion - sometimes it is possible to manually detwist the torsioned testicle. When the testicle is untwisted (and it may need to be twisted more than 360 degrees), the pain should be relieved. If not, try twisting the testicle the other way. If successful, check the testicles blood supply using a colour Doppler ultrasound. The patient will still need a orchidopexy before they can leave hospital to secure the testicles and prevent it from happening again. However, it is not as urgent as before.

       

      3. Surgical Exploration - If the manual detorsion is unsuccessful or there is doubt about the diagnosis, then a surgical scrotal exploration should take place as soon as possible, preferably within six hours. During this, if the spermatic cord is twisted, then it should be untwisted to salvage the testicle if it is still viable. If not, the testicle should be removed. Whether the testicle is saved or not, the patient should undergo an orchidopexy on both testicles, as the patient is at a higher risk of the torsion reoccurring on either testicle. This should be done at the same time as the exploration or soon after manual detorsion if it was successful. 

       

      4. Cosmetics - If the testicle has to be removed, a prosthetic testicle can be inserted for cosmetic purposes, however, this cannot be done until a few months after the initial removal of the testicle. 

       

        Prognosis

         

        If treated within 6 hours of the presenting pain, there is a good outcome for saving the affected testicle. Figures show that, the percentage of testicles saved according to the number of hours treated in are:

        • Within 6 hours: 90-100% testicles saved
        • After 12 hours: 20-50% testicles saved
        • After 24 hours: 0-10% testicles saved

        (From http://emedicine.medscape.com/article/778086-overview, Dec 2010) 

          Even if a testicle is no longer viable, the patient must still have surgery to remove it, to prevent it from becoming gangrenous. 

          If only one testicle was affected, and the other testicle is normal, then the patient's fertility is not affected.

          Remember: Rapid assessment, diagnosis and intervention is key to a successful outcome, so don't delay!

          Bibliography

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