Testicular Torsion

Testicular torsion is the sudden rotation of the testicle, specifically the spermatic cord, around its axis in the inguinal canal or below. The acute rotation results in compromised blood flow to and from the testicle, which puts the testicle at risk for necrosis. Quick diagnosis and intervention is key to saving the affected testicle. Emergent surgical exploration with subsequent orchidopexy is required. Ultrasound or manual detorsion should not delay definitive care.

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Overview

Definition

  • Sudden rotation of the testicle, specifically the spermatic cord, around its axis
  • A urological emergency

Epidemiology

  • Can occur at any age 
  • Peak incidence: 
    • Neonatal period 
    • Boys 12–18 years old
  • Yearly incidence: 3.8 per 100,000 boys < 18 years old
  • Cryptorchidism increases the risk of testicular torsion.

Pathophysiology and Clinical Presentation

Pathogenesis

  • Extravaginal torsion: 
    • Manifests in the neonatal period
    • Involves twisting of the entire testicle and tunica vaginalis (testicle covering) 
    • Tunica vaginalis is not fixed to the scrotal wall in neonates. 
  • Intravaginal torsion: 
    • Typically seen in older adolescents
    • Testicle and spermatic cord twisting within the tunica vaginalis
  • Bell clapper deformity: 
    • The testicle lies horizontally from the tunica vaginalis and extends over the spermatic cord.
    • Increases risk of intravaginal torsion

Testicular torsion:
The left image depicts a normal testicle. Testicular torsion is seen on the right: The testicle lies horizontally, creating an increased risk of torsion of the spermatic vessels.

Image by Lecturio.

Clinical presentation

  • Newborn: 
    • Hard scrotal mass that does not transilluminate
    • Discolored or bruised hemiscrotum with swelling 
    • Acute tenderness on exam
  • Older patients: 
    • Acute-onset, severe, constant testicular or scrotal pain (typically < 12-hour duration)
    • Associated nausea and vomiting 
    • No clear inciting factor, but history of strenuous activity or trauma reported
    • Children may awaken at night with scrotal pain from cremasteric contraction.

Diagnosis and Management

Clinical findings

  • Physical exam: 
    • Edematous, tender, indurated testicle/scrotum 
    • Affected testicle lies horizontally.
    • High-riding testicle due to spermatic cord shortening
  • Key physical exam maneuvers: 
    • Cremasteric reflex (elevation of testicle when stroking upper inner thigh) is usually absent.
    • Prehn sign: Lifting the scrotum relieves pain in epididymitis and increases pain in torsion. 
  • Scrotal ultrasound: 
    • Should not delay definitive management 
    • Color Doppler will demonstrate decreased testicular vascular perfusion.

Treatment

  • Time is essential in testicle preservation:
    • Within 4–6 hours: 95% viability
    • After 12 hours: 20%–60% viability
    • After 24 hours: 0%–20% viability
  • Emergency surgical exploration of the affected testicle with reduction (untwisting) and bilateral orchidopexy (fixation of testicle to scrotal wall) indicated
  • Manual detorsion:
    • Bedside procedure is attempted if emergency operative care is not readily available.
    • Grasp the affected testicle and rotate from medial to lateral direction (“open book technique”). 
    • May provide prompt relief of pain prior to going to the operating room

Intraoperative scrotal exploration for testicular torsion:
A: blue discolored testicle devoid of blood supply and twisted spermatic cord
B: prior orchiopexy sutures denoting recurrent testicular torsion

Image: “Intraoperative image of emergent scrotal exploration” by Department of Urology, University General Hospital of Heraklion, Heraklion, Crete, Greece. License: CC BY 2.0

Manual testicular detorsion:
Image A depicts a right testicular torsion.
Image B illustrates the manual detorsion method of grasping and rotating the affected testicle with the “open book technique” from the medial to lateral position.

Image by Lecturio.

Differential Diagnosis

  • Torsion of appendix testis (Müllerian duct remnant) or appendix epididymis (Wolffian duct remnant): sudden onset of testicular pain similar to testicular torsion. However, the testicle itself is not tender and the pain is focused at the superior pole of the testicle depicting a “blue dot sign” (inflamed appendage visualized through the scrotal skin). Doppler ultrasound shows normal flow to the testicle and torsion of the appendage. Management is supportive with analgesics and bedrest. 
  • Intermittent testicular torsion: acute, sudden-onset testicular pain with scrotal swelling and rapid resolution. The cycle may go on for several hours or days but must be worked up in the same manner as a suspected testicular torsion. Clinical diagnosis includes a physical exam and Doppler scrotal ultrasound for radiographic evidence of halted blood flow to the testicles.  
  • Epididymitis and orchitis: inflammatory process of the epididymis or testicle causing gradual-onset pain and swelling. Condition commonly presents with dysuria, urinary frequency, discharge, and fevers. Diagnosis consists of physical exam, history of gradual-onset pain (vs. acute with torsion), and urinalysis/culture. Sexually transmitted disease testing or Doppler scrotal ultrasound should be considered based on the clinical scenario. Treatment is antibiotics, analgesics, and scrotal support.
  • Immunoglobulin A (IgA) vasculitis: systemic vasculitis syndrome with nonthrombocytopenic purpura, arthralgia, renal disease, abdominal pain, and sometimes scrotal pain. The onset of scrotal pain may be acute or gradual. Torsion should be suspected if the patient does not exhibit any other sequelae of vasculitis; otherwise, treatment is supportive.  
  • Inguinal canal and hernias: Incarcerated inguinal hernias will cause acute-onset inguinal or scrotal pain. Physical exam reveals inguinal swelling, pain, and sometimes bowel sounds in the scrotum due to herniated bowel. Ultrasound may be necessary for a definitive diagnosis if the presentation is unclear. Management consists of attempted hernia reduction or, in the case of incarceration, immediate operative care. 
  • Varicocele, hydrocele, and spermatocele: scrotal conditions that are usually asymptomatic or associated with dull, aching sensation. Key physical exam findings include: “bag of worms” for varicocele, tense scrotum and large swelling for hydrocele, and cyst-like mass of the epididymis for spermatocele. Management consists of conservative care or surgical excision based on the patient’s level of discomfort. 

References

  1. Brenner, J.S. (2020). Causes of scrotal pain in children and adolescents. UpToDate. Retrieved January 23, 2021, from https://www.uptodate.com/contents/causes-of-scrotal-pain-in-children-and-adolescents
  2. Hittelman, A.B. (2020). Neonatal testicular torsion. UpToDate. Retrieved January 25, 2021, from https://www.uptodate.com/contents/neonatal-testicular-torsion
  3. Sharp, V., Kieran, K., Arlen, A.  (2013) Testicular torsion: Diagnosis, Evaluation and Management. Am Fam Physician. 15;88(12):835-840.

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