Testicular Torsion

Testicular torsion is the sudden rotation of the testicle, specifically the spermatic cord, around its axis in the inguinal canal Inguinal canal The inguinal region, or the groin, is located in the RLQ and LLQ of the anterior abdominal wall, bordered by the thigh inferiorly, the pubis medially, and the iliac crest superolaterally. The inguinal canal is a tubular structure that runs in a straight line from the anterior superior iliac spine to the pubic tubercle. Inguinal Canal and Hernias or below. The acute rotation results in compromised blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure 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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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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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 Cryptorchidism Cryptorchidism is one of the most common congenital anomalies in young boys. Typically, this asymptomatic condition presents during a routine well-child examination where 1 or both testicles are not palpable in the scrotum. 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

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 Newborn A neonate, or newborn, is defined as a child less than 28 days old. A thorough physical examination should be performed within the first 24 hours of life to identify abnormalities and improve outcomes by offering timely treatment. Physical Examination of the 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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of 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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of 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 Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh) is usually absent.
    • Prehn sign: Lifting the scrotum relieves pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain in epididymitis Epididymitis Epididymitis and orchitis are characterized by acute inflammation of the epididymis and the testicle, respectively, due to viral or bacterial infections. Patients typically present with gradually worsening testicular pain and scrotal swelling along with systemic symptoms such as fever, depending on severity. Epididymitis and Orchitis and increases pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of 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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain prior to going to the operating room
Testicular torsion surgery

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

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 Müllerian duct A pair of ducts near the wolffian ducts in a developing embryo. In the male embryo, they degenerate with the appearance of testicular anti-mullerian hormone. In the absence of anti-mullerian hormone, mullerian ducts give rise to the female reproductive tract, including the oviducts; uterus; cervix; and vagina. Uterus, Cervix, and Fallopian Tubes remnant) or appendix epididymis ( Wolffian duct Wolffian duct A pair of excretory ducts of the middle kidneys of an embryo, also called mesonephric ducts. In higher vertebrates, wolffian ducts persist in the male forming vas deferens, but atrophy into vestigial structures in the female. Kidneys remnant): sudden onset of testicular pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain similar to testicular torsion. However, the testicle itself is not tender and the pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain is focused at the superior pole of the testicle depicting a “blue dot sign” (inflamed appendage visualized through the scrotal skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin). Doppler ultrasound shows normal flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure to the testicle and torsion of the appendage. Management is supportive with analgesics and bedrest. 
  • Intermittent testicular torsion: acute, sudden-onset testicular pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of 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 Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure to the testicles Testicles The testicles, also known as the testes or the male gonads, are a pair of egg-shaped glands suspended within the scrotum. The testicles have multiple layers: an outer tunica vaginalis, an intermediate tunica albuginea, and an innermost tunica vasculosa. The testicles are composed of testicular lobules and seminiferous tubules. Testicles.  
  • Epididymitis and orchitis Orchitis Epididymitis and orchitis are characterized by acute inflammation of the epididymis and the testicle, respectively, due to viral or bacterial infections. Patients typically present with gradually worsening testicular pain and scrotal swelling along with systemic symptoms such as fever, depending on severity. Epididymitis and Orchitis: inflammatory process of the epididymis or testicle causing gradual-onset pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and swelling. Condition commonly presents with dysuria, urinary frequency, discharge, and fevers. Diagnosis consists of physical exam, history of gradual-onset pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain (vs. acute with torsion), and urinalysis/culture. Sexually transmitted disease Sexually Transmitted Disease Sexually transmitted diseases (STDs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Overview: Sexually Transmitted Infections 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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, and sometimes scrotal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain. The onset of scrotal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of 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 Inguinal Hernias An abdominal hernia with an external bulge in the groin region. It can be classified by the location of herniation. Indirect inguinal hernias occur through the internal inguinal ring. Direct inguinal hernias occur through defects in the abdominal wall (transversalis fascia) in Hesselbach's triangle. The former type is commonly seen in children and young adults; the latter in adults. Inguinal Canal and Hernias will cause acute-onset inguinal or scrotal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain. Physical exam reveals inguinal swelling, pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of 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 Varicocele A condition characterized by the dilated tortuous veins of the spermatic cord with a marked left-sided predominance. Adverse effect on male fertility occurs when varicocele leads to an increased scrotal (and testicular) temperature and reduced testicular volume. Varicocele, Hydrocele, and Spermatocele, hydrocele Hydrocele Accumulation of serous fluid between the layers of membrane (tunica vaginalis) covering the testis in the scrotum. Varicocele, Hydrocele, and Spermatocele, and spermatocele Spermatocele A cystic dilation of the epididymis, usually in the head portion (caput epididymis). The cyst fluid contains dead spermatozoa and can be easily differentiated from testicular hydrocele and other testicular lesions. 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 Hydrocele Accumulation of serous fluid between the layers of membrane (tunica vaginalis) covering the testis in the scrotum. Varicocele, Hydrocele, and Spermatocele, and cyst-like mass of the epididymis for spermatocele Spermatocele A cystic dilation of the epididymis, usually in the head portion (caput epididymis). The cyst fluid contains dead spermatozoa and can be easily differentiated from testicular hydrocele and other testicular lesions. Varicocele, Hydrocele, and 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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