Testicular torsion

Testicular torsion - wd1
Classification and external resources
ICD-10	N44.
ICD-9	608.2
OMIM	187400
DiseasesDB	12984
eMedicine	med/2780
MeSH	D013086

In testicular torsion the spermatic cord that provides the blood supply to a testicle is twisted, cutting off the blood supply, often causing orchialgia. Prolonged testicular torsion will result in the death of the testicle and surrounding tissues.

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

Risk factors

In most males, the testes are attached posteriorly to the inner lining of the scrotum by the mesorchium. When the mesorchium terminates early and does not attach the testis, this is called a bell clapper deformity as the testis is free floating in the tunica vaginalis, only attached to the spermatic cord, like a bell clapper. A bell clapper deformity is a predisposing factor for testicular torsion in non-neonates. Currently there is no recommended clinical examination for a bell clapper deformity.

Torsions are sometimes called "winter syndrome". This is because they often happen in winter, when it is cold outside. The scrotum of a man who has been lying in a warm bed is relaxed. When he arises, his scrotum is exposed to the colder room air. If the spermatic cord is twisted while the scrotum is loose, the sudden contraction that results from the abrupt temperature change can trap the testicle in that position. The result is a testicular torsion.

Incidence

While torsion is most frequent among adolescents, it should be considered in all cases where there is testicular pain. Torsion occurs more frequently in patients who do not have evidence of inflammation or infection. Two risk factors are trauma and strenuous physical activity.

Diagnosis

Emergency testing for torsion may be indicated when the onset of pain is sudden and/or severe, or the test results available during the initial examination do not enable a diagnosis of urethritis or urinary tract infection to be made. A doppler ultrasound scan of the scrotum, if available, is of help in the diagnosis by showing the presence or absence of blood flow to the testicle. However, if suspicion is high, immediate untwisting is advised in order to prevent infarction and subsequent testicular loss with or without sterility (i.e. incidental and unfortunate testiculectomy). Dizziness and nausea are often present when there is an absence of blood supply to the testicle, as well as a tremendous amount of pain. If the diagnosis is questionable, a urologist should be consulted immediately, because testicular viability may be compromised. If physical examination suggests a compromised blood supply and the patient has had such symptoms for a significant period, medical personnel may choose to bring the patient directly to surgery without an ultrasound since the time required for ultrasound testing could affect testicular viability. Prehn's sign is a physical exam finding that helps distinguish torsion and other causes of testicular pain such as epididymitis. Increasing pain with scrotal elevation from further reduced blood flow is a positive finding but is not very reliable. In cases of true torsion the cremasteric reflex is typically absent, the scrotum is generally not very swollen, and the affected testis may have a horizontal lie. A general rule of thumb is that a doppler ultrasound should be obtained only in low suspicion cases to rule torsion out but in those cases with a convincing history and physical exam an emergent attempt at surgical detorsion is recommended.

Color Doppler sonography is used to identify the absence of blood flow typically found in a twisted testicle, which distinguishes the condition from epididymitis. ^[1]

Urinalysis (analyzing chemical composition of urine) can be used to rule out bacterial infections.

Surgical exploration may be necessary if diagnosis cannot be made using other methods. If there is the slightest hint of a torsion of the testicle, then doctors will perform surgery; even if the testicle turns out not to have twisted, they will still protect it by attaching the testicle to the scrotum wall.

Treatment

With prompt diagnosis and treatment the testicle can be saved in a high number of cases.^[2]

Testicular torsion is a surgical emergency that needs immediate surgical intervention. If treated within 6 hours, there is an excellent chance of saving the testicle. Within 12 hours the rate decreases to 70%, within 24 hours is 20%, and after 24 hours the rate approaches 0. (eMedicineHealth) Once the testicle is dead it can be removed to prevent gangrenous infection.

A simple and minimally invasive surgery pioneered in Dallas by Dr. Dean Moheet in 1952 effectively corrects and further prevents future testicular torsion. It can be done in an emergency situation after determination that the testicle is cut off from blood supply or as an outpatient procedure for patients who have experienced recurrent episodes of testicular torsion. A small scrotal incision is made, the testis is isolated and untwisted. The surgeon will then fix the testicle in place within the scrotum. The surgeon may suture both testicles to prevent torsion from occurring on the other side.

In some cases the testicle can untwist on its own or it can also be manually untwisted, which can be attempted with pain relief as the guide for successful detorsion. Manual detorsion is successful in 26.5% to greater than 80% of patients based upon a number of reviewed studies. ^[3]

In Popular Culture

In the TV show Scrubs, Turk gets testicular torsion when his daughter Izzie kicks him. This results in the removal of one of his testicles.

In The Venture Brothers episode "Are You There, God? It's Me, Dean", Dean Venture is diagnosed with testicular torsion which results in an operation. Doc Hammer wrote this episode, basing it off his own bout with testicular torsion. He has fully recovered.

In "The TiVo Guy" episode from the sixth season of the TV series Curb Your Enthusiasm, Larry suffers testicular torsion as part of a gag involving his curmudgeonly refusal to wear trendy "no-fly" underwear. He is encouraged by Leon to change his style of underwear because he's got "long balls."

References

1. ^ 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. 
2. ^ Cattolica E, Karol J, Rankin K, Klein R (1982). "High testicular salvage rate in torsion of the spermatic cord.". J Urol 128 (1): 66–8. PMID 7109074. 
3. ^ http://emedicine.medscape.com/article/778086-treatment

External links

Adapted from the public domain document Centers for Disease Control and Prevention. 1998 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR 1998;47(No. RR-1) at http://wonder.cdc.gov/wonder/STD/STD98TG/STD98T12.HTM and other sources.

The Scrotal Safety Commission http://web.archive.org/web/20061108115535/http://www.scrotalsafetycommission.com/

Photos of swollen, excised, and detorsed testicles of patient who sought treatment within four hours of onset of pain. http://www.vesalius.com/graphics/archive/archtn.asp?VID=1235&nrVID=1234