Testicular torsion

Definition

Testicular torsion is the twisting of a testis (testicle) such that the spermatic cord becomes twisted, cutting off blood flow to the testis.

Description

The testes are suspended in the scrotum by a single bundle of tissues called the spermatic cord. Normally this bundle of tissue holds the testes in place. Each testis receives blood through the spermatic cord. When the testicle is not held firmly in place it can twist, creating a kink in the spermatic cord. When this happens blood supply to the testis is cut off. The resulting situation is an emergency, because the testis will die within hours if the blood supply is not restored.

Demographics

There is approximately one case of testicular torsion in every 4,000 men under age 25 in the United States. There are two times in life when torsion is most common, although it can occur at any age. Testicular torsion is most common in the first year of life and during adolescence. Torsion is more common in adolescents that it is in newborns.

Causes and Symptoms

Testicular torsion is caused by the rotating of the testicle is such a way that the blood flow to it is cut off. Symptoms of testicular torsion are sudden severe pain in the scrotum, swelling and/or discoloration of the scrotum, nausea, and vomiting. Approximately 40 percent of patients with testicular torsion reported having a similar pain sometime before, but at that time the pain resolved without treatment.

When to Call the Doctor

Testicular torsion is an emergency, and the child should be taken to the doctor or emergency room immediately if he shows the signs or symptoms of testicular torsion. The chance that the testicle will be saved is directly linked to how long the testicle is without blood flow. If the torsion occurs for less than six hours, there is a high chance the testicle can be saved. If the torsion occurs for more than 24 hours, it is very unlikely that the testicle can be saved.

Diagnosis

The doctor usually first performs a visual examination of the scrotum. The affected testis may appear to be slightly higher than the unaffected one. The scrotum may be swollen or discolored. If the doctor is unsure, diagnostic tests may also be performed.

One such diagnostic test is a nuclear scan of the scrotum. In this procedure, a tiny amount of radioactive fluid is injected into the blood and detected as it flows through the scrotum and testicles. Torsion is indicated if the radioactive fluid does not flow through the sore testis. Ultrasound scan accompanied by a contrast agent can also be used to diagnose testicular torsion. Other diagnostic tests may be performed to help the doctor determine if torsion has occurred.

Treatment

Surgery performed within the first six hours has an 80 to 100 percent chance of saving the affected testis. This likelihood goes down the longer blood flow to the testis has been cut off. After 24 hours, it is very unlikely that the testicle can be saved. During the procedure, the surgeon untwists the cord and secures the testis in place so that it cannot rotate again. This securing is called orchiopexy. The other testicle is also secured during the surgery to prevent future testicular torsion, because children who have had one episode of testicular torsion are likely to experience it again. If the testicle has not been untwisted in time and is dead, the surgeon will remove it.

While waiting for surgery, the doctor may try to restore blood flow to the testis by hand. This can help to save the testis if surgery is not possible right away. Surgery is still necessary, however, even if blood flow to the testis has been restored, because it is very likely that torsion will occur again.

Prognosis

If the torsion is relieved within six hours, it is very likely that the testis will recover normal blood flow and function. If the torsion continues for more than 24 hours, it is unlikely that the testis can be saved. One testis is all that is necessary for normal growth and maturation, as well as normal fertility later in life.

Prevention

The only way to prevent torsion is to surgically anchor the testes so that they cannot move. This is frequently done after an occurrence of torsion, both to the torsed testis and the unaffected testis.

Parental Concerns

Testicular torsion is usually very painful. If the torsion is not corrected quickly, the testis usually loses function. Only one healthy and functioning testis is required for normal growth and development and for normal fertility later in life.

Resources

Periodicals

Adelman, William P., and Alain Joffe. "The Adolescent with a Painful Scrotum." Contemporary Pediatrics 17 (March 2000): 111.

Kirn, Timothy, F. "Time Is Critical with Testicular Torsion." Family Practice News 34 (April 15, 2004): 86.

Little, Cindy. "Testicular Torsion." Nursing 30 (April 2000): 33.

Organizations

American Urological Association. 1000 Corporate Blvd., Linthicum, MD 21090. Web site: www.auanet.org.

Web Sites

Paushter, David. "Testicular Torsion." eMedicine, July 20, 2004. Available online at www.emedicine.com/radio/topic683.htm (accessed December 1, 2004).

[Article by: Tish Davidson, A.M. Ricker Polsdorfer, MD]

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

Testicular torsion is when the spermatic cord to a testicle twists, cutting off the blood supply. The most common symptom is acute testicular pain and the most common underlying cause is a congenital malformation known as a "bell-clapper deformity". The diagnosis is often made clinically but if it is in doubt an ultrasound is helpful in ruling in or out the condition. Emergency diagnosis and treatment is required in order to save the viability of the testicle.

Contents 1 Signs and symptoms 2 Risk factors 2.1 Congenital 2.2 Size 2.3 Temperature 3 Diagnosis 3.1 Clinical exam 3.2 Imaging 4 Pathophysiology 5 Treatment 6 Epidemiology 7 References 8 External links

Signs and symptoms

Testicular torsion usually presents with an acute onset of diffuse testicular pain and tenderness of less than 6 hours of duration. There is often an absent or decreased cremasteric reflex.^[1] Many of the symptoms of testicular torsion are similar to the infection epididymitis.

Risk factors

Congenital

Conditions that allow the testicle to rotate predispose to torsion.^[2] A congenital malformation of the processus vaginalis known as the "bell-clapper deformity" accounts for 90% of all cases.^[3] 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.

Size

A larger testicle either due to normal variation or a tumor increases the risk of torsion.^[2]

Temperature

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.^[4]

Diagnosis

Immediate testing for torsion is indicated when the onset of testicular pain is sudden and/or severe. In general a doppler ultrasound should be obtained only in low suspicion cases to rule out torsion while in those cases with a convincing history and physical exam immediate surgical detorsion (Derotation) is reasonable.^[2]

Clinical exam

Prehn's sign though a classic physical exam finding has not been found to be reliable in distinguishing torsion from other causes of testicular pain such as epididymitis.^[5] 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.^[2]

Imaging

A doppler ultrasound scan of the scrotum is nearly 100% accurate at detecting torsion.^[2] It is identified by the absence of blood flow in the twisted testicle, which distinguishes the condition from epididymitis.^[6]

Pathophysiology

Torsion is due to a mechanical twisting process. 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).^{[citation needed]}

Treatment

With prompt diagnosis and treatment the testicle can be saved in a high number of cases.^[2] In some cases the testicle can untwist on its own or it can 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.^[7]

Testicular torsion is a surgical emergency that needs immediate intervention.^[2] If treated within 6 hours, there is an excellent chance (90%) of saving the testicle. Within 12 hours the rate decreases to 50%, within 24 hours is 10%, and after 24 hours the rate approaches 0.^[2] Once the testicle is dead it must be removed to prevent gangrenous infection.

Epidemiology

Torsion is most frequent among adolescents with about 65% of cases presenting between 12 – 18 years of age.^[8] It occurs in about 1 in 160 males or 1 in 4000 males per year before 25 years of age.^[2][3]

References

1. ^ Karmazyn B, Steinberg R, Kornreich L et al (March 2005). "Clinical and sonographic criteria of acute scrote in children: a retrospective study of 172 boys". Pediatr Radiol 35 (3): 302–10. doi:10.1007/s00247-004-1347-9. PMID 15503003. 
2. ^ ^{a b c d e f g h i} 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. 
3. ^ ^{a b} Ringdahl E, Teague L (November 2006). "Testicular torsion". Am Fam Physician 74 (10): 1739–43. PMID 17137004. 
4. ^ "Climatic Conditions and the Risk of Testicular Torsion in Adolescent Males". Jurology.com. http://www.jurology.com/article/S0022-5347%2807%2902056-3/abstract. Retrieved 2011-09-28. 
5. ^ Lavallee ME, Cash J (April 2005). "Testicular torsion: evaluation and management". Curr Sports Med Rep 4 (2): 102–4. PMID 15763047. 
6. ^ 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. 
7. ^ "Testicular Torsion in Emergency Medicine". Emedicine.medscape.com. http://emedicine.medscape.com/article/778086-treatment. Retrieved 2011-09-28. 
8. ^ Edelsberg JS, Surh YS (August 1988). "The acute scrotum". Emerg. Med. Clin. North Am. 6 (3): 521–46. PMID 3292226. 

External links

• Photos of swollen, excised, and detorsed testicles of patient who sought treatment within four hours of onset of pain.

v d e Male diseases of the pelvis and genitals (N40–N51, 600–608) Internal Testicular Orchitis · Hydrocele testis · Testicular cancer · Testicular torsion · Male infertility (Azoospermia, Oligospermia) Epididymis Epididymitis · Spermatocele · Hematocele Prostate Prostatitis (Acute prostatitis, Chronic bacterial prostatitis, Chronic prostatitis/chronic pelvic pain syndrome, Asymptomatic inflammatory prostatitis) · Benign prostatic hyperplasia External Penis Balanoposthitis/Balanitis · Phimosis · Priapism · Sexual dysfunction (Erectile dysfunction) · Peyronie's disease · Penile cancer · Penile fracture · Balanitis xerotica obliterans Other Hematospermia · Retrograde ejaculation M: ♂ MRS anat/phys/devp noco/cong/tumr, sysi/epon proc, drug (G3B/4BE/4C)

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