Testicular Torsion

Patients present with pain of sudden onset.

TTs most common symptom in children is sudden, severe testicular pain.

It usually presents with severe testicular pain or pain in the groin and lower abdomen.

Pain generally begins suddenly and typically is unilateral.

It is often associated nausea and vomiting.

The testicle may lie higher in the scrotum due to twisting and subsequent shortening of the spermatic cord or may be positioned in a horizontal orientation. 

The testis can be swollen, tender, high-riding, and with an abnormal transverse lie.

Clinically, warmth and redness of the overlying area may be present. 

Elevating the testicle may worsen the pain. 

Urinary symptoms are typically absent.

Symptom onset often follows physical activity or trauma to the testes or scrotum. 

TT in children may cause awakening  or abdominal pain in the middle of the night or in the morning.

Some patients have a history of previous similar episodes of scrotal pain due to prior transient testicular torsion,  with spontaneous resolution.

It is most common just after birth and during puberty.

A urologic emergency which is more common in neonates and postpubertal boys.

It occurs in about 1 in 4,000 to 1 in 25,000 males under 25 years of age each year.

It is the most common cause of rapid onset testicular pain and swelling in people under 18 years old.

Torsion is most frequent among adolescents with about 65% of cases presenting between 12–18 years of age.

In children with testicular pain of rapid onset, testicular torsion is the cause of about 10% of cases.

Requires early surgical intervention to prevent testicular infarction.

Torsion of an undescended testes within the abdomen is rare.

The testicle may be positioned higher than usual in the scrotum.

Vomiting may occur.

In newborns, the scrotum may become discolored or the testicle may disappear from its usual place, and pain may not be appreciated.

Treatment is  the physical untwisting of the testicle by surgery.

With rapid treatment the prognosis is good.

Frequency is 1 in 15,000 per year, under 25 years old.

Most affected patients are in good health.

A  testicular tumor or prior trauma may increase the risk.

Other risk factors include:  a congenital malformation where  the testis is inadequately attached to the scrotum allowing it to move more freely and thus potentially twist, and cold temperatures.

This congenital malformation of the processus vaginalis known as “bell-clapper deformity” accounts for 90% of all cases.

In this congenital condition, rather than the testes attaching posteriorly to the inner lining of the scrotum by the mesorchium, it terminates early and the testis is free floating in the tunica vaginalis. 

The diagnosis  is made based on the presenting symptoms.

The diagnosis  requires a timely diagnosis and treatment to avoid testicular loss.

Ultrasound can be useful when the diagnosis is unclear.

Treatment involves physically untwisting the testicle, if possible, followed by surgery.

Outcome is related to the time to correction.

Treatment within six hours is associated with a good outcome.

Delayed treatment of 12 or more hours will result in a testicle that is typically not salvageable. 

About 40% of people require orchiectomy.

Testicular infarction occurs as a consequence of decreased blood flow, and therefore decreased oxygen and nutrient supply, to the testicle. 

Complications may include infertility.

TT may cause abnormal sperm function which are more likely to be found in adolescents and in adults, but does not seem to affect long-term sperm function in neonates.

It is theorized that following injury to the testicle, the body’s immune system creates anti-testicular cell antibodies, or proteins that cross the injured blood-testis barrier and damage both the affected and contralateral testicles.

In extremely rare cases (0,03%), delayed treatment could lead to sepsis and cause severe life-threatening infections.

Testicular torsion often occurs before or during puberty, prior to complete testicular descent. 

Congenital anatomic malformations or variations in the testicle or the surrounding structures may permit increased scrotal rotation and increase the risk of testicular torsion.

Intravaginal testicular torsion occurs when the testicle rotates on the spermatic cord within the tunica vaginalis.

Intravaginal testicular torsion occurs 

more commonly in older children and adults. 

With the  “bell-clapper deformity,” there is inappropriately high attachment of the tunica vaginalis over the spermatic cord and failure of the normal posterior attachment of the testicle to the inner scrotum, allowing the testicle to move freely within the tunica vaginalis and be predisposed to intravaginal testicular torsion.

Additionally, anatomic risk factors include horizontal lie of the testicle or a spermatic cord with a long intrascrotal portion.

Cryptorchidisim risk factor for torsion

 is as high as 10-fold higher risk.

Only 4-8% of TT cases are the result of trauma: to the scrotum or exercise, in particular, bicycle riding.

There is a possible genetic basis for predisposition to torsion, based on multiple reports of familial testicular torsion.

Controversy exists over whether cold weather months are associated with an increased risk.

The degree of arterial and venous obstruction depends on the duration and severity of the torsion.

Venous blood flow is usually compromised first.

The increase in venous pressure subsequently causes decreased arterial blood flow, leading to decreased oxygen supply to the testicle, and if untreated, testicular infarction.

Torsion during fetal development can lead to so-called neonatal torsion or vanishing testis.

This process is one of the causes of an infant being born with one testicle.

A chronic variant of torsion is intermittent testicular torsion a less serious variant.

Intermittent testicular torsion is 

characterized by intermittent scrotal or testicular pain, followed by eventual spontaneous detorsion and resolution of pain. 

Intermittent testicular torsion may be associated with nausea and vomiting.

Patients with intermittent testicular torsion are at significant risk of complete torsion and possible subsequent orchiectomy and the recommended treatment is elective bilateral orchiopexy. 

Ninety-seven percent of patients who undergo such surgery experience complete relief from their symptoms.

Torsion occurring outside of the tunica vaginalis, when the testis and gubernaculum can rotate freely, is termed an extravaginal testicular torsion. 

Extravaginal testicular torsion type occurs exclusively in newborns.

Newborns can be affected by other testicular torsion variants as well.

Neonates experiencing testicle torsion, typically present with painless scrotal swelling, discoloration, and a firm, painless mass in the scrotum. 

Testes with neonatal torsion are usually necrotic from birth and must be removed surgically.

The testicular appendix, an embryonic remnant, is located in the upper pole of the testicle, and is at risk for torsion.

The testicular appendix type of torsion is the most common cause of acute scrotal pain in boys ages 7–12.

The testicular appendix type of torsion 

onset of pain is typically gradual. 

On palpation there is a small firm nodule on the upper portion of the testis which displays a characteristic “blue dot sign”. 

The appendix of the testis which has become discolored and is noticeably blue through the skin. 

The testicular appendix type of torsion 

has a persistent cremasteric reflex.

Typical treatment involves the use of over-the-counter analgesics and the condition resolves within 2–3 days.

An undescended testis is at increased risk of testicular torsion, due to the increased weight and size compared to a healthy testicle.

Torsion in the undescended testicle is may be due to abnormal contractions of the cremaster muscle, which is responsible for raising and lowering the testicle to regulate scrotal temperature. 

The diagnosis is made basis of presenting symptoms.

An ultrasound can be useful when the diagnosis is unclear.

Immediate surgery is recommended regardless of imaging findings if there is a high degree of suspicion based on history and physical examination.

It is important to distinguish testicular torsion from epididymitis, which can present similarly. 

The pain of epididymitis is typically localized to the epididymis at the rear pole of the testicle. 

Epididymitis may be characterized by discoloration and swelling of the testis, and fever. 

The cremasteric reflex in epididymitis is usually present. 

The absence of the cremasteric reflex in an acutely painful testicle is most indicative of testicular torsion.

The twisting of the spermatic cord of the testicle makes reflexive responses unlikely.

By stroking the inner thigh, the cremasteric reflex causes elevation of the testicle 

The cremasteric reflex absence is especially common in children.

An ultrasound scan of the scrotum can identify the absence of blood flow in the twisted testicle and is nearly 90% accurate in diagnosis.

An ultrasound scan of the scrotum can 

help distinguish torsion from epididymitis.

Radionuclide scanning of the scrotum is the most accurate imaging technique, using technetium-99m pertechnetate.

In testicular torsion, the images may show heterogenous activity within the affected testicle.

Testicular torsion is a surgical emergency that requires immediate intervention to restore the flow of blood to the testicle.

If treated within six hours, there is a high chance of approximately 90%of saving the testicle. 

If treated  at 12 hours the rate decreases to 50%; at 24 hours it drops to 10%, and after 24 hours the ability to save the testicle approaches 0.

About 40% of cases result in loss of the testicle.[2]

Torsion results in the surface of the testicle has rotated towards the midline of the body. 

Correction can sometimes be accomplished by manually rotating the testicle in the opposite direction.

A repeat doppler ultrasound scan may confirm restoration of blood flow to the testicle following manual detorsion. 

The success rate of manual detorsion is not known with confidence.

Long-term testicular damage is common: Testicular size is often diminished, and injury to the unaffected testicle is common

An orchiopexy is performed to both the affected and unaffected testicles in order to prevent recurrence. 

If the testis is not viable, it is orchiectomized.