Testicular torsion

Question 1

Pathophys of testicular torsion

Answer 1

• Mobile testes rotates on spermatic cord
• = reduced arterial flow, impaired venous return, venous congestion, oedema and then infarction of testes if not corrected

Question 2

What is ‘bell clapper’ deformity?

Answer 2

• Anatomical variant
• Testis dont have a normal attachment to tunica vaginalis, tunica vaginalis attaches high
• Therefore more mobile so more risk of twisting

Question 3

What is neonatal testicular torsion?

Answer 3

• Attachment between scrotum and tunica vaginalis is not fully formed
• Entire testes and tunica vaginalis can twist = extra-vaginal torsion
• Can occur in utero and new borns need to be examined
• All other torsions are intra-vaginal with the freely moving cord and testes torting within vaginalis

Question 4

RF for testicular torsion

Answer 4

• Age - 12-25 most common
• Previous torsion (previous non specific testicular pain that self resolved could be this)
• FH of testicular torsion
• Undescended testes

Question 5

Symptoms of testicular torsion

Answer 5

• Sudden onset
• Severe unilateral testicular pain
• N+V secondary to pain
• Can get referred pain to abdomen

Question 6

Examination findings for testicular torsion

Answer 6

• High position testis - compared to contralateral side
• Horizontal lie
• Swollen
• Tender
• Cremasteric reflex absent
• Prehns sign negative

Question 7

Differentias for testicular pain

Answer 7

• Epididymo-orchitis - more gradual, LUTS +/- pyrexia
• Inguinal hernia
• Testicular cancer
• Renal colic
• Torsion of hydatid of Morgagni

Question 8

What is hydatid of morgagni?

Answer 8

• Remnant of Mullerian duct
• Common testicular appendage
• Can become torted - similar onset pain to testicular torsion
• Blue dot sign may be present - infarcted hydatid

Question 9

Investigations testicular torsion

Answer 9

• Clinical diagnosis - straight to theatre for scrotal exploration
• If uncertain if scrotal exploration will be beneficial - Doppler USS can investigate compromised blood flow
• Urine dip can assess for infection - rule out differentials

Question 10

Management testicular torsion

Answer 10

• Urgent surgical exploration of testes - surgical emergency
• Untwist and bilateral orchidopexy - fix testes to scrotum
• If non-viable testis - orchidectomy, prosthesis inserted at the time or later date

Question 11

Complications testicular torsion

Answer 11

• Infarction
• Affected testes –> atrophy after treatment
• Post surgery - chronic pain, palpable suture, risk to fertility, future torsion despite fixation

Question 12

Time to fix torsion

Answer 12

• Rates for salvage are good if surgery done within 6hrs of pain onset
• Drop to 50% if present symptoms for more than 12 hrs