Testicular Torsion

Question 1

Define testicular torsion

Answer 1

Urological emergency caused by twisting of the testicle on the spermatic cord, leading to constriction of the vascular supply and time-sensitive ischaemia and/or necrosis of testicular tissue

Question 2

What is the pathophysiology/aetiology of testicular torsion

Answer 2

The testicle travels through the inguinal canal that is covered by peritoneum, the tunica vaginalis
Intra-vaginal torsion is the most common type of torsion due to the abnormally high attachment of the tunica vaginalis to the spermatic cord, allowing rotation of the testicle within the sac.

Question 3

What is the epidemiology of testicular torsion

Answer 3

Most common in post-pubertal boys, but may occur at any age, including the newborn
Common in young males (11-22), rare >35 year olds
Extra-vaginal torsion affects neonates in the perinatal period

Question 4

What are the risk factors for testicular torsion

Answer 4

Bell Clapper (intra-vaginal), testis lying transversely on its attachment to the spermatic cord
Young male <25 (post-pubertal)
Neonates
Trauma/exercise, intermittent testicular pain, undescended testicle, cold weather

Question 5

What are the symptoms of testicular torsion

Answer 5

Sudden onset testicular pain
- Extremely painful
- May be localised to the groin, scrotum or lower abdomen
- Often Hx of trauma, no Hx of sexual activity
- May be intermittent (torsion and de-torsion)
- No relief on elevation of the scrotum
Testicular swelling and redness
Nausea and vomiting
Malaise
Abdominal pain

Question 6

What are the differentials for testicular torsion

Answer 6

Epididymo-orchitis
Idiopathic scrotal oedema
Incarcerated hernia
Trauma
Hydrocoele
Varicocoele
Testicular cancer

Question 7

What are the signs of testicular torsion on examination

Answer 7

Obs: Fever
Testicular exam
- Erythema and oedema of scrotal skin
- Tenderness
- High-riding, erythematous swollen testicle
- No relief of pain on scrotal elevation
- Horizontal lie (testicle is horizontal)
- Absent cremasteric reflex

(“blue dot” sign suggests testicular appendix torsion)

Question 8

What investigations should be done for testicular torsion

Answer 8

None - should refer for urgent scrotal exploration
Can do urine microscopy in the meantime to exclude epididymo-orchitis

Bedside: urinalysis
Bloods: FBC, CRP
Other:
- USS: presence of fluid and whirlpool sign (swirling appearance of spermatic cord from torsion)
- US doppler: Absent or decreased blood flow in the affected testicle
- Spectral doppler: non-homogeneous and/or asymmetrical vascular perfusion compared with the unaffected testis
- Scintigraphy: decreased uptake of radioactive technetium-99m to the affected testicle in patients with testicular torsion.

Question 9

What is the management for testicular torsion

Answer 9

Must be treated within hours of the onset of symptoms to lower risk of testicular loss

1. Immediate urological consultation for emergency scrotal exploration
   - Urgent BILATERAL scrotal exploration and orchidoplexy
   - Consent for orchidectomy
   - Fixation of BOTH testis (due to increased risk of contralateral torsion)
2. Analgesia: morphine + ondansteron
3. Manual de-torsion if surgery not available or waiting for surgery: Open-book method - rotating the right testicle counter-clockwise and the left testicle clockwise

Question 10

What are the complications of testicular torsion

Answer 10

Infarction and necrosis of testicle leading to permanent damage or loss
Infertility due to loss of testicle
Psychological implications and cosmetic deformity
Recurrent torsion
Impaired pubertal development

Question 11

What is the prognosis for testicular torsion

Answer 11

Testicle is salvageable if <8 hours from onset (100% <6h), but salvageability rapidly drops as time progresses
Outcome is variable, depending on time of correction
Perinatal testicular torsion - testicular loss is almost inevitable
Recurrent torsion may develop in patients with a past history of testicular fixation
Can offer prosthetic device to avoid cosmetic and psychological impacts

Question 12

Describe torsion of the appendix testis

Answer 12

A testicular appendage (hydatid of Morgagni) is a Mullerian remnant usually located on the upper pole of the testis.
Torsion of the appendix testis tends to affect prepubertal boys and is more common than torsion of the testis.
Pain evolves over days, but is not as dramatic as in testicular torsion.
Scrotal exploration and excision of the appendage is often necessary because it cannot be differentiated reliably from torsion of the testis.
If a ‘blue dot’ can be seen through the scrotal skin and pain is controlled with analgesia, surgery may not be necessary