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Testicular torsion

Testicular torsion is a twist of the spermatic cord leading to cessation of testicular blood flow , ischaemia and infarction if left untreated Occurs most often in the neonatal period and around puberty ( bimodal with two peaks ) More common at puberty 
○ peak incidence 13-15 yrs of age
but it can occur in any age group Left > common than right Incidence in men < 25 yrs is 1 in 4000  intravaginal-Most common type Anatomic anomaly- Bell clapper deformity-↑↑ testicular mobility In adolescents and older males B/L in 40 % cases Extravaginal-More often in neonates In utero or around time of birth Both the spermatic cord & tunica vaginalis undergo torsion together – in or just below the inguinal canal

When the testis twists around the spermatic cord venous blood supply is cut off leading
 to venous congestion and ischaemia of the testicle which becomes swollen, tender and possibly erythematous


Testicle twists further compromising arterial blood supply with eventual testicular ischaemia and necrosis

PresentationPain, duration , severity Speed of onset- sudden or gradual What was the patient doing when pain started Previous episodes – self limiting pain and swelling Other symptoms
○ LUTS
○ urethral discharge
○ parotid swelling –> mumps orchitis
○ back pain , breathlessness or weight loss –> metastatic testicular cancer H/O Trauma Sexual history Sudden onset hemiscrotal pain→ acute and excruciating Can sometimes wake the patient up from sleep Scrotal swelling , nausea and vomiting Pain may radiate to loin , groin or the epigastrium Poorly localized abdominal pain Sometimes h/o minor trauma to testis Pain may be intermittent – suggesting torsion and detorsion Patient may have slight fever but generally no urinary symptoms Usually unilateral Torsion in undescended testis is more common ( ten times ) and is more on left

Differential diagnosisStrangulated hernias
 Torsion of testicular appendage- can mimick testiclar torsion
○ ischaemia of cyst of Morgagni
○ onset gradual
○ blue dot sign
○ localised pain at upper pole of testes
○ abscence of nausea and vomiting
○ cremasteric reflex present

Clinical differentiation can be extremely difficult and advisable to manage as torsion – ie admit immediately
 Epididymo-orchitis
○ tender epididymis
○ isolated orchitis is rare
○ fever
○ history of dysuria , frequency and foul smelling urine may suggest epididymo-orchitis 2ary to UTI
○ urethritis , penile discharge ( often absent ) may indicate epididymo-orchitis 2 ary to a STI
○ mumps infection can cause epididymo-orchitis at any age
 Varicocele Scrotal trauma Appendicitis ( paediatric age group ) Inguinal hernia Testicular cancer Hydrocele ( acute ) Idiopathic scrotal oedema Scrotal vasculitis – usually 2ary to HSP Referred pain

ExaminationPosition size and symmetry of testes Skin- erythema Blue dot sign
○ tender nodule with blue discloloration on the upper pole of testes
○ can help in diagnosing- torsion of appendix of testis Check cremasteric reflex Examine and determine site of max tenderness
○ testes –> torsion testes
○ epididymis–> acute epididymitis
○ upper pole of testes–> torsion appendix testes Abdominal and inguinal examintion ( r/o hernia , appendicitis ) Testis usually swollen and exquisitely tender Affected testis tends to be retracted and highter in scrotum and usually horizontal Examination may not be possible due to pain Cremasteric reflex – absent
○ most sensitive clinical finding
○ What is it – stroking or pinching the medial thigh normally causes contraction of cremaster muscle –> elevation of testis
○ presence of reflex suggests but does not confirm absence of testicular torsion Scrotal skin can become red and edematous Parotid swelling –> mumps orchitis Infants and young children may have no signs
○ testicular swelling non-tender and hard at birth


True surgical emergency Admit immediately – urology or surgery Prompt restoration of blood supply to testicle is critical Irreversible ischaemic injury can begin within 4 hrs of spermatic cord occlusion
○ reduced fertility
○ death of testicle Complete testicular atrophy in most cases after 24 hrs Detorsion witthin 6 hrs –> salvage rate of 90-100 % Treatment is surgical -
○ orchidopexy ( if viable)
○ contraleteral testes must also be fixed
○ orchidectomy

Have a very low thresold for suspecting testicular torsion Testicular torsion can
 be difficult to exclude if 
symptoms atypical or intermittent- must be considered in 
all cases of scrotal pain

Complications -Testicular death- loss Infection Infertility Cosmetic deformity

LINKS AND RESOURCES

PATIENT INFORMATION

Urology Care Foundation on testicular torsion https://www.urologyhealth.org/urologic-conditions/testicular-torsion

Kidhealth org https://kidshealth.org/en/teens/torsion.html

British Association of Urological Surgeons leaflet https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Torsion%20of%20testis.pdf

American Pediatric Surgical Association https://eapsa.org/parents/learn-about-a-condition/p-z/testicular-torsion/

INFORMATION FOR CLINICIANS

Society of Academic Emergency Medicine  a review of testicular torsion- https://www.saem.org/cdem/education/online-education/m4-curriculum/group-m4-genitourinary/testicular-torsion

CORE EM article on torsion by Dr Swaminathan MD a good read to enhance your knowledge https://coreem.net/core/testicular-torsion/

Surgical management of testicular torsion GAJBHIYE, Ashok Suryabhanji et al. Surgical management of testicular torsion. International Surgery Journal, [S.l.], v. 3, n. 1, p. 195-200, dec. 2016. ISSN 2349-2902. Available at: <https://www.ijsurgery.com/index.php/isj/article/view/541>. Date accessed: 18 jan. 2020. doi:http://dx.doi.org/10.18203/2349-2902.isj20160225.

Ultrasound video on torsion https://www.youtube.com/watch?v=01zce5o-D58

International Emergency Medicine Educational Project Testicular torsion https://iem-student.org/testicular-torsion/

Acute Scrotal Pain article by Australian Family Physician https://www.racgp.org.au/afp/2013/november/acute-scrotal-pain/

 

References
 Testicular torsion : Diagnosis Evaluation , and Management Am Fam Physician.2013 Dec 15;88 (12):835-840 Testicular Torsion in Emergency Medicine Timothy J Rupp , MD et al Medscape Aug 2015 The management of acute testicular pain in children and adolescents BMJ 2015;350:h1563 Easily Missed ? Testicular torsion BMJ 2010;341:c3213 Testicular Torsion Ferri’s Clinical Advisor 2017 CKS NHS Scrotal swellings Feb 2010 Testicular lumps and swellings- Causes NHS Choices Guidelines on Paediatric Urology European Society for Paediatric Urology European Association of Urology 2015 Testicular torsion: a race against time The International Journal of Clinical Practice 10.1111/j.1742-1241.2008.01727.x Testicular torsion Sabiston Textbook of Surgery Smith, Thomas Gillispie;Coburn,Michael. Published January 2017 Testicular torsion Seidels Guide to Physical Examination Ball et al Jan 2015 Torsion of the testis and testicular appendages Oxford Handbook of Urology Oxford University Press Testicular Torsion Am Fam Physician .2006 Nov 15;74 (10):1739-1743 Stat Pearls Testicular torsion accessed via https://www.statpearls.com/kb/viewarticle/29993



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