Testicular torsion occurs when the spermatic cord twists within the tunica vaginalis, resulting in ischemia to the epididymis and the testis. Testicular torsion may occur in the absence of a preceding event or after minor trauma. Patients typically experience acute severe pain that may be accompanied by nausea and vomiting. | Testicular Torsion: Jorge Muniz, PA-C
Contents
Twisting of spermatic cord of testes compromising blood supply.
SURGICAL EMERGENCY
Epidemiology
Testicular torsion is a twisting of the spermatic cord and its contents and is a surgical emergency affecting 3.8 per 100,000 males younger than 18 years annually. It accounts for 10% to 15% of acute scrotal disease in children, and results in an orchiectomy rate of 42% in boys undergoing surgery for testicular torsion. Prompt recognition and treatment are necessary for testicular salvage, and torsion must be excluded in all patients who present with acute scrotum.
Etiopathogenesis
Risk factors:
The majority of cases occur in younger patients (< 25 years old) and are usually due to a congenital abnormality of the processus vaginalis. The history of onset may be spontaneous, exertional, or, in fewer instances, associated with trauma. Testicular torsion accounts for roughly one-quarter of scrotal complaints that present to the emergency department.
Inversion of testes (M/C predisposing factor)
Bell clapper deformity: High investment of tunica vaginalis
Undescended testis
Separation of epididymis from body of testes
The bell-clapper deformity with abnormal fixation of the tunica vaginalis to the testicle. | Sharp, V. J., Kieran, K., & Arlen, A. M. (2013). Testicular torsion: diagnosis, evaluation, and management. American family physician, 88(12), 835–840.
Presentation
Classic presentation:
The classic presentation of testicular torsion is sudden onset of severe unilateral testicular pain associated with nausea and vomiting.
Sudden agonising pain: In groin & lower abdomen
Nausea/vomiting
Other features:
Although there are no clear precipitating factors, many patients describe a recent history of trauma or strenuous physical activity.
Non-specific symptoms: Fever or urinary problems.
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Physical examination:
The ipsilateral scrotal skin may be indurated, erythematous, and warm, although changes in the overlying skin reflect the degree of inflammation and may change over time.
Ipsilateral scrotal skin: Indurated, erythematous, and warm
Differentiating tests from epididymo-orchitis:
Deming sign: High testes (lower in epididymo-orchitis)
Prehn sign: Pain increases on lifting testes (reduces on epididymo-orchitis)
Angel sign: Testes transversely placed
Diagnosis
Testicular torsion is a clinical diagnosis, and patients typically present with severe acute unilateral scrotal pain, nausea, and vomiting. Physical examination may reveal a high-riding testicle with an absent cremasteric reflex.
Urgent USG:
Ultrasound is the ideal imaging modality to evaluate the scrotal contents.
Reduced/absent doppler color or waveforms
Parenchymal heterogeneity compared with contralateral testis
Side-by-side US with Doppler imaging: Note the decreased Doppler flow of the left testicle indicating a torsion of the left testicle. Original image by Dr. Allison Tadros (photo courtesy of WVU Department of Radiology). Used under the Creative Commons Attribution-ShareAlike 4.0.
Scrotal whirlpool sign: Spiral-like pattern of the spermatic cord and is virtually pathognomonic of testicular torsion
“Whirlpool sign” of the spermatic cord. (A) Gray-scale transverse US image of upper left scrotal sac shows an eddy swirl (arrow) of the spermatic cord suggesting torsion of the cord. This 12-year-old boy woke with acute left testicular pain and experienced nausea and vomiting along with the pain. (B) Power Doppler US image of the same twisted cord shows concentric pattern of preserved flow in the vessels of the twisted cord. The flow in the left testis (not shown) was minimally decreased compared to the right side and bilateral bell clapper deformity was found during orchiopexy along with complete torsion of the left testis with 360° twist. (C) Gray-scale longitudinal US image of the left scrotum in a 13-year-old boy with 1 day of left-side pain shows abrupt spiral twisting of the spermatic cord (arrow) at the external inguinal ring, creating a whirlpool sign. (D) Color Doppler transverse image of the testes in the same boy as in (C) shows preserved and symmetrical flow bilaterally. After manual detorsion in the emergency room, he underwent orchiopexy and was diagnosed with intermittent torsion. | Bandarkar AN, Blask AR. Testicular torsion with preserved flow: key sonographic features and value-added approach to diagnosis. Pediatr Radiol. 2018;48(5):735–744. doi:10.1007/s00247-018-4093-0.27 Distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/)
Redundant spermatic cord sign, where the spermatic cord appears torturous, indicating an abnormality in the attachment of the tunica vaginalis
Intermittent torsion in a 17-year-old boy who presented with 5 h of acute right testicular pain after a game of football. He had experienced 6–7 similar episodes in the last 2 years where the pain had spontaneously resolved. Cremasteric reflex was absent on the right. (A) Gray-scale transverse US image of the right testis shows a redundant spermatic cord (arrow) occupying the medial half of the scrotal sac, with a mildly edematous epididymis (E) adjacent to it. The echogenic mediastinum testis faced medially instead of posterolaterally, which was concerning for altered testicular lie. (B) Color Doppler longitudinal image of the right scrotum shows excess and tortuous spermatic cord bunched up in the scrotal sac superior to the testis and formation of a pseudomass, suggesting torsion of the spermatic cord. Note that this extratesticular pseudomass is not hyperemic and should not be confused with epididymitis. Orchiopexy was recommended; however, the family chose to wait because his pain had improved. Elective orchiopexy was performed 7 months later and bilateral bell clapper anomaly was noted; he was diagnosed with intermittent torsion. | Bandarkar AN, Blask AR. Testicular torsion with preserved flow: key sonographic features and value-added approach to diagnosis. Pediatr Radiol. 2018;48(5):735–744. doi:10.1007/s00247-018-4093-0.27 Distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/).
Horizontal lie of testes: Indicative of the clapper-bell deformity
Testicular lie—normal and abnormal. (A) Color Doppler transverse US image of the testes in a 12-year-old boy with mild groin pain demonstrates normal vertical lie with the testes seen in round cross-section and with the mediastinum testis (arrows) directed posterolaterally. (B) Color Doppler transverse US image of both testes in a 14-year-old boy who woke with acute right scrotal pain demonstrates abnormal horizontal lie of the right testis (arrow) with slightly decreased intratesticular flow compared to the normal left side. He had experienced similar episodes of pain in the past and was diagnosed with intermittent torsion. During orchiopexy 12 h later, a bell clapper deformity was noted bilaterally. (C) Gray-scale transverse US image of both testes in a 16-year-old boy with right testicular pain demonstrates abnormal oblique lie of the right testis (arrows), which is oriented diagonally compared to the normal left side. Intermittent torsion was diagnosed intraoperatively. | Bandarkar AN, Blask AR. Testicular torsion with preserved flow: key sonographic features and value-added approach to diagnosis. Pediatr Radiol. 2018;48(5):735–744. doi:10.1007/s00247-018-4093-0.27 Distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/)
Differential diagnosis:
Acute scrotum is defined as a sudden painful swelling of the scrotum or its contents, accompanied by local signs or systemic symptoms. In a patient presenting with acute scrotum, it is imperative to rule out testicular torsion, which is a true surgical emergency.
Epididymo-orchitis
Orchitis of chord (in mumps): Often bilateral
Idiopathic scrotal oedema: Bilaterally swollen scrotum with little pain
Small tense strangulated hernia: Compressing cord and causing compression of pampiniform plexus
Acute Scrotum Algorithm | Acute Scrotum Algorithm. (2021, August 25). Manual of Medicine. https://manualofmedicine.com/topics/emergency-acute-medicine/acute-scrotum-algorithm/
Management
Testicular torsion is a time-dependent diagnosis, a true urologic emergency, and early evaluation can assist in urologic intervention to prevent testicular loss. Surgery is the only treatment.
Testicular tissue viability:
There is typically a 4 to 8-hour window before significant ischemic damage occurs, manifested by morphologic changes in testicular histopathology and deleterious effects on spermatogenesis. Altered semen parameters and potential decreased fertility secondary to increased permeability of the blood-testicle barrier may not normalize even after blood flow has been successfully restored. The viability of the testicle in cases of torsion is difficult to predict; hence, emergent surgical treatment is indicated despite many patients presenting beyond the 4 to 8-hour time frame. Reported testicular salvage rates are 90% to 100% if surgical exploration is performed within 6 hours of symptom onset, decrease to 50% if symptoms are present for more than 12 hours, and are typically less than 10% if symptom duration is 24 hours or more.
< 6 hours: 100% testicular salvage
6-12 hours: 50% testicular salvage
12-24 hours: 20% testicular salvage
> 24 hours → Testicular necrosis: Orchiectomy
Manual detorsion maneuver:
Manual detorsion can be performed but should not be used to delay surgery because the maneuver can inadvertently twist the cord further, causing worse ischemia, or incompletely untwist, resulting in partial torsion. Intervention within 8 hours is critical to prevent permanent testicular loss or atrophy from compromised testicular arterial flow
Manual detorsion maneuver for testicular torsion: With the physician facing the patient, the right testis is rotated clockwise while the left is rotated counterclockwise. This is referred to as the “open book” maneuver, as the movement is akin to opening a book. (Artwork by Dr. Amanda Webb) | Thomas, S. Z., Diaz, V. I., Rosario, J., Kanyadan, V., & Ganti, L. (2019). Emergency Department Approach to Testicular Torsion: Two Illustrative Cases. Cureus, 11(10), e5967. https://doi.org/10.7759/cureus.5967
Orchidopexy:
If the affected testicle is deemed viable, orchiopexy with permanent suture should be performed to permanently fix the testicle within the scrotum.
Torsed testicle with twisting of the spermatic cord visualized. | Sharp, V. J., Kieran, K., & Arlen, A. M. (2013). Testicular torsion: diagnosis, evaluation, and management. American family physician, 88(12), 835–840.
Orchiectomy:
Performed if affected testicle grossly necrotic or nonviable. Orchiectomy rates vary widely in the literature, typically ranging from 39% to 71% in most series. Age and prolonged time to definitive treatment have been identified as risk factors for orchiectomy.
