- SURGICAL EMERGENCY
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.
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
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
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.
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.
- High-riding testicle: Indicate twisted, foreshortened spermatic cord
- 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
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
- Scrotal whirlpool sign: Spiral-like pattern of the spermatic cord and is virtually pathognomonic of testicular torsion
- Redundant spermatic cord sign, where the spermatic cord appears torturous, indicating an abnormality in the attachment of the tunica vaginalis
- Horizontal lie of testes: Indicative of the clapper-bell deformity
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.
- 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
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
Orchidopexy:If the affected testicle is deemed viable, orchiopexy with permanent suture should be performed to permanently fix the testicle within the scrotum.
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.