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Testicular Torsion

Spermatic Cord Torsion

Testicular torsion is defined as a torsion of the spermatic cord resulting in the loss of blood supply to the testicle. 


Presentation

Intravaginal testicular torsion brings about a sudden onset of sever unilateral scrotal pain which is often followed by inguinal and/or scrotal swelling [7]. Gradual onset of pain is an uncommon presentation. Torsion may happen following physical activity or sports. It can also be related to trauma in around 4 to 8% of cases. It can also develop spontaneously.

Generally, one third of patients present with gastrointestinal upset followed by nausea and vomiting. In the pediatric group, nausea and vomiting often leads to a positive diagnosis 96% of the time.

Crying
  • Discuss with Paediatric surgeon Incarcerated hernia Intermittent inguinoscrotal swelling, associated irritability Pain Worse with crying Nausea and Vomiting – if bowel entrapment Firm, tender, irreducible inguinoscrotal swelling Requires reduction as[rch.org.au]
Hypoxemia
  • Special attention needs to be paid in the event of fetal distress without obvious hypoxemia as antenatal testicular torsion may have been the cause of distress. In general, increased awareness by both caregivers and parents seems mandatory. 4.[doi.org]
Abdominal Pain
  • RESULTS: The most common presenting symptoms were abdominal pain and vomiting.[ncbi.nlm.nih.gov]
  • Diagnosis of intra-abdominal testicular torsion should be considered in patients with impalpable testis and abdominal pain, but could not be excluded in those with no symptoms.[ncbi.nlm.nih.gov]
  • The major clinical manifestations are cutaneous purpura, arthritis, abdominal pain, gastrointestinal bleeding, and nephritis.[ncbi.nlm.nih.gov]
  • Besides the most common clinical manifestations such as palpable purpura, arthralgia, abdominal pain and renal disease, it can have urological manifestations.[ncbi.nlm.nih.gov]
  • Second, his severe abdominal pain interfered with the detection of mild testicular tenderness at presentation; only after his abdominal pain had improved was it possible to confirm the presence of scrotal tenderness.[consultant360.com]
Palpable Purpura
  • Besides the most common clinical manifestations such as palpable purpura, arthralgia, abdominal pain and renal disease, it can have urological manifestations.[ncbi.nlm.nih.gov]
Arthritis
  • The major clinical manifestations are cutaneous purpura, arthritis, abdominal pain, gastrointestinal bleeding, and nephritis.[ncbi.nlm.nih.gov]
Ataxia
  • Isolated central nervous system vasculitis, seizures, coma and hemorrhage, Guillan--Barré syndrome, ataxia and central and peripheral neuropathy, ocular involvement, orchitis, epididymitis or testicular torsion are medical or surgical complications.[ncbi.nlm.nih.gov]
Peripheral Neuropathy
  • Isolated central nervous system vasculitis, seizures, coma and hemorrhage, Guillan--Barré syndrome, ataxia and central and peripheral neuropathy, ocular involvement, orchitis, epididymitis or testicular torsion are medical or surgical complications.[ncbi.nlm.nih.gov]
Scrotal Pain
  • The present study assessed parental knowledge regarding acute scrotal pain.[ncbi.nlm.nih.gov]
  • CONCLUSION: A standardized process with use of a scrotal pain checklist and prompt communication between the ER, Urology, and Radiology teams led to significantly reduced times from the ER to the OR.[ncbi.nlm.nih.gov]
  • Six patients who presented clinically with acute scrotal pain and had spermatic cord torsion, proven at surgery. All patients were initially studied with color Doppler US, and intratesticular flow was detected in all of them.[ncbi.nlm.nih.gov]
  • Patients and methods: Six patients who presented clinically with acute scrotal pain and had spermatic cord torsion, proven at surgery. All patients were initially studied with color Doppler US, and intratesticular flow was detected in all of them.[doi.org]
  • Algorithmic approach to the evaluation of the patient with acute scrotal pain. Evaluation of Acute Scrotal Pain Figure 2. Algorithmic approach to the evaluation of the patient with acute scrotal pain.[aafp.org]
Testicular Pain
  • Advanced practice nurses should consider the differential diagnosis of testicular torsion for any patient with testicular pain despite the patient's age, history, or physical examination findings.[ncbi.nlm.nih.gov]
  • The most common symptom in children is sudden, severe testicular pain. The testicle may be higher than usual in the scrotum and vomiting may occur.[en.wikipedia.org]
  • A 9-year-old boy presented with left, intermittent testicular pain that was present for 3 days. On physical examination, left testis was grossly enlarged and firm but mildly tender.[ncbi.nlm.nih.gov]
  • The case demonstrates the importance of bilateral hemi-scrotal exploration in a patient presenting with acute testicular pain due to a testicular torsion.[ncbi.nlm.nih.gov]
  • Abstract We present a case of subacute left testicular pain and enlargement. Scrotal Doppler ultrasound revealed an enlarged left testicle with symmetrical intra-testicular colour flow bilaterally.[ncbi.nlm.nih.gov]
Swelling of the Scrotum
  • Take your child to the emergency department immediately if he experiences any of the following symptoms: Scrotal pain that develops suddenly Increasing scrotal pain despite treatment with pain medication Redness and swelling of the scrotum Scrotal pain[chop.edu]
  • Men with testicular torsion will likely experience acute, intense pain and swelling in the scrotum.[denverurology.com]
  • Boys with testicular torsion get sudden pain and swelling of the scrotum. The affected testicle usually becomes reddened and very painful. The condition may be so painful that it causes nausea and vomiting.[netdoctor.co.uk]
  • Testicular torsion accounts for around 26% of cases of acute scrotum pain – a condition where the patient complains of extreme pain and swelling in the scrotum. It is also the main cause for loss of testicles among men.[momjunction.com]
Scrotal Mass
  • Abstract To salvage the testis, most urological surgeons advocate early exploration of enlarging scrotal masses or suspected testicular ruptures resulting from trauma.[ncbi.nlm.nih.gov]
  • Here, we describe two cases of bilateral asynchronous perinatal torsion, in which the only presenting abnormality on exam after birth was a unilateral scrotal mass.[ncbi.nlm.nih.gov]
  • RESULTS: The common clinical presentation in the neonate group was a solid, nontender scrotal mass apparent in 13 of 17 patients (76%).[ncbi.nlm.nih.gov]
  • Prenatal torsion manifests as a firm, hard, scrotal mass, and is usually asymptomatic. The scrotal skin characteristically fixes to the necrotic gonad.[sonoworld.com]
Testicular Disease
  • Several studies have demonstrated its potential in the differentiation between diseased and normal tissue in clinical practices, however the applicability to testicular disease has not been well elucidated.[ncbi.nlm.nih.gov]
  • Ultrasonography also can differentiate testicular disease (e.g., torsion, tumor) from extratesticular disease (e.g., hydrocele, abscess, hematoma).[aafp.org]
  • disease to sympathetic ophthalmia, a cell-mediated immune response.[emedicine.com]

Workup

Diagnosis for this condition is often made based on the history of the individual and the signs and symptoms they present [8]. In cases where the history and physical examinations are convincing enough, instant surgery can commence. A Doppler ultrasound can be used when diagnosis is not clear. Diagnostic procedures must however, not delay treatment. The cost of surgery following unsure diagnosis is far lower than the cost of testicular loss as a result of delayed treatment following lengthy diagnostic procedures.

Treatment

Surgery is often required to properly correct testicular torsion [9]. Manual detorsion may be able to untwist the testicle but to prevent future occurrence of torsion, surgery is required. The surgery for testicular torsion is often done under general anesthesia and patient doesn’t necessarily have to be treated as inpatient.

Prognosis

Successful management of spermatic cord torsion is measured by immediate testicular salvage as well as the incidence of late testicular atrophy [6]. The length of time between onset of symptoms and detorsion (treatment) and the corresponding rate of successful testicular salvage is as follows:

  • Less than 6 hours: 90 to 100% salvage rate
  • 12 to 24 hours: 20 to 50% salvage rate
  • Higher than 24 hours: 0 to 10% salvage rate

The complications of testicular torsion include:

Etiology

In neonates or fetus, extravaginal torsion often occurs because the testes may freely rotate before the development of testicular fixation through the tunica vaginalis within the scrotum [3].

With normal testicular suspension comes firm fixation of the epididymal-testicular complex posteriorly and this generally prevents the spermatic cords from twisting. In males with the bell-clapper condition, torsion often occurs as a result of a lack of fixation and this leads to the testes becoming freely suspended within the tunica vaginalis.

An abnormal mesentery between the testes as well as its blood supply can predispose it to torsion as long as the testicle is broader than the mesentery. Contraction of the spermatic muscles usually shortens the spermatic cords and can also lead to testicular torsion.

Epidemiology

Extarvaginal torsion is the cause of 5% of all torsion cases [4]. Out of these 5% of cases, 70% will occur prenatally and the other 30% will occur postnatally. Extravaginal torsion is often linked with high birth weight. Bilateral perinatal torsion is believed to be rare but there has been an increase in reported number of cases, with 56 cases currently documented in diverse literature.

Intravaginal torsion is the cause of 16% of cases. This type of testicular torsion is mostly seen in males who are younger than 30 years of age with majority of cases affecting people aged 12 to 18 years. The peak of incidence is placed at 13 to 14 years. The left testis is often most affected with bilateral cases only accounting for 2% of all torsions.

The incidence of torsion in males that are younger than 25 is approximately 1 in 4000.

Familial testicular tension has been described as 11.4% of cases have a positive family history.

Sex distribution
Age distribution

Pathophysiology

The testicle is able to rotate freely in the spermatic cord within the tunica vaginalis amongst males who have a very high attachment of the tunica vaginalis as well as abnormal fixation to the muscles and fascial coverings of the spermatic cord [5]. This anomaly is congenital and is referred to as the bell-clapper deformity. It often results in the long axis of the testicle showing transverse orientation instead of showing cephalocaudal orientation.

This congenital abnormality is seen in 12% of males and is bilateral in around 40% of cases. The bell-clapper deformity makes it possible for the testicle to twist spontaneously on the spermatic cord. Torsion is seen when the testicle rotates between 90° and 180°. This normally compromises blood flow to and from the testicle. When the testicle twists 360° or more, complete torsion is said to have occurred. Incomplete or partial torsion often occurs with lesser degrees of rotation. In some cases, degree of torsion may extend to as much as 720°.

With the twisting of the testicle comes venous occlusion and engorgement and also arterial ischemia and testicular infarction.

Prevention

The bell-clapper syndrome is a trait seen in some males. Since this is the major risk factor in testicular torsion, it is important for such people to undergo surgery so as to have both testicles attached properly to the inside of the scrotum [10].

Summary

Testicular torsion is defined as the torsion of the spermatic cord structures. When this happens there is a loss of blood supply to the ipsilateral testicle [1]. The condition is treated as an emergency because the preservation of the testicle and ultimately fertility is dependent on early diagnosis and treatment.

Testicular torsion is a disease that primarily affects adolescents and neonates and it is the main cause of testicular loss within this age.

Surgical treatment helps prevent additional ischemic damage to the testis. Observation, instead of treatment may be appropriate in some cases however, depending on pathology [2]. Diagnosis of testicular torsion is clinically and it is very important for diagnostic procedures to not get in the way of early treatment.

Patient Information

Testicular torsion is seen when the testicles rotate within the scrotum. In the process, the spermatic cord which brings blood to the scrotum is twisted. With this reduced blood flow comes sudden and often severe pain and swelling. Testicular torsion is most common between the ages of 12 and 16. However it can occur at any age or even before birth.

Testicular torsion often warrants emergency surgery. When treated with a few hours, the testicle can be saved. Waiting longer often leads to permanent damage and will affect the ability of the individual to produce children. When blood flow has been cut off for too long, the testicle becomes severely damaged, leading to the need for it to be removed.

References

Article

  1. Schneck FX, Bellinger ME. Abnormalities of the testis and scrotum and their surgical management. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell- Walsh Urology. 9th ed. Philadelphia, Pa: WB Saunders; 2007:Chapter 127.
  2. Dogra V, Bhatt S. Acute painful scrotum. Radiol Clin North Am. Mar 2004;42(2):349-63.
  3. Roth CC, Mingin GC, Ortenberg J. Salvage of bilateral asynchronous perinatal testicular torsion. J Urol. Jun 2011;185(6 Suppl):2464-8.
  4. Kar A, Ozden E, Yakupoglu YK, Kefeli M, Sarikaya S, Yilmaz AF. Experimental unilateral spermatic cord torsion: the effect of polypolymerase enzyme inhibitor on histopathological and biochemical changes in the early and late periods in the ipsilateral and contralateral testicles. Urology. Aug 2010;76(2):507.e1-5.
  5. Beni-Israel T, Goldman M, Bar Chaim S, Kozer E. Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med. Sep 2010;28(7):786-9.
  6. Das S, Singer A. Controversies of perinatal torsion of the spermatic cord: a review, survey and recommendations. J Urol 1990; 143:231.
  7. Gillenwater JY, Burros HM. Torsion of the spermatic cord in utero. JAMA 1966; 198:1123.
  8. McFarland JB. Testicular strangulation in children. Br J Surg 1966; 53:110.
  9. Visser AJ, Heyns CF. Testicular function after torsion of the spermatic cord. BJU Int 2003; 92:200.
  10. Kaye JD, Levitt SB, Friedman SC, et al. Neonatal torsion: a 14-year experience and proposed algorithm for management. J Urol 2008; 179:2377.

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Last updated: 2018-06-22 05:33