Testicular torsion

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Testicular torsion
Illu testis surface.jpg
1. Epididymis 2. Head of epididymis 3. Lobules of epididymis 4. Body of epididymis 5. Tail of epididymis 6. Duct of epididymis 7. Deferent duct (ductus deferens or vas deferens)
Specialty Urology
Symptoms Severe testicular pain, elevated testicle [1]
Complications Infertility [2]
Usual onsetSudden [1]
TypesIntravaginal torsion, extravaginal torsion [1]
Risk factors "Bell clapper deformity", testicular tumor, cold temperature [1]
Diagnostic method Based on symptoms [1]
Differential diagnosis Epididymitis, inguinal hernia, torsion of the appendix testicle [2]
TreatmentPhysically untwisting the testicle, surgery [1]
Prognosis Generally good with rapid treatment [1]
Frequency~1 in 15,000 per year (under 25 years old) [2] [3]

Testicular torsion occurs when the spermatic cord (from which the testicle is suspended) twists, cutting off the blood supply to the testicle. [3] The most common symptom in children is sudden, severe testicular pain. [1] The testicle may be higher than usual in the scrotum and vomiting may occur. [1] [2] In newborns, pain is often absent and instead the scrotum may become discolored or the testicle may disappear from its usual place. [1]

Contents

Most of those affected have no obvious prior underlying health problems. [1] Testicular tumor or prior trauma may increase risk. [1] [3] Other risk factors include a congenital malformation known as a "bell-clapper deformity" wherein the testis is inadequately attached to the scrotum allowing it to move more freely and thus potentially twist. [1] Cold temperatures may also be a risk factor. [1] The diagnosis should usually be made based on the presenting symptoms, but requires timely diagnosis and treatment to avoid testicular loss. [4] [ page needed ] [1] [2] An ultrasound can be useful when the diagnosis is unclear. [2]

Treatment is by physically untwisting the testicle, if possible, followed by surgery. [1] Pain can be treated with opioids. [1] Outcome depends on time to correction. [1] If successfully treated within six hours onset, it is often good. However, if delayed for 12 or more hours the testicle is typically not salvageable. [1] About 40% of people require removal of the testicle. [2]

It is most common just after birth and during puberty. [2] It occurs in about 1 in 4,000 to 1 in 25,000 males under 25 years of age each year. [2] [3] Of children with testicular pain of rapid onset, testicular torsion is the cause of about 10% of cases. [2] Complications may include an inability to have children. [2] The condition was first described in 1840 by Louis Delasiauve. [5]

Signs and symptoms

Testicular torsion usually presents with severe testicular pain or pain in the groin and lower abdomen. [2] Pain generally begins suddenly and typically involves only one side. [6] There is often associated nausea and vomiting. [2] The testicle may lie higher in the scrotum due to twisting and subsequent shortening of the spermatic cord [6] or may be positioned in a horizontal orientation. Mild warmth and redness of the overlying area may be present. Elevation of the testicle may worsen the pain. Urinary symptoms, such as pain or increased frequency of urination are also typically absent. [7] Symptom onset often follows physical activity or trauma to the testes or scrotum. Children with testicular torsion may awaken with testicular or abdominal pain in the middle of the night or in the morning. [8] There may be a history of previous, similar episodes of scrotal pain due to prior transient testicular torsion with spontaneous resolution. [6]

Complications

Risk factors

Most of those affected with testicular torsion have no prior underlying health problems or predisposing conditions. [1] However, there are certain factors that may increase risk of testicular torsion. A larger testicle either due to normal variation or testicular tumor increases the risk of torsion. [3] Similarly, the presence of a mass or malignancy involving the spermatic cord can also predispose to torsion. [1]

Age is also an important risk factor for torsion. Torsion most commonly occurs either in the newborn or just before or during puberty. [2] Testicular torsion often occurs before or during puberty, prior to complete testicular descent. Epididymitis is more commonly a postpubertal condition. [8]

Several congenital anatomic malformations or variations in the testicle or the surrounding structures may allow for increased scrotal rotation and increase the risk of testicular torsion. [3] A congenital malformation of the processus vaginalis known as "bell-clapper deformity" accounts for 90% of all cases. [3] [16] In this condition, rather than the testes attaching posteriorly to the inner lining of the scrotum by the mesorchium, the mesorchium terminates early and the testis is free floating in the tunica vaginalis. Other anatomic risk factors include horizontal lie of the testicle or a spermatic cord with a long intrascrotal portion. [3] Cryptorchidisim is also a risk factor for torsion [3] with some studies proposing a 10-fold higher risk. [17] Testicular torsion may also be caused by trauma to the scrotum or exercise (in particular, bicycle riding); [10] however, only about 4–8% of cases are the result of trauma. [1] [2] There is thought to be a possible genetic basis for predisposition to torsion, based on multiple published reports of familial testicular torsion. [10] There is controversy whether cold weather months are associated with an increased risk. [10]

Pathophysiology

Testicular torsion occurs when there is mechanical twisting of the spermatic cord, which suspends the testicle within the scrotum and contains the testicular artery and vein. Twisting of the cord reduces or eliminates blood flow to the testicle. [3] The degree of arterial and venous obstruction depends on the duration and severity of the torsion event. Typically, venous blood flow is compromised first. [1] The increase in venous pressure subsequently causes decreased arterial blood flow, leading to decreased oxygen supply to the testicle, and if untreated, testicular infarction. [2]

It is also believed that torsion occurring during fetal development can lead to so-called neonatal torsion or vanishing testis, and is one of the causes of an infant being born with monorchism (one testicle). [18]

Intermittent testicular torsion

Intermittent testicular torsion (ITT) is a less serious but chronic variant of torsion. It is characterized by intermittent scrotal or testicular pain, followed by eventual spontaneous detorsion and resolution of pain. Nausea and vomiting may also occur. [7] : 150  Though less pressing, such individuals are at significant risk of complete torsion and possible subsequent orchiectomy and the recommended treatment is elective bilateral orchiopexy. Ninety-seven percent of patients who undergo such surgery experience complete relief from their symptoms. [19] : 316 

Extravaginal testicular torsion

Torsion occurring outside of the tunica vaginalis, when the testis and gubernaculum can rotate freely, is termed an extravaginal testicular torsion. This type occurs exclusively in newborns, however, newborns can be affected by other testicular torsion variants as well. [2] Neonates experiencing such a torsion typically present with painless scrotal swelling, [2] discoloration, and a firm, painless mass in the scrotum. Such testes are usually necrotic from birth and must be removed surgically. [19] : 315  The exact cause of or specific risk factors for extravaginal torsion in this population remain unclear. [2]

Intravaginal testicular torsion

Intravaginal testicular torsion occurs when the testicle rotates on the spermatic cord within the tunica vaginalis. [2] This variant more commonly occurs in older children and adults. The "bell-clapper deformity," in which there is inappropriately high attachment of the tunica vaginalis over the spermatic cord and failure of the normal posterior attachment of the testicle to the inner scrotum, which allows the testicle to move freely within the tunica vaginalis and predisposes to intravaginal testicular torsion. [2]

Torsion of the testicular appendix

The testicular appendix is located in the upper pole of the testicle. It is an embryonic remnant that has no known function, but is at risk for torsion events. [19] This type of torsion is the most common cause of acute scrotal pain in boys ages 7–14. Its appearance is similar to that of testicular torsion but the onset of pain is typically more gradual. Palpation reveals a small firm nodule on the upper portion of the testis which displays a characteristic "blue dot sign". This is the appendix of the testis which has become discolored and is noticeably blue through the skin. Unlike other torsions, however, the cremasteric reflex is still active. Typical treatment involves the use of over-the-counter analgesics and the condition resolves within 2–3 days. [19] : 316 

Torsion of the undescended testicle

The undescended testis is at increased risk of testicular torsion. [17] The mechanism for torsion in the undescended testicle is not fully understood, though it may be due to abnormal contractions of the cremaster muscle, which covers the testicle and spermatic cord and is responsible for raising and lowering the testicle to regulate scrotal temperature. The undescended testicle is also at higher risk for testicular tumor, which due to the increased weight and size compared to a healthy testicle can predispose to torsion. [17]

Diagnosis

The diagnosis should generally be made based on the presenting symptoms. [1] [2] An ultrasound can be useful when the diagnosis is unclear. [2] However, imaging should not delay surgical intervention as complications develop with prolonged ischemia. [2] Immediate surgery is recommended regardless of imaging findings if there is a high degree of suspicion based on history and physical examination. [1] [2]

Given the treatment implications of testicular torsion, it is important to distinguish testicular torsion from other causes of testicular pain, such as epididymitis, which can present similarly. While both conditions can cause testicular pain, the pain of epididymitis is typically localized to the epididymis at the rear pole of the testicle. Epididymitis may also be characterized by discoloration and swelling of the testis, and fever. The cremasteric reflex in epididymitis is usually present. Testicular torsion, or more probably impending testicular infarction, can also produce a low-grade fever. [19] There is often an absent or decreased cremasteric reflex. [2]

Clinical exam

The absence of the cremasteric reflex in an acutely painful testicle is most indicative of testicular torsion (the twisting of the spermatic cord of the testicle makes reflexive responses all but impossible). The cremasteric reflex normally causes elevation of the testicle by stroking the inner thigh. [1] Absence is especially common in children, but its presence does not exclude a diagnosis of testicular torsion. [6]

On physical examination, the testis can be swollen, tender, high-riding, and with an abnormal transverse lie. [20]

Prehn's sign, a classic physical exam finding, has not been reliable in distinguishing torsion from other causes of testicular pain such as epididymitis. [21] The individual will not usually have a fever, though nausea is common.[ citation needed ]

Imaging

A doppler ultrasound scan of the scrotum can identify the absence of blood flow in the twisted testicle and is nearly 90% accurate in diagnosis. [2] [3] It can also help distinguish torsion from epididymitis. [22]

Radionuclide scanning (scintigraphy) of the scrotum is the most accurate imaging technique, but it is not routinely available, particularly with the urgency that might be required. [23] The agent of choice for this purpose is technetium-99m pertechnetate. [24] Initially it provides a radionuclide angiogram, followed by a static image after the radionuclide has perfused the tissue. In the healthy patient, initial images show symmetric flow to the testes, and delayed images show uniformly symmetric activity. [24] In testicular torsion, the images may show heterogenous activity within the affected testicle. [24]

Image of testicular torsion Torsion teste aguda (cropped).jpg
Image of testicular torsion

Treatment

Testicular torsion is a surgical emergency that requires immediate intervention to restore the flow of blood to the testicle. [3] If treated either manually or surgically within six hours, there is a high chance (approximately 90%) of saving the testicle. At 12 hours the rate decreases to 50%; at 24 hours it drops to 10%, and after 24 hours the ability to save the testicle approaches 0, although salvage of the testicle has been reported beyond 24 hours. [3] [25] About 40% of cases result in loss of the testicle. [2]

With prompt diagnosis and treatment the testicle can often be saved. [3] Typically, when a torsion takes place, the surface of the testicle has rotated towards the midline of the body. Non-surgical correction can sometimes be accomplished by manually rotating the testicle in the opposite direction (i.e., outward, towards the thigh); if this is initially unsuccessful, a forced manual rotation in the other direction may correct the problem. [7] : 149  The success rate of manual detorsion is not known with confidence.[ citation needed ]

When salvage of the testicle is accomplished, long-term testicular damage is common. Testicular size is often diminished, and injury to the unaffected testicle is common. [10] The effect of a torsion event on long-term fertility is not fully understood. [10]

A repeat doppler ultrasound scan may confirm restoration of blood flow to the testicle following manual detorsion. However, surgical exploration is often performed in order to assess the health and viability of the testicle. An orchiopexy is performed to both the affected and unaffected testicles in order to prevent recurrence. If the testis is not viable, it is removed (orchiectomy). [26]

Epidemiology

Torsion is most frequent among adolescents with about 65% of cases presenting between 12 and 18 years of age. [27] It is the most common cause of rapid onset testicular pain and swelling in people under 18 years old. [27] It occurs in about 1 in 4,000 to 1 per 25,000 males per year before 25 years of age; [2] [3] [16] but it can occur at any age, including infancy. [7] : 149 

See also

Related Research Articles

<span class="mw-page-title-main">Testicle</span> Internal organ in the male reproductive system

A testicle or testis is the male gonad in all bilaterians, including humans. It is homologous to the female ovary. The functions of the testicles are to produce both sperm and androgens, primarily testosterone. Testosterone release is controlled by the anterior pituitary luteinizing hormone, whereas sperm production is controlled both by the anterior pituitary follicle-stimulating hormone and gonadal testosterone.

<span class="mw-page-title-main">Testicular cancer</span> Medical condition

Testicular cancer is cancer that develops in the testicles, a part of the male reproductive system. Symptoms may include a lump in the testicle or swelling or pain in the scrotum. Treatment may result in infertility.

<span class="mw-page-title-main">Spermatic cord</span> Structure in the human male reproductive system

The spermatic cord is the cord-like structure in males formed by the vas deferens and surrounding tissue that runs from the deep inguinal ring down to each testicle. Its serosal covering, the tunica vaginalis, is an extension of the peritoneum that passes through the transversalis fascia. Each testicle develops in the lower thoracic and upper lumbar region and migrates into the scrotum. During its descent it carries along with it the vas deferens, its vessels, nerves etc. There is one on each side.

<span class="mw-page-title-main">Cryptorchidism</span> Medical condition

Cryptorchidism, also known as undescended testis, is the failure of one or both testes to descend into the scrotum. The word is from Greek κρυπτός 'hidden' and ὄρχις 'testicle'. It is the most common birth defect of the male genital tract. About 3% of full-term and 30% of premature infant boys are born with at least one undescended testis. However, about 80% of cryptorchid testes descend by the first year of life, making the true incidence of cryptorchidism around 1% overall. Cryptorchidism may develop after infancy, sometimes as late as young adulthood, but that is exceptional.

<span class="mw-page-title-main">Cremaster muscle</span> Muscle covering the testicles and spermatic cords

The cremaster muscle is a paired structure made of thin layers of striated and smooth muscle that covers the testicles and the spermatic cords in human males. It consists of the lateral and medial parts. Cremaster is an involuntary muscle, responsible for the cremasteric reflex; a protective and physiologic superficial reflex of the testicles. The reflex raises and lowers the testicles in order to keep them protected. Along with the dartos muscle of the scrotum, it regulates testicular temperature, thus aiding the process of spermatogenesis.

<span class="mw-page-title-main">Hydrocele testis</span> Medical condition

A hydrocele testis is an accumulation of clear fluid within the cavum vaginale, the potential space between the layers of the tunica vaginalis of the testicle. It is the most common form of hydrocele and is often referred to simply as a "hydrocele". A primary hydrocele testis causes a painless enlargement in the scrotum on the affected side and is thought to be due to the defective absorption of fluid secreted between the two layers of the tunica vaginalis. A secondary hydrocele is secondary to either inflammation or a neoplasm in the testis.

<span class="mw-page-title-main">Epididymitis</span> Medical condition

Epididymitis is a medical condition characterized by inflammation of the epididymis, a curved structure at the back of the testicle. Onset of pain is typically over a day or two. The pain may improve with raising the testicle. Other symptoms may include swelling of the testicle, burning with urination, or frequent urination. Inflammation of the testicle is commonly also present.

<span class="mw-page-title-main">Cremasteric reflex</span> Human reflex affecting the testicles

The cremasteric reflex is a superficial reflex observed in human males.

<span class="mw-page-title-main">Orchiopexy</span> Surgery to fix a testicle into the scrotum

Orchiopexy is a surgery to move and/or permanently fix a testicle into the scrotum. While orchiopexy typically describes the operation to surgically correct an undescended testicle, it is also used to resolve testicular torsion.

<span class="mw-page-title-main">Inguinal hernia</span> Medical condition in which contents of the abdominal cavity protrude through the inguinal canal

An inguinal hernia or groin hernia is a hernia (protrusion) of abdominal cavity contents through the inguinal canal. Symptoms, which may include pain or discomfort especially with or following coughing, exercise, or bowel movements, are absent in about a third of patients. Symptoms often get worse throughout the day and improve when lying down. A bulging area may occur that becomes larger when bearing down. Inguinal hernias occur more often on the right than left side. The main concern is strangulation, where the blood supply to part of the intestine is blocked. This usually produces severe pain and tenderness of the area.

<span class="mw-page-title-main">Spermatocele</span> Medical condition

Spermatocele is a fluid-filled cyst that develops in the epididymis. The fluid is usually a clear or milky white color and may contain sperm. Spermatoceles are typically filled with spermatozoa and they can vary in size from several millimeters to many centimeters. Small spermatoceles are relatively common, occurring in an estimated 30 percent of males. They are generally not painful. However, some people may experience discomfort such as a dull pain in the scrotum from larger spermatoceles. They are not cancerous, nor do they cause an increased risk of testicular cancer. Additionally, unlike varicoceles, they do not reduce fertility.

<span class="mw-page-title-main">Hydrocele</span> Accumulation of fluid in a body cavity

A hydrocele is an accumulation of serous fluid in a body cavity. A hydrocele testis, the most common form of hydrocele, is the accumulation of fluids around a testicle. It is often caused by fluid collecting within a layer wrapped around the testicle, called the tunica vaginalis, which is derived from peritoneum. Provided there is no hernia present, it goes away without treatment in the first year. Although hydroceles usually develop in males, rare instances have been described in females in the canal of Nuck.

<span class="mw-page-title-main">Hematocele</span> Medical condition

A hematocele is a collections of blood in a body cavity or potential space. The term most commonly refers to the collection of blood in the tunica vaginalis around the testes, known as a scrotal hematocele. Hematoceles can also occur in the abdominal cavity and other body cavities. Hematoceles are rare, making them harder to diagnose and treat. They are very common especially as slowly growing masses in the scrotum usually in men older than 50 years.

<span class="mw-page-title-main">Testicular pain</span> Medical condition

Testicular pain, also known as scrotal pain, occurs when part or all of either one or both testicles hurt. Pain in the scrotum is also often included. Testicular pain may be of sudden onset or of long duration.

<span class="mw-page-title-main">Prehn's sign</span> Medical sign for testicular pain

Prehn's sign is a medical diagnostic indicator that was once believed to help determine whether the presenting testicular pain is caused by acute epididymitis or from testicular torsion. Although elevation of the scrotum when differentiating epididymitis from testicular torsion is of clinical value, Prehn's sign has been shown to be inferior to Doppler ultrasound to rule out testicular torsion.

<span class="mw-page-title-main">Appendix of testis</span> Part of the testis

The appendix testis is a vestigial remnant of the Müllerian duct, present on the upper pole of the testis and attached to the tunica vaginalis. It is present about 90% of the time and is homologous to the fallopian tubes in females.

<span class="mw-page-title-main">Testicular vein</span>

The testicular vein, the male gonadal vein, carries deoxygenated blood from its corresponding testis to the inferior vena cava or one of its tributaries. It is the male equivalent of the ovarian vein, and is the venous counterpart of the testicular artery.

<span class="mw-page-title-main">Orchiectomy</span> Surgical removal of one or both testicles

Orchiectomy is a surgical procedure in which one or both testicles are removed. The surgery can be performed for various reasons:

<span class="mw-page-title-main">Scrotal ultrasound</span> Medical ultrasound examination of the scrotum.

Scrotalultrasound is a medical ultrasound examination of the scrotum. It is used in the evaluation of testicular pain, and can help identify solid masses.

Male genital examination is a physical examination of the genital in males to detect ailments and to assess sexual development, and is normally a component of an annual physical examination. The examination includes checking the penis, scrotum, and urethral meatus. A comprehensive assessment of the male genitals assesses the pubic hair based on Sexual Maturity Rating and the size of the testicles and penis. The exam can also be conducted to verify a person's age and biological sex. The genitourinary system can also be assessed as part of the male genital examination. During a genital examination, the doctor can detect any of the following: structural abnormalities, urethral opening abnormalities, problems related to not being circumcised, lumps, tumors, redness, excoriation, edema, lesions, swelling, cancer, hair-related issues, and many others. In some instances where a physical examination of the male genitals is not sufficient to diagnose an individual, then an internal genital examination using imaging or ultrasounds will be needed for further evaluation.

References

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