> Table of Contents > Testicular Torsion
Testicular Torsion
Jonathan Green, MD
Michael P. Hirsh, MD
image BASICS
DESCRIPTION
  • Twisting of testis and spermatic cord, resulting in acute ischemia and loss of testis if unrecognized.
    • Intravaginal torsion: occurs within tunica vaginalis, only involves testis and spermatic cord
    • Extravaginal torsion: involves twisting of testis, cord, and processus vaginalis as a unit. Typically seen in neonates
  • System(s) affected: reproductive
Geriatric Considerations
Very rare in this age group
Pediatric Considerations
Peak incidence is at 14 years of age (1)
EPIDEMIOLOGY
Incidence
  • ˜ 1/4,000 males before age 25 years
  • Predominant age
    • Occurs from newborn period to 7th decade of life
    • 65% of cases occur in 2nd decade, with peak at age 14 years (1).
    • 2nd peak in neonates (in utero torsion usually occurs around week 32 of gestation) (1)
ETIOLOGY AND PATHOPHYSIOLOGY
  • Twisting of spermatic cord causes venous obstruction, edema of testis, and arterial occlusion.
  • “Bell clapper” deformity is most common anatomic anomaly predisposing to intravaginal torsion.
    • High insertion of the tunica vaginalis on the spermatic cord, results in increased testicular mobility within tunica vaginalis (2)
    • Bilateral in ˜ 80% of patients (1,2)
  • No clear anatomic defect is associated with extravaginal testicular torsion.
    • In neonates, the tunica vaginalis is not yet well attached to scrotal wall, allowing torsion of entire testis including tunica vaginalis (1).
  • Usually spontaneous and idiopathic (1)
  • 20% of patients have a history of trauma.
  • 1/3 have had prior episodic testicular pain.
  • Contraction of cremasteric muscle or dartos may play a role and is stimulated by trauma, exercise, cold, and sexual stimulation.
  • Increased incidence may be due to increasing weight and size of testis during pubertal development.
  • Possible alterations in testosterone levels during nocturnal sex response cycle; possible elevated testosterone levels in neonates (1)
  • Testis must have inadequate, incomplete, or absent fixation within scrotum (1,2).
  • Torsion may occur in either clockwise or counterclockwise direction (3).
Genetics
  • Unknown
  • Familial testicular torsion, although previously rarely reported, may involve as many as 10% of patients (4).
RISK FACTORS
  • May be more common in winter
  • Paraplegia
  • Previous contralateral testicular torsion
image DIAGNOSIS
PHYSICAL EXAM
  • Scrotum is enlarged, red, edematous, and painful (1,2).
  • Testicle is swollen and exquisitely tender (1,2).
  • Testis may be high in scrotum with a transverse lie.
  • Absent cremasteric reflex (1,2,3)
DIFFERENTIAL DIAGNOSIS
  • Torsion appendix testis (this may account for 35-67% of acute scrotal pain cases in children) (2)
  • Epididymitis (8-18% of acute scrotal pain cases) (2)
  • Orchitis
  • Incarcerated or strangulated inguinal hernia
  • Acute hydrocele
  • Traumatic hematoma
  • Idiopathic scrotal edema
  • Acute varicocele
  • Epididymal hypertension (venous congestion of testicle or prostate due to sexual arousal that does not end in orgasm)
  • Testicular tumor
  • Henoch-Schönlein purpura
  • Scrotal abscess
  • Leukemic infiltrate
DIAGNOSTIC TESTS & INTERPRETATION
  • Doppler US may confirm testicular swelling, but is diagnostic by demonstrating lack of blood flow to the testicle; positive predictive value (PPV) of
    89.4% (5,7)[B].
  • In boys with intermittent, recurrent testicular torsion, both Doppler US and radionuclide scintigraphy findings will be normal (7)[B].
Diagnostic Procedures/Other
  • Doppler US flow detection demonstrates absent or reduced blood flow with torsion and increased flow with inflammatory process (reliable only in first 12 hours) (7)[B].
  • Radionuclide testicular scintigraphy with technetium-99m pertechnetate demonstrates absent/decreased vascularity in torsion and increased vascularity with inflammatory processes (including torsion of appendix testes) (8)[C].
Test Interpretation
  • Venous thrombosis
  • Tissue edema and necrosis
  • Arterial thrombosis
  • Decreased Doppler flow also seen in hydrocele, abscess, hematoma, or scrotal hernia (7).
  • Sensitivity of radionuclide testicular scintigraphy is decreased relative to ultrasonography because hyperemia in the torsed testicle can mimic flow (8).
image TREATMENT
  • Manual reduction: Best performed by experienced physician; may be successful, facilitated by lidocaine 1% (plain) injection at level of external ring
    • Difficult to determine success of manual reduction, especially after giving local anesthesia.
    • Manual reduction might require sedation, and the entire process may delay definitive treatment.
    • Even if successful, must always be followed by surgical exploration, urgently but not emergently (6)[C]
  • P.1023

  • Surgical exploration via scrotal approach at the median raphe allows for exposure of both testes, detorsion, evaluation of testicular viability, orchidopexy of viable testicle, and orchiectomy of nonviable testicle (5)[B].
  • In boys with a history of intermittent episodes of testicular pain, scrotal exploration is warranted with testicular fixation if abnormal testicular attachments are confirmed (5)[B].
GENERAL MEASURES
Early exam is crucial because necrosis of the testicle can occur after 6 to 8 hours (1,9)[C].
SURGERY/OTHER PROCEDURES
  • Operative testicular fixation of the torsed testicle after detorsion and confirmation of viability. At least 3- or 4-point fixation with nonabsorbable sutures between the tunica albuginea and the tunica vaginalis (5)[B]
  • Excision of window of tunica albuginea with suture to dartos fascia (5,10)[B]
  • Any testis that is not clearly viable should be removed (5)[B].
  • Testes of questionable viability that are preserved and pexed invariably atrophy (5)[B]
  • Bilateral testicular fixation is recommended by many surgeons (5)[B].
  • Contralateral testicle frequently has similar abnormal fixation and should be explored (5)[B],(6)[C].
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • Postoperative visit at 1 to 2 weeks
  • Yearly visits until puberty may be needed to evaluate for atrophy.
DIET
Regular
PATIENT EDUCATION
Possibility of testicular atrophy in salvaged testis with depressed sperm counts. Importantly, fertility rates in patients with one testicle remain excellent.
PROGNOSIS
  • Testicular salvage
    • Salvage is related directly to duration of torsion (85-97% if within 6 hours, 20% after 12 hours <10% if >24 hours) (9).
    • The degree of torsion is related to testicular salvage.
      • The median degree of torsion is <360 in patients who are explored and orchidopexy performed.
      • The median degree of torsion is 540 in patients who undergo exploration and require orchiectomy (3).
  • 80-94% may have depressed spermatogenesis related to duration of ischemic injury (possibly related to autoimmune-mediated injury) (9).
  • Up to 45% of patients undergoing orchiopexy for testicular torsion will develop atrophy of testicle.
REFERENCES
1. Boettcher M, Bergholz R, Krebs TF, et al. Clinical predictors of testicular torsion in children. Urology. 2012;79(3):670-674.
2. Edelsberg JS, Surh YS. The acute scrotum. Emerg Med Clin North Am. 1988;6(3):521-546.
3. Sessions AE, Rabinowitz R, Hulbert WC, et al. Testicular torsion: direction, degree, duration and disinformation. J Urol. 2003;169(2):663-665.
4. Cubillos J, Palmer JS, Friedman SC, et al. Familial testicular torsion. J Urol. 2011;185(6)(Suppl): 2469-2472.
5. Van Glabeke E, Khairouni A, Larroquet M, et al. Acute scrotal pain in children: results of 543 surgical explorations. Pediatr Surg Int. 1999;15(5-6): 353-357.
6. Eaton SH, Cendron MA, Estrada CR, et al. Intermittent testicular torsion: diagnostic features and management outcomes. J Urol. 2005;174 (4, Pt 2):1532-1535.
7. Yagil Y, Naroditsky I, Milhem J, et al. Role of doppler ultrasonography in the triage of acute scrotum in the emergency department. J Ultrasound Med. 2010;29(1):11-21.
8. Saleh O, El-Sharkawi MS, Imran MB. Scrotal scintigraphy in testicular torsion: an experience at a tertiary care centre. Int Med J Malaysia. 2012;11(1):9-14.
9. Kapoor S. Testicular torsion: a race against time. Int J Clin Pract. 2008;62(5):821-827.
10. Figueroa V, Pippi Salle JL, Braga LH, et al. Comparative analysis of detorsion alone versus detorsion and tunica albuginea decompression (fasciotomy) with tunica vaginalis flap coverage in the surgical management of prolonged testicular ischemia. J Urol. 2012;188(4)(Suppl): 1417-1422.
Codes
&NA;
ICD10
  • N44.00 Torsion of testis, unspecified
  • N44.03 Torsion of appendix testis
  • N44.01 Extravaginal torsion of spermatic cord
Clinical Pearls
&NA;
  • The diagnosis of testicular torsion is usually made on physical exam. Patients with suspected torsion should be taken to the OR without delay. If diagnosis is in question, a testicular Doppler US may be done to evaluate blood flow.
  • Although testicular necrosis may be present within 6 to 8 hours of torsion, this is highly variable.
  • Infertility can be a problem even if the testicle is viable. Autoimmune antibodies may be produced, and they may affect subsequent fertility.