Testicular torsion

• Testicular torsion:

  • When the spermatic cord and its contents twists within the tunica vaginalis - compromises the blood supply to the testicle
  • Leads to occlusion of testicular venous return and subsequent compromise of the arterial supply
  • Surgical emergency - without treatment the affected testicle will infarct within hours. 4-6 hour window to salvage the testis, after 6 hours viability of testis drops rapidly
• Pathophysiology:

  • Testes normally lie in a vertical position with the scrotum, enclosed by the tunica vaginalis that holds the posterolateral portion of the testes in place
  • Intravaginal torsion - minor anatomical variations can produce a narrow based pedicle with a horizontal (bell-clapper) testicular lie that allows the testicle that twists
  • Extravaginal - in neonates the attachment of the testes to tunica vaginalis is not fully formed and sometimes there can be twisting of these structures (including the tunica vaginalis) - this can occur in-utero
• In infants, the newly descended testis and its investing tunica vaginalis are mobile within the scrotum. These testes may undergo extravaginal torsion , which presents as a hard, swollen testis; those of acute onset should have urgent surgery
• Risk factors:

  • Age (most common 12-25 years)
  • Previous testicular torsion
  • Family history
  • Undescended testes
• Clinical features:

  • Sudden onset severe unilateral testicular pain
  • Nausea and vomiting secondary to pain
  • Referred abdominal pain
  • On exam testis will have a high position (clarify normal position)
  • Swollen and extremely tender
  • Horizontal lie of testicle
  • Absent cremasteric reflex
  • Negative Prehn's sign (pain continues on elevation)
• Investigation:

  • The diagnosis is a clinical one, any suspected cases should be taken straight to theatre for scrotal exploration
  • If sufficient doubt over diagnosis - doppler ultrasound can reveal if any blood flow to testis
  • Urine dip stick can asses for any potential infective component
• Management:

  • Surgical emergency - 4-6 hour window before significant ischaemic damage occurs
  • Urgent surgical exploration
  • NBM with maintenance fluids
  • Strong analgesia and antiemetics
  • If torsion confirmed - the cord and testis will be untwisted and BOTH testicles fixed to the scrotum (prevent further torsion episodes) - bilateral orchidopexy
  • If testis is non-viable an orchidectomy may be needed, prosthesis can be inserted
• Despite expedient scrotal exploration, de-torsion, and orchidopexy, the affected testis may later undergo atrophy.