Overview
Testicular torsion is a urologic emergency and occurs when the spermatic cord twists, cutting off blood supply to the testicles, resulting in ischaemia and necrosis. In general, after around 6 hours, testicular tissue starts to become necrotic and non-viable.
Pathophysiology
The tunica vaginalis is a membrane that lines the testis and epididymis within the scrotum. It is used to divide testicular torsion into two types:
- Intravaginal torsion – due to absent fixation of the posterior part of the testis to the tunica vaginalis in the scrotum:
- This results in the testicle being free to rotate freely, increasing the risk of torsion
- This is also known as the ‘bell clapper deformity’
- Extravaginal torsion – seen nearly always in neonates and can occur prenatally:
- The tunica vaginalis itself is free to move more than usual, increasing the risk of torsion
Epidemiology
- Testicular torsion can occur at any age but is most common in young people aged 10-20 years, peaking in adolescence
- Although rare, extravaginal torsion is most common in neonates <1 year old
- Testicular torsion is generally not seen in older people (around >60 years old)
Risk Factors
- Bell clapper deformity – accounts for up to 90% of cases
- Neonates – increased risk of extravaginal torsion
- 10-20 years old – incidence is highest in this group and peaks in adolescence
- Trauma/sport – up to 8% of cases are caused by trauma
Presentation
Overview
The main feature of testicular torsion is acute scrotal pain which may have associated swelling. Key features are:
- Severe, acute, scrotal pain – may be in the groin or referred to the lower abdomen
- Nausea and vomiting are often seen
- Symptoms may have arisen during trauma or sports
- Some people may have recurrent attacks that resolve spontaneously – this may be due to intermittent testicular torsion and detorsion
Physical examination
Physical examination findings include:
- The testis may be swollen, tender, and retracted upwards
- The cremasteric reflex is absent
- Pinching/gently rubbing the inner thigh normally elicits the cremasteric reflex
- Prehn’s sign is negative – elevating the testis does not alleviate pain
- In neonates, there may be a firm, hard, non-transilluminable mass that may be painless
Differential Diagnoses
Epididymo-orchitis
- Pain and swelling usually develop over a few days unlike testicular torsion, which is often sudden
- Dysuria and increased urgency may be seen in epididymo-orchitis but not in testicular torsion
- Prehn’s sign is positive in epididymo-orchitis
- The cremasteric reflex is present in epididymo-orchitis
Management
Overview
Imaging studies are not generally performed if testicular torsion is suspected as this can delay treatment and increase the risk of ischaemia. Patients should undergo immediate surgical exploration
If testicular torsion is identified and not necrotic, then both testes are fixed (orchidopexy). This is because up to 90% of cases are associated with the bell clapper deformity, which means there is an increased risk of another testicular torsion on the other side.
If the testis is necrotic and no longer viable (usually >24 hours), then the affected testis may be removed (orchiectomy). The contralateral testis should be fixed.
Neonates with testicular torsion have the affected testis removed as they are non-viable from birth. The contralateral testis should be fixed.
Complications
- Testicular necrosis:
- Usually starts at around 6 hours and beyond
- Subfertility/infertility:
- Affects up to 39% of patients after torsion
- Recurrent torsion or torsion in the other testis:
- Around 90% of cases are due to the bell clapper deformity
- Hypogonadism and impaired puberty:
- If bilateral or significant testicular loss occurs in an adolescent, may require hormone replacement therapy
- Psychological implications and self-esteem problems
Prognosis
- If treated within 6 hours, salvation rates are around 90-100%
- This decreases to around 10% at 12-24 hours
