Testicular torsion Flashcards
what is the definition of testicular torsion?
Testicular torsion is a urological emergency caused by the twisting of the testicle on the spermatic cord leading to constriction of the vascular supply, time-sensitive ischaemia, and/or necrosis of testicular tissue.
what is the epidemiology of testicular torsion?
Torsion can be seen at any age but it is not generally a disease affecting the elderly
what is the aetiology of testicular torsion?
The bell clapper deformity is the most common anatomical defect associated with the development of intra-vaginal testicular torsion. Other causes include trauma. The inciting event for this type of testicular torsion is usually unknown; however, trauma may be the cause in a minority of cases (4-8%).
The exact aetiology of extra-vaginal torsion is unknown and an anatomical defect is not usually identified
what are the risk factors for testicular torsion?
Under 25
Neonate
Bell clapper deformity
what is the pathophysiology of testicular torsion?
Normally, the testicle descends through the inguinal canal covered by a layer of peritoneum. This layer, the tunica vaginalis, normally attaches to the posterior wall inferiorly near the inferior posterior testicle and superiorly at the superior testicular region. If both attachments of the tunica vaginalis occur superior to the testicle, the bell clapper deformity develops, which increases the likelihood of torsion because the testicle is freely mobile within the tunica. This abnormality has been reported in 12% of cases in an autopsy series and is frequently a bilateral phenomenon.
Once torsion has occurred, time to de-torsion and restoration of the vascular supply will determine the extent of testicular viability. Humoral factors may play a role in the spermatogenesis of the unaffected, contralateral testicle as well. The exact mechanism responsible for the effect of torsion/de-torsion injury on the contralateral testicle is unknown. Testicular germ cell death occurs secondary to decreased oxygen supply, cellular energy depletion, and toxic metabolite formation. Mechanisms for ischaemia/reperfusion injury that can affect both testes have been suggested, including inflammatory mechanisms and/or free oxygen radical formation.
Number of rotations, which can range from 180° to 1080°, and duration of ischaemia both determine the degree of tissue viability. If de-torsion occurs within 4 to 6 hours after the onset of symptoms then the affected testis will most likely remain viable. If the testes remain twisted for more than 10 to 12 hours, ischaemia and irreversible testicular damage are likely. After 12 hours, necrosis has most likely occurred.
what are the key presentations of testicular torsion?
Testicular pain Intermittent pain No pain relief upon elevation of scrotum Scrotal swelling or oedema Scrotal erythema Reactive hydrocele High riding testicle Horizontal lie Absent cremasteric reflex
what are the signs of testicular torsion?
Scrotal swelling or oedema Scrotal erythema Reactive hydrocele High riding testicle Horizontal lie Absent cremasteric reflex
what are the symptoms of testicular torsion?
Testicular pain Intermittent pain No pain relief upon elevation of scrotum Nausea Abdo pain fever
what are the first line and gold standard investigations for testicular torsion?
surgical exploration - GOLD STANDARD
Grey-scale ultrasound - presence of fluid and the whirlpool sign (the swirling appearance of the spermatic cord from torsion as the ultrasound probe scans downwards perpendicular to the spermatic cord). The whirlpool sign is of limited utility in neonates, and the sensitivity of detecting a whirlpool sign varies with ultrasonographer experience. Therefore, sonographic findings must be interpreted in combination with clinical findings.
Power doppler ultrasound - absent or decreased blood flow in the affected testicle; decreased flow velocity in the intra-testicular arteries, increased resistive indices in the intra-testicular arteries
Colour doppler ultrasound - absent or decreased blood flow in the affected testicle; decreased flow velocity in the intra-testicular arteries, increased resistive indices in the intra-testicular arteries
what are the differential diagnoses for testicular torsion?
Testicular appendix torsion, epididymitis or epididymo-orchitis, hydrocele
how is testicular torsion managed?
Acute (non-neonate):
Immediate urological consultation for emergency scrotal exploration, supportive care, prosthetic device, manual de-torsion followed by scrotal exploration
(neonate):
Initial stabilisation and urological consulation and semi-elective scrotal exploration, supportive care
how is testicular torsion monitored?
Patients should be monitored for postoperative complications, including infection, and delayed complications such as testicular atrophy and infertility.
what are the complications of testicular torsion?
Infarction of testicle, infertility secondary to loss of teaticale, psychological impairment of losing a testicle
what is the prognosis of testicular torsion?
The adage ‘time is testicle’ applies to patients with testicular torsion because the longer it takes for diagnosis and definitive repair, the greater the likelihood that the patient will develop tissue necrosis, decreased tissue viability, decreased spermatogenesis, and possible infertility
