Testicular Torsion

Question 1

… is a urological emergency, that without intervention leads to ischaemia and loss of the testis.

Answer 1

Testicular torsion is a urological emergency, that without intervention leads to ischaemia and loss of the testis.

Question 2

Testicular torsion is a rare but serious condition. Successful treatment requires prompt recognition, referral and surgical intervention.

It exhibits a … distribution with peaks …

Answer 2

Testicular torsion is a rare but serious condition. Successful treatment requires prompt recognition, referral and surgical intervention.

It exhibits a bimodal distribution with peaks in the neonatal period and around puberty.

Question 3

Differential Diagnosis for testicular torsion

Answer 3

Trauma
Epididymo-orchitis
Torsion of the epididymal appendage
Testicular tumour (an association between testicular cancer and torsion has been described)
Hydrocele
Inguinal hernia
Systemic diseases (e.g. Henoch-Schönlein purpura, Mumps)

Question 4

Testicular torsion may be … or ….

Answer 4

Testicular torsion may be intravaginal or extravaginal.

Question 5

.. torsion occurs in-utero and in neonates. It occurs as the tunica vaginalis is not fixed to the gubernaculum and can tort en masse with the spermatic cord.

Answer 5

Extravaginal torsion occurs in-utero and in neonates. It occurs as the tunica vaginalis is not fixed to the gubernaculum and can tort en masse with the spermatic cord.

Question 6

Intravaginal torsion occurs due to torsion of the spermatic cord within the tunica vaginalis, it most commonly occurs in …. Patients with a ‘bell clapper’ deformity, where they have a high insertion of the tunica vaginalis, are predisposed to testicular torsion.

Answer 6

Intravaginal torsion occurs due to torsion of the spermatic cord within the tunica vaginalis, it most commonly occurs in adolescence. Patients with a ‘bell clapper’ deformity, where they have a high insertion of the tunica vaginalis, are predisposed to testicular torsion.

Question 7

Clinical features of testicular torsion?

Answer 7

Patients will complain of testicular pain, usually with a quick onset.

Question 8

Symptoms of testicular torsion

Answer 8

Acute, severe, testicular pain

Nausea and vomiting

Question 9

Signs of testicular torsion

Answer 9

Testicular swelling
Testicular erythema
Tenderness
High riding testicle
Prehn’s sign: states that elevation of the affected testicle relives the pain of epididymitis but not of testicular torsion.
Cremasteric reflex: a reflex caused by stroking the inner thigh leading to cremasteric contraction and elevation of the scrotum on the same size. May be absent in torsion.

Question 10

… reflex: a reflex caused by stroking the inner thigh leading to … contraction and elevation of the scrotum on the same size. May be absent in torsion.

Answer 10

Cremasteric reflex: a reflex caused by stroking the inner thigh leading to cremasteric contraction and elevation of the scrotum on the same size. May be absent in torsion.

Question 11

… sign: states that elevation of the affected testicle relives the pain of epididymitis but not of testicular torsion.

Answer 11

Prehn’s sign: states that elevation of the affected testicle relives the pain of epididymitis but not of testicular torsion.

Question 12

Bedside tests in suspected testicular torsion

Answer 12

Vital signs
Urine dipstick (send MSU)
Consider sexual health screen (if epididymo-orchitis considered)
BM (if diabetic or suspected diabetic)

Question 13

Bloods in suspected testicular torsion

Answer 13

FBC
UEs
CRP

Question 14

Imaging in testicular torsion?

Answer 14

Imaging is not typically indicated or recommended, it can lead to unnecessary delays and the sequelae of a false-negative are significant.

Literature has indicated a reasonable sensitivity and specificity of Doppler USS, though with a great deal of inter-operator variability.

The decision to obtain a USS in equivocal cases should be made by a urology consultant.

Question 15

Management of testicular torsion

Answer 15

Prompt surgical exploration is key, viability of the testicle reduces significantly after 4-6 hours.

Question 16

Referring for testicular torsion

Answer 16

Once suspicion of torsion has been raised, an urgent referral to paediatric surgery or urology should be made. The patient should be made nil by mouth, and appropriate basic investigations obtained.

Question 17

Surgery for testicular torsion

Answer 17

Emergency testicular exploration is indicated in patients with suspected testicular torsion. If confirmed (and the testicle is viable) torsion is managed with detorsion and orchidopexy (fixation of the testicle with sutures). The contralateral testicle should also be explored and fixed in place due to the increased risk of further testicular torsion.

Care should be taken to clearly explain that this is in part a diagnostic procedure and no evidence of torsion (or indeed any pathology) may be found. Additionally, you must explain that orchidectomy may be required if a non-viable testicle is found. An implant can be placed at a later date.

In the setting of a very delayed presentation with a missed testicular torsion, consult with the urology consultant on-call about how to proceed.

Question 18

Follow-up in testicular torsion

Answer 18

Patients, particularly paediatric patients, should be followed up at 6 months for review and assessment of the testis.

In cases of orchidectomy a prosthesis should be offered (though delayed until after puberty if pre-pubescent). Psychological support, for both the patient and their guardian, should be offered.

Question 19

Complications of testicular torsion

Answer 19

Misdiagnosis or incorrect management may result in a number of complications.

Orchidectomy
Delayed testicular atrophy
Recurrence
Fertility issues

Question 20

What is eequired if a non-viable testicle is found on exploration? (Testicular torsion)

Answer 20

Orchidectomy
Required if a non-viable testicle is found on exploration. Viability drops off rapidly after 6 hours from the onset of symptoms. If < 6 hours viability is approximately 90%, this falls to around 10% at 24 hours. The degree of torsion impacts this, a 360-degree twist may result in testicular necrosis in under 4 hours.

Question 21

An orchidectomy is required if a non-viable testicle is found on exploration.

Viability drops off rapidly after … hours from the onset of symptoms.

Answer 21

An orchidectomy is required if a non-viable testicle is found on exploration.

Viability drops off rapidly after 6 hours from the onset of symptoms. If < 6 hours viability is approximately 90%, this falls to around 10% at 24 hours. The degree of torsion impacts this, a 360-degree twist may result in testicular necrosis in under 4 hours.

Question 22

Delayed testicular atrophy

Answer 22

May occur even after successful detorsion with a viable appearing testicle. Again risk is increased the greater the delay to surgery

Question 23

Unfortunately, orchidopexy does not guarantee torsion cannot recur though rates are estimated to be < ,,,%. There remains debate and differing practice in exact fixation techniques and suture material used.

Answer 23

Unfortunately, orchidopexy does not guarantee torsion cannot recur though rates are estimated to be < 5%. There remains debate and differing practice in exact fixation techniques and suture material used.

Question 24

Fertility after testicular torsion?

Answer 24

Some studies have shown impaired semen in patients undergoing delayed surgery. Most men will not have trouble conceiving following an orchidectomy providing the remaining testicle is healthy.