Testicular Torsion

Question 1

Define

Answer 1

MOST COMMON in post-pubertal boys

• Sudden onset, very painful, with redness and oedema of the scrotal skin, N+V
• Pain may localise to the groin or lower abdomen

IMPORTANT: this is why you need to examine the testes of a boy presenting with sudden onset groin/ abdominal pain

• Must be distinguished from an incarcerated inguinal hernia
• Undescended testes are at increased risk of torsion
• A testis that is lying transversely on its attachment to the spermatic cord (bell clapper testis) is also at increased risk

Must be treated within HOURS of onset of symptoms to avoid testicular loss

SURGICAL EXPLORATION in any acute scrotal presentation is mandatory unless torsion can be excluded with certainty

During surgery, fixation of the contralateral testis is essential because of the increased risk of contralateral torsion

In perinatal testicular torsion, loss of the testis is almost inevitable

Question 2

Signs and symptoms

Answer 2

Signs & symptoms:

o Redness, oedema, N&V

o Sudden onset pain – localised in testis or in the abdomen

Question 3

Investigation

Answer 3

Doppler USS (but this cannot delay surgery)

Lifting testes increases pain (in epididymitis, it relieves / Prehn’s sign)

Cremasteric reflex absent

Do a quick urine microscopy to rule out Epididymo-orchitis

Question 4

Management

Answer 4

Patients presenting within 4-6 hours of symptom onset have a greater likelihood of testicular viability

Non-Neonates
* Immediate urological consultation for operative repair
* Decision about orchidectomy vs orchiopexy is based on the extent of damage to the testicular tissue
* During surgery, the contralateral testis is fixed to the posterior wall

Neonates

• Born with torsion- debate about whether surgical intervention is necessary (risk of anaesthesia)
• Born with normal testes but develop torsion- urgent surgical exploration is necessary
• Manual detortion may be attempted if surgery is not available within 6 hours

Supportive Care

Pain relief and sedation

Anti-emetics

Question 5

Torsion of appendix testis

Answer 5

A testicular appendage (Hyatid of Morgagani) is a Mullerian (paramesonephric) remnant usually located on the upper pole of the testis

Tends to affect pre-pubertal boys

Torsion of the testicular appendage is MORE COMMON than the testicular torsion

Pain will develop over days and is NOT as dramatic as testicular torsion

Scrotal exploration and excision of the appendage is often necessary because it CANNOT be reliably differentiated from testicular torsion

If a ‘blue dot’ can be seen through the scrotal skin and the pain is controlled with analgesia, surgery may not be necessary

NOTE: Epididymo-orchitis can mimic but is usually more insidious, in older patients and is associated with urinary symptoms often.