Testicular Torsion

Question 1

Definition of testicular torsion

Answer 1

Is a urological surgical emergency that is caused by the twisting/torsion of the spermatic cord, leading to constriction of vascular supply, time sensitive ischaemia and/or necrosis of the testicular tissue

Question 2

Aetiology of testicular torsion

Answer 2

• Split into intra-vaginal and extra-vaginal torsion:
• Intra-vaginal torsion: Bell clapper deformity is the most common anatomical defect associated with this. TRAUMA comes too. Spermatic cord twists within the tunica vaginalis (layer or peritoneum surrounding testicle)
• Extra-vaginal torsion: unknown cause

Question 3

Pathophysiology of testicular torsion

Answer 3

• Once torsion has occurred, the amount of time that the vascular supply has been cut off would influence the risk fo ischaemia and necrosis of the testicular tissue
• Detorsion within 4-6 hours is the best chance to ensure the testicle is viable
• 10-12 hours indicates a high risk of irreversible testicular damage due to ischaemia

Question 4

History and Examination of testicular torsion

Answer 4

• Testicular pain: SEVERE and SUDDEN onset scrotal pain on side of affected testicle
• Nausea and vomiting: pain usually associated with this
• Referred lower abdominal pain
• Scrotal swelling or oedema
• Scrotal erythema: skin can redden with time
• High riding testicle: may have retracted upwards
• No relief upon elevation of scrotum
• Horizontal lie of affected testicle

Question 5

Risk factors for testicular torsion

Answer 5

• Age under 25 years old
• Neonate
• Bell clapper deformity
• Trauma
• Intermittent testicular pain: due to intermittent torsion and detorsion

Question 6

Investigations for testicular torsion

Answer 6

• Grey-scale ultrasound: Most specific sign is the Whirlpool sign (swirling of spermatic cord). There would also be presence of fluid
• Power Doppler ultrasound: would show absent or decreased blood flow in the affected testicle
• DO NOT DELAY surgical exploration

Question 7

Treatment of testicular torsion

Answer 7

High suspicion of torsion:
1) Immediate urological consultation for emergency scrotal exploration:
◦ explore with possible detorsion.
◦ Testicular function likely to be compromised due to torsion. Check viability of testcicle before considering orchidectomy
◦ If colour looks fine, attach to the scrotum wall to prevent future torsion
◦ The contralateral testicle is fixed to the posterior wall to prevent future torsion

+ Supportive care: treat severe pain with morphine sulphate

Question 8

Prevention and prognosis of testicular torsion

Answer 8

• Any patient with undescended testes or intermittent testicular pain (intermittent torsion) should be referred for repair
• Secondary: during exploration, the testes should be attached to the posterior wall of the scrotum to prevent future torsion

Fast and effective treatment increases the chance of saving the testicle (within 4-6 hours)
There is risk of recurrent torsion

Question 9

Complications of testicular torsion

Answer 9

• Infarction of testicle/permanent damage/loss of testicle: twisted for more than 10-12 hours likely ischameia and necrosis
• Infertility secondary to loss of testicle
• Recurrent torsion: increased risk in those with past torsion