Testicular torsion

Question 1

What is it?

Answer 1

Testicular torsion refers to twisting of the spermatic cord with rotation of the testicle. It is a urological emergency, and a delay in treatment increases the risk of ischaemia and necrosis of the testicle, leading to sub-fertility or infertility.

The typical patient is a teenage boy, but it can occur at any age.

There may be a history of recurrent symptoms in patients where there is intermittent testicular torsion.

Question 2

Examination

Answer 2

Testicular torsion is often triggered by activity, such as playing sports. Ask what the patient was doing at the time when the pain started.

It presents with an acute rapid onset of unilateral testicular pain, and may be associated with abdominal pain and vomiting. Sometimes abdominal pain is the only symptom in boys, and testicular examination to exclude torsion is essential.

Examination findings are:

Firm swollen testicle
Elevated (retracted) testicle
Absent cremasteric reflex
Abnormal testicular lie (often horizontal)
Rotation, so that epididymis is not in normal posterior position

If in doubt, or if there is any suspicion of torsion, get an immediate senior urology opinion.

Question 3

Bell-Clapper Deformity

Answer 3

A bell-clapper deformity is one of the causes of testicular torsion.

Normally, the testicle is fixed posteriorly to the tunica vaginalis. A bell-clapper deformity is where the fixation between the testicle and the tunica vaginalis is absent. The testicle hangs in a horizontal position (like a bell-clapper) instead of the typical more vertical position. It is also able to rotate within the tunica vaginalis, twisting at the spermatic cord. As it rotates, it twists the vessels and cuts off the blood supply.

Question 4

Management

Answer 4

Testicular torsion is a urological emergency, and there is an urgent requirement for treatment. Any delay in treatment will prolong the ischaemia and reduce the chances of saving the testicle.

The management of testicular torsion involves:

Nil by mouth, in preparation for surgery
Analgesia as required
Urgent senior urology assessment
Surgical exploration of the scrotum
Orchiopexy (correcting the position of the testicles and fixing them in place)
Orchidectomy (removing the testicle) if the surgery is delayed or there is necrosis

A scrotal ultrasound can confirm the diagnosis. However, any investigation that will delay the patient going to theatre for treatment is not recommended. Ultrasound can show the whirlpool sign, a spiral appearance to the spermatic cord and blood vessels.