testicular torsion Flashcards
what is it?
testicle twists around the spermatic cord leading to the obstruction of blood flow to the affected testicle
results in testicular necrosis and atrophy.
who does it happen in?
Testicular torsion has two peaks in incidence: in the neonatal period and at age 13-16 years
It can occur in men of any age
what is the aetiology In utero or in neonates?
extravaginal torsion occurs which is when the entire spermatic cord twists including the processus vaginalis (this is before the testes are fixed in the scrotum).
what is the aetiology beyond utero or in neonates?
Beyond the neonatal period, intravaginal torsion predominates which refers to the cord twisting within the tunica vaginalis. This is often because of a bell clapper deformity where the testes are not attached properly to the tunica vaginalis and so they are more mobile and more liable to twist.
what are the risks factors?
Previous testicular torsion (suspect if history of episodes of testicular pain that self-resolved)
Family history of testicular torsion
Undescended testes
Testicular tumours
May be precipitated by trauma or exercise
what are the features?
Sudden onset severe pain in one testicle
N+V due to pain
Abdominal or groin pain
On examination:
Unilateral tender testicle
may appear swollen
may be high riding in the scrotum or lying in the transverse plane
Unilateral loss of cremasteric reflex
Persistent pain despite elevation of the testicle (negative Prehn’s sign)
what are differentials?
epididymo-orchitis - slower onset, may be 2ndry to UTI, Prehn’s +ve
Torsion of epididymal appendage - tender blue spot on scrotum, localised to upper pole
Incarcerated inguinal hernia - presents with groin pain and swelling in the groin or scrotum; features of bowel obstruction may be present e.g. vomiting and abdominal pain
Trauma- may lead to a variety of injuries including haematocele, haematoma, testicular contusion or rupture, these generally present with pain and swelling after local trauma and ultrasound may be useful to differentiate these
what ix are done?
usually clinical
baseline bloods eg group + save, clotting screen, ECG
doppler USS to demonstrate reduced/absent blood flow
urinalysis if epididymo-orchitis suspected
what is the conservative mx?
Immediate referral to urology for emergency surgery
Keep patients nil by mouth
Manual reduction of the torsion may be attempted (immediate surgery is still required for orchidopexy if this is successful)
what is the medical mx?
Ensure adequate analgesia is given for pain
Antiemetics may be required for nausea and vomiting
what is the surgical mx?
Urgent surgical exploration is crucial to confirm the diagnosis and to attempt to salvage the testicle
If the testicle is viable, bilateral orchidopexy should be carried out
If it is not viable, it should be removed (an orchidectomy) - a prosthesis may be implanted at a later date for cosmetic reasons
Orchidopexy of the contralateral testicle should always be carried out to reduce the risk of recurrence on the other side
what are the complications?
Testicular atrophy, ischaemia and necrosis
Impaired fertility
Chronic intermittent torsion may cause segmental ischaemia of the testicle
Without orchidopexy of the contralateral testicle, there is a 40% risk of torsion on the other side
