Testicular Torsion

Question 1

Pathology

Answer 1

Testicular torsion is caused by the twisting of the testis and spermatic cord within the scrotum, with resulting in occlusion of venous return and and edema. If the torsion persists, it can result in arterial occlusion and ischemia. Ischemia eventually leads to infarction and, resulting in decreased fertility due to loss of the testicle.

• Normally the testicle is anchored within the scrotum by the tunica vaginalis, which surrounds the testicle and attaches posteriorly to the scrotal wall and epididymis

Question 2

When is testicular torsion most common?

Answer 2

First year of life and puberty

Question 3

Symptoms

Answer 3

fairly sudden, severe unilateral testicular pain, sometimes radiating into the abdomen, associated with nausea and vomiting. They may also report urgency, frequency, and dysuria. The left testicle is more frequently affected.

Question 4

What is the most accurate physical exam sign for torsion

Answer 4

Several studies have found loss of the cremasteric reflex to be the most accurate sign of testicular torsion. This reflex is elicited by stroking the ipsilateral thigh which leads to reflex elevation of the ipsilateral testicle by greater than 0.5cm

Question 5

Other physical exam findings

Answer 5

Significant distress.
Always examine the unaffected testicle first in both the supine and standing position.
Tremendous amount of discomfort. The testicle is usually exquisitely tender and swollen. It may sit higher within the scrotum than the opposite testis, and may have a transverse lie.
- Prehns sign. Relief of pain with elevation of the testicle used to indicate epidydimitis, and decrease concern for torsion, but this is not the most reliable.

Question 6

Lab work

Answer 6

If infectious epididymitis or orchitis is suspected, it is reasonable to perform a urinalysis or urethral swab for gonorrhea and chlamydia. Caution should be exercised since as many as 30% of patients with torsion will have white blood cells present on the urinalysis.

Question 7

Best imaging choice?

Answer 7

US
The painful testicle is usually enlarged and hypoechoic, with decreased blood flow, compared to the asymptomatic side. Twisting of the spermatic cord may be also visible on ultrasound.
- Complete absence of Doppler flow confirms the diagnosis of torsion, but is a relatively late finding.
- By contrast, epididymitis is usually associated with increased blood flow to the testicle and the epididymis, as part of the body’s inflammatory response.

Question 8

Treatment of torsion?

Answer 8

Surgery. Within 6 hours is best.

• Can do manual detorsion with sedated patient if no access to surgery. Twist testicle manually, starting with away from the midline like you are opening a book if you are standing at the patient’s head.
• In addition, bilateral orchiopexy is usually done to prevent future torsion and preserve fertility.

Question 9

Comparing Testicular torsion, torsion of testicular appendage, and epidydimitis
- Testicular torsion

Answer 9

Age: Infant and puberty
Features of pain: Entire testicle, onset over hours
Associated S/S: Nausea
PE: Cremasteric reflex absent. Diffusely swollen tender testicle
Labs: Not helpful
US: Affected testicule large and hypoechoic compared to asymptomatic side with decreased flow.
Treatment: Surgical detorsion and bilateral orchiopexy
Outcome if no treatment: Testicular infarction, decreased fertility

Question 10

Comparing Testicular torsion, torsion of testicular appendage, and epidydimitis
- Torsion of testicular appendage

Answer 10

Age: 7-14
Features of pain: Upper pole of testicle, onset over hours to day
Associated S/S: None
PE: Cremasteric reflex present
Labs: Not helpful
US: Body of testis similar to asymptomatic side with focal hypo echoic area.
Treatment: Supportive
Outcome if no treatment: Infarction and resorption of appendage, no effect on fertility

Question 11

Comparing Testicular torsion, torsion of testicular appendage, and epidydimitis
- Epidydimitis

Answer 11

Age: Adult
Features of pain: Epididymis, onset over days
Associated S/S: Fever, dysuria
PE: Cremasteric reflex present. Epididymal tenderness with or without testicular tenderness.
Labs: WBC, LE, nitrites
US: Body of testis similar to asymptomatic side with hypoechoic epididymis
Treatment: Antibiotics
Outcome if no treatment: Possible scarring, possible impaired fertility