Testicular torsion

Question 1

Define

Answer 1

• A SURGICAL EMERGENCY. Twisting or torsion of the spermatic cord results, initially, in venous outflow obstruction from the testicle, progressing to arterial occlusion and testicular infarction if not corrected.

Question 2

What are the two types?

Answer 2

• Intravaginal (MOST COMMON)
o The spermatic cord twists within the tunica vaginalis
o Bell clapper deformity (due to tunica vaginalis attaching superiorly only)
• Extravaginal (usually in neonates)
o The entire testis and tunica vaginalis twist in a vertical axis on the spermatic cord
o Due to incomplete fixation of the gubernaculum to the scrotal wall allowing free rotation

Question 3

What are the risk factors?

Answer 3

o Imperfectly descended testes
o High investment of the tunica vaginalis (bell clapper deformity) – MOST COMMON
o Age under 25

Question 4

Epidemiology

Answer 4

• Most common cause of acute scrotal pain in 10-18 yr olds

Question 5

WHat are the presenting symptoms?

Answer 5

• Sudden-onset severe hemiscrotal pain
• Abdominal pain
• Nausea and vomiting

Question 6

What are the signs?

Answer 6

• Swollen, erythematous scrotum on the affected side
• Swollen testicle will lie slightly higher than the unaffected one
• Testicle might lie horizontal
• Thickened cord
• Absent cremasteric reflex

Question 7

What are the appropriate investigations?

Answer 7

•	Doppler/Duplex Imaging of the Testes
o	Do NOT delay surgery
o	Arterial inflow 
•	REDUCED in testicular torsion
•	INCREASED in epididymo-orchitis 

Also do FBC, CRO and urinalysis to rule out other causes such as epididymitis

Question 8

How do you manage?

Answer 8

• Immediate urology consultation, exploration of the scrotum within 6 hrs of onset of symptoms
• After the testicle is twisted back into place, a bilateral orchidopexy is performed
• This involves suturing the testicle to the scrotal tissue to prevent recurrence
• If the testicle is necrotic, orchidectomy may be performed

Question 9

WHat are the possible complications?

Answer 9

• Testicular infarction
• Testicular atrophy
• Infertility secondary to loss of testicle
• Infection
• Impaired fertility (due to production of anti-sperm antibodies)
• Impaired pubertal development
• Recurrent torsion

Question 10

Whats the prognosis?

Answer 10

• From the onset of torsion, a testicle may only survive 4-6 hrs
• With prompt surgical intervention, most testicles are salvaged