Testicular Torsion

Question 1

def

Answer 1

a urological emergency whereby twisting of the testicle on the spermatic cord leads to constriction of the vascular supply
this leads to ischaemia and/or necrosis of the teste

Question 2

epi

Answer 2

bimodal distribution
babies - extra-vaginal torsion
adolescent boys - intra-vaginal torsion

Question 3

what is extra-vaginal torsion

Answer 3

rare
occurs during the perinatal period as the testicle descends and twists around the spermatic cord before attaching to the posterior scrotal wall

Question 4

what is intra-vaginal torsion

Answer 4

most common type of testicular torsion
occurs because of an abnormally high attachment of the tunica vaginalis to the spermatic cord, which allows rotation of the testicle within the sac

Question 5

aetiology

Answer 5

1 intra-vaginal torsion (adolescent boys) most common
2 extra-vaginal torsion (babies) rare
3 trauma

Question 6

what is the most common anatomical defect associated with intra-vaginal torsion

Answer 6

bell clapper deformity

Question 7

risk factors

Answer 7

neonate (extra-vaginal torsion)
adolescent boys (intra-vaginal torsion)
bell clapper deformity

Question 8

what is the bell clapper deformity

Answer 8

anatomical anomaly which allows the testicles to rotate freely within the tunica vaginalis, this leads to constriction of the vascular supply

Question 9

why does intra-vaginal torsion occur

Answer 9

there is an abnormally high attachment of the tunica vaginalis to the spermatic cord which allows rotation of the testicle

Question 10

history

Answer 10

sudden onset scrotal pain, commonly with N+V
scrotal swelling, redness
Hx of intermittent scrotal pain may indicate periods of torsion and spontaneous de-torsion

Question 11

examination

Answer 11

scrotal tenderness, swelling, erythema
high-riding testicle (due to twisting of testicle, it appears higher than the unaffected testicle)
loss of the cremasteric reflex
no pain relief on elevation of the scrotum (excludes hydrocele)

Question 12

investigations

Answer 12

1 grey-scale USS
-presence of fluid
-whirlpool sign (swirling appearance of spermatic cord)
2 doppler USS
-absent or reduced blood flow

Question 13

a 13y/o boy developed sudden onset unilateral scrotal pain which woke him from his sleep. Presents with left scrotal pain, N+V, and lower left abdominal pain. O/E has a tender, enlarged, high-riding testicle, there is an absent cremasteric reflex

Answer 13

testicular torsion

Question 14

management of a non-neonate (adolescent boy) with testicular torsion

Answer 14

first line treatment would involve immediate urological consultation for operative repair with pain relief
second line treatment would be attempted if surgery was not immediately available, this is manual de-torsion (right testicle twisted counterclockwise and the left testicle twisted clockwise) with pain relief

Question 15

management of a neonate with testicular torsion

Answer 15

generally require urological consultation + exploration

with pain relief

Question 16

complications

Answer 16

irreversible testicle damage leading to loss of the testicle and infertility

Question 17

how does time between onset of symptoms and treatment affect prognosis

Answer 17

if treatment is started within 4-6hrs after onset of symptoms - good prognosis, if 6-10hrs, ischaemia and irreversible testicular damage is likely, if longer than 12hrs necrosis is likely

Question 18

prognosis

Answer 18

“time is testicle” the longer it takes for treatment, the worse the outcome