Testicular torsion

Question 1

what is it?

Answer 1

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.

SURGICAL EMERGENCY

Question 2

What causes it?

Answer 2

Intravaginal (MOST COMMON)
The spermatic cord twists within the tunica vaginalis

Due to incomplete fixation of the gubernaculum to the scrotal wall allowing free rotation - The Bell Clapper deformity

Extravaginal (usually in neonates)
The entire testis and tunica vaginalis twist in a vertical axis on the spermatic cord

Question 3

Risk Factors

Answer 3

Imperfectly descended testes

High investment of the tunica vaginalis

Question 4

Summarise the epidemiology of testicular torsion

Answer 4

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

Question 5

Recognise the presenting symptoms of testicular torsion

Answer 5

Sudden-onset severe hemiscrotal pain (more acute than epididymitis!)

Abdominal pain

Nausea and vomiting

Question 6

Recognise the signs of testicular torsion on physical examination

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

Testicular Appendix ;
twisted. There may be a visible necrotic lesion on transillumination

Differential Diagnosis ;
Epididymo-orchitis
Incarcerated inguinal hernia

Question 7

What are appropriate investigations?

Answer 7

1. Grey scale ultrasound*
2. Power or colour doppler ultrasound **

• presence of fluid and the whirlpool sign (the swirling appearance of the spermatic cord from torsion)
• *absent or decreased blood flow in the affected testicle; decreased flow velocity in the intra-testicular arteries

Question 8

Compare blood flow in torsion vs epididymo-orchitis

Answer 8

REDUCED in testicular torsion

INCREASED in epididymo-orchitis

Question 9

Management plan for torsion?

Answer 9

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 10

prognosis of torsion?

Answer 10

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