Testicular torsion

Question 1

Testes anatomy

Answer 1

Question 2

Describe testicular torsion?

Answer 2

• Spermatic cord twists within the tunica vaginalis, compromising the blood supply to testicle
• Surgical emergency
  
  • Infarction within hours if untreated
• Peak incidence is in neonates and 12-25 year olds

Question 3

Describe the pathophysiology of testicular torsion?

Answer 3

• Torsion occurs when a mobile testis rotates on the spermatic cord. This leads to reduced arterial blood flow, impaired venosu return, venous congestion, oedema and infarction to the testis if not corrected.
• Males with bell-clapper deformity have an increased risk

Question 4

Describe bell-clapper deformity?

Answer 4

• Males who have a horizontal lie to their testes
• Testis lacks a normal attachment to the tunica vaginalis => more mobile
• Increased liklihood of it twisting on the cord structures

Question 5

Describe neonatal testicular torsion?

Answer 5

• Attachment between the scrotum and tunica vaginalis is not fully formed
  
  • => The entire testis and tunica vaginalis can tort
  • Known as extra-vaginal torsion
• Can occur in-utero so new-borns must be thoroughly examined at their first check

Question 6

What are the most common risk factors for developing a torsion?

Answer 6

• Age (12-25yrs)
• Previous testicular torsion
• Family history of testicular torsion
• Undescended testes

Question 7

What are the clinical features of testicular torsion?

Answer 7

• Sudden onset severe unilateral testicular pain
  
  • Often associated with N/V
  • Referred abdominal pain can occur
• Testis have a high position on examination with a horizontal lie
• Absent cremasteric reflex
• Negative Prehn’s sign: pain continues despite testicle elevation

Question 8

Describe the investigations that should be performed for a suspected testicular torsion?

Answer 8

• Clinical diagnosis
• Any suspected cases should be taken for scrotal exploration in theatre
• Doppler US can be used
  
  • Investigate compromised blood flow to testis
• Urine dipstick
  
  • Rule out an infective component

Question 9

Describe the management of testicular torsion?

Answer 9

• 4-6 hr window to salvage testis before irreversible damage
• Urgent surgical exploration
• Analgesia and anti-emetics
• Nil by mouth with maintenance fluids

Question 10

Surgical approaches to testicular torsion?

Answer 10

• Bilateral orchidopexy
  
  • Cord and testis are untwisted
  • Both testicles are fixed to the scotum to prevent recurrence
• If testis are unviable:
  
  • Orchidectomy +/- prosthesis insertion

Question 11

What are the complications of testicular torsion?

Answer 11

• Testicular infarction from prolonged ischaemia
• Atrophy can occur despite treatment
• Impact on fertility

Question 12

How does testicular torsion present?

Answer 12

Unilateral testicular pain

Question 13

What pathology does the blue dot sign classically suggest?

Answer 13

Torsion of the Hydatid of Morgagni