Testicular torsion Flashcards
Define testicular torsion.
A urological emergency caused by the twisting of the testicle on the spermatic cord leading to constriction of the vascular supply and time-sensitive ischaemia and/or necrosis of testicular tissue.
How common is testicular tortion? Who is most affected?
Has a bimodal distribution -
- extra-vaginal torsion affecting neonates in the perinatal period,
- intra-vaginal torsion affecting males of any age but most commonly adolescent boy. Uncommon in elderly .
What are the risk factors for testicular torsion?
- <25yrs old
- neonate
- bell clapper deformity
- trauma/exercise
- intermittent testicular pain
- undescended testicle
- cold weather - higher incidence in winter
What is the aetiology of testicular torsion?
- Bell clapper deformity - most common anatomical defect associated with development of intra-vaginal testicular torsion
- Trauma
Extra-vaginal torsion aetiology is unknown and no anatomical defect is usually identified.
Long mesorchium (dense band of connective tissue which attaches the efferent ductules of epididymis to the posterolateral wall of the testes), if elongated may allow the testicle to twist and epididymis to remain fixed.
What is the most common type of testicular torsion?
Intra-vaginal- due to abnormally high attachment of the tunica vaginalis
What is the bell clapper deformity?
The tunica vaginalis, normally attaches to the posterior wall inferiorly near the inferior posterior testicle and superiorly at the superior testicular region. If both attachments of the tunica vaginalis occur superior to the testicle, the bell clapper deformity develops, which increases the likelihood of torsion because the testicle is freely mobile within the tunica.
Describe a typical presentation of testicular torsion.
- Sudden onset testicular pain
- Intermittent pain - periods of torsion and de-torsion
- Scrotal swelling/oedema, erythema
- Reactive hydrocele - may develop with time
- High-riding testicle - higher than unaffected side
- Horizontal lie of affected side
- No pain relief on elevation of scrotum
- Absent cremasteric reflex - stroking inner part of thigh causes the cremaster muscle to contract and pull up the ipsilateral testicle towards inguinal canal
- N&V - common in children
- Abdominal pain - in undescended testis always assess for torsion
Uncommon - fever, urinary frequency (more suggestive of infective cause)
What investigations would you do for testicular tortion?
Physical examination - clinical relief/improvement may occur after manual de-torsion of the testicle suggesting torsion
ASAP determine if surgical intervention is necessary. Usually urological consultation is required for this.
US testicle +/- colour Doppler - analgesia necessary; grey scale US may show whirlpool sign (swirling appearance of spermatic cord from torsion as the US probe scans downwards perpendicular to spermatic cord). Doppler shows direction of blood flow to identify perfusion of testis
FBC, CRP, urinalysis to rule out epididymo-orchitis, Fournier’s gangrene, scrotal abscess.
What is the (non-neonate) management of testicular torsion?
1st line - Immediate urological consultation for emergency scrotal exploration - suitability for surgical exploration/repair and optimisation of salvageability.
2nd line - Manual detorsion followed by scrotal exploration -“open book method” - right testicle is rotated counter-clockwise and left clockwise.
Supportive care - morphine sulphate for severe pain and sedation for manual de-torsion
NB: if testicle is lost, prosthetic may be inserted.
What are the complications of testicular torsion?
- Infarction of testicle/permanent damage/loss of testicle - rotations can range from 18-720 degrees and duration of ischaemia determine degree of viability. Testes usually viable if treated within 4-6 hours.
- Infertility secondary to testicle loss - if testes remain twisted for 10-12 hours; spermatogenesis severely impaired in most.
- Psychological impact
- Cosmetic deformity - silicone filled implants may be considered
- Recurrent torsion - regardless whether absorbable or non-absorbable sutures were used
- Impaired pubertal development - patients with significant or bilateral testicular loss, hormone replacement therapy may be needed to improve the likelihood of appropriate pubertal development of secondary sex characteristics.
What is the prognosis of testicular torsion?
- “Time is testicle” - the longer it takes to diagnose and repair the worse the prognosis leading to infertility
- Psychological wellbeing may be imporved by inserting a prosthetic device (saline-filled silicone implant).Recent advances have begun to look at testosterone-releasing prosthetic devices.
What are the differentials for testicular tortion?
- torted appendix testis,
- epididymitis,
- viral orchitis,
- bleed into testicular tumour
What is the problem with appendix testis? How might you recognise it ?
Cannot distinguish from testicular tortion - should only manage conservatively if confident of diagnosis
Blue dot sign - a tender nodule with blue discoloration on the upper pole of the testis
Which one of these investigations would you do in suspected testicular torsion?
- Testicular ultrasound
- Urine dipstick
- Intravenous urogram
- Abdominal x-ray
- ECG
2.
Testicular torsion is an emergency. The patient needs emergency surgery. This should not be delayed for any investigation. Urine dipstick is a quick and simple investigation and can be performed with other routine observations. It is usually normal in torsion.
How does torsion of the hydatid of Morgagni present compared to testicular torsion?
The hydatid of Morgagni is a remnant of the Mullerian duct. The pain is usually less intense and the whole testicle should not be involved.
