Testicular Torsion

Question 1

Define testicular torsion

Answer 1

Urological emergency caused by twisting of the testicle on the spermatic cord -> constriction of vascular supply and ischaemia

All sudden onset testicular pain should be regarded torsion until proven otherwise

Question 2

Aetiology of testicular torsion

Answer 2

Exact cause unknown
Bell Clapper deformity most common anatomical defect associated with intra-vaginal testicular torsion
Trauma

Neonates: extra-vaginal

Question 3

Risk factors of testicular torsion

Answer 3

Young male <25
Neonates
Bell clapper deformities
Trauma/exercise, intermittent testicular pain, undescended testicle, cold weather

Question 4

Epidemiology of testicular torsion

Answer 4

Common in younger males (11-25), rare >35

Extra-vaginal torsion affects mainly neonates

Question 5

Symptoms of testicular torsion

Answer 5

Sudden onset testicular pain (May be intermittent (torsion and de-torsion) | Swelling and redness | No relief on elevating scrotum | often Hx of trauma)
Nausea and vomiting
Malaise
Abdominal pain

Question 6

Signs of testicular torsion

Answer 6

High-riding, erythematous swollen testicle 
Horizontal lie (testicle is horizontal)
Flushed and in pain 
Absent cremasteric reflex
Fever

Question 7

Investigations for testicular torsion

Answer 7

Any sudden onset testicular pain should be referred for scrotal exploration

If not: ultrasound (fluid, whirpool sign, decreased blood flow in testicle)
Urinalysis, FBC and CRP to rule out other causes
Scintigraphy very sensitive, but takes a long time

Question 8

Management for testicular torsion

Answer 8

1. Analgesia
   a. Morphine 10mg IM/IV (adults) + Ondansetron 4mg IM/IV single dose (adults)
2. Manual de-torsion if surgery not available or waiting for surgery
   a. Open-book method - rotating the right testicle counter-clockwise and the left testicle clockwise
3. Referral for urgent scrotal exploration and orchidoplexy BILATERALLY - Consent for orchidectomy

Question 9

Complications for testicular torsion

Answer 9

Infarction and necrosis of testicle leading to permanent damage or loss
Infertility due to loss of testicle
Psychological implications and cosmetic deformity
Recurrent torsion
Impaired pubertal development

Question 10

Prognosis for testicular torsion

Answer 10

Time is testicle - Testicle is salvageable if <8 hours from onset (100% <6h), but salvageability rapidly drops as time progresses
Recurrent torsion may develop in patients with a past history of testicular fixation
Can offer prosthetic device to avoid cosmetic and psychological impacts