testicular torsion Flashcards
definition of testicular torsion
twisting or torsion of spermatic cord that results in initially venous outflow obstruction from the testicle, progressing to arterial occlusion and testicular infarction if not corrected
pathophysiology of testicular torsion
twisting = compression of veins in pampiniform plexus from the testes and venous congestion
with progressive ischemia and infarction of blood supply not restored by detortion
aetiology of testicular torsion
intravaginal (most common) - high investment of tunica vaginalis around the spermatic cord enables the testis to twist within the vaginalis
extravaginal (in neonates) entire testis and tunica vaginalis twist in vertical axis on spermatic cord (due to incomplete fixation of gubernaculum to scrotal wall allowing free rotation)
twist in the spermatic cord shortens the cord and so raises the testicle to a higher position.
cuts off the blood supply = very painful.
RF for testicular torsion
imperfectly descended testes
high investment of tunica vaginalis (bell clapper testes = epididymis is only applied to lower 1/2 of testes)
long epididymal mesentry
mobile testicle
clapper bell - underlying deformity, extension of tunica vaginalis behind testical, horizontal lie
epidemiology of testicular torsion
annual incidence 1/4000
most common cause of acute scrotal pain in 10-18yr olds (intravaginal)
rare >35yrs
sx of testicular torsion
sudden onset severe hemiscrotal pain - may be associated with abdo pain, nausea, vom - may resist examination because of pain
high lying
pain makes walking uncomfortable
may awake from sleep
or history of similar pain that spontaneously resolved
temperature
signs of testicular torsion
scrotum swollen and erythmatous, swollen, hot, tender (inflammed) testicle lying higher than contralateral, may be horizontal (contralateral = horizontal)
thickened cord may be palpable and epididymis may be anterior
cremasteric reflex absent
testicular appendix (appendix testes, appendix epididymis, hydatid of Morgagni): may be a visible necrotic lesion on transillumination (blue dot sign).
differential of testicular torsion
o epididymo-orchitis
o viral orchitis
o Prepubertal – torted hydatid cyst (appendix of testes – rudimentary structure, twists on own axis and blocks blood supply, symptoms similar to torsion, if hydatid will cut blood supply and settle down – have to be confident not torsion)
o Appendix testes
- Blue dot sign – not obvious in a lot of pts – see blue dot under scrotal skin (necrotic appendage)
- Manage conservatively if confident ddx
- If not explore
o bleed into testicular tumour
Ix of testicular torsion
acutely tender/swollen testis = torsion until proven otherwise
exploration needed - urgent
consent should include counselling about bilateral orchidopexy and orchidectomy
doppler or duplex imaging of testes - may be performed but shouldn’t delay surgery - arterial in flow may be reduced in torsion, and increased in epididymo-orchitis
MSU and urgent microscopy if suspect UTI/epididymitis
Mx of testicular torsion
exploration of the scrotum within 6hrs
horizontal or midline raphe incision is made through skin and dartos muscle
tunica vaginalis is opened up and testis is delivered and inspected
untwisting is usually carried out by rotating laterally
testis allowed to reperfuse, covered with warm saline soaked swab for a few minutes
bilateral orchidopexy (foxation of testis by suturing testes with non-absorbable sutures to scrotal tissues at 3 points of a triangle to prevent recurrence
if necrotic, orchidectomy is performed
complications of testicular torsion
testicular infarction and atrophy
if left testes might become infected or impair fertility by promoting formation of anti-sperm bodies
Counsel to say that if they get similar pain need to come back – because fixation stitch can be undone and get another torsion- rare but happens
intermittent torsion
recurrent torsion
Px of testicular torsion
From onset of pain, a testicular torsion may only survive 4–6 h.
With prompt exploration most cases can be salvaged.
The salvage rate is 100% within 6 hours, but this drops to approximately 20% at 12 hours and 0% after 24 hours.
follow up issues with testicular torsion
recurrent testicular pain
fertility - not affected by loss of 1
prosthesis
medico-legal
