Testicular torsion (SURG) Flashcards
Define testicular torsion.
Urological emergency caused by sudden twisting of the testicle on the spermatic cord –> constriction of vascular supply, time-sensitive ischaemia and/or necrosis of testicular tissue
How does testicular torsion cause an issue?
Results in venous outflow obstruction from testicle –> arterial occlusion and testicular infarction
Constriction of vascular supply, time-sensitive ischaemia and/or necrosis of testicular tissue
What is the peak incidence of testicular torsion?
Usually affects young males but may affect males of any age
Peak incidence in first 30 days of life and during puberty (10-18y)
What are the most common causes of testicular torsion? (3)
- Bell clapper deformity (horizontal lie of the testes)
- cryptorchidism (undescended testes)
- trauma
- (mostly unknown)
What is Bell clapper deformity (testicular torsion)?
Both attachments of the tunica vaginalis occur superior to the testicle (instead of one attachment to the posterior wall inferiorly); hypermobility
(Horizontal lie of the testes)
What occurs secondary to testicular torsion?
Testicular germ cell death occurs secondary to decreased O2 supply, cellular energy depletion and toxic metabolite formation
How can we classify testicular torsion? (3)
- intra-vaginal (most common) - abnormally high attachment of tunica vaginalis to the spermatic cord (twisting within the tunica vaginalis)
- extra-vaginal (neonates)
- long mesochorium
When does testicular torsion damage become irreversible?
If de-torsion started within 4-6 hours of Sx onset, the affected testis will most likely remain valuable
Irreversible damage occurs after 6-12 hours of torsion
What are the clinical features of testicular torsion? (5)
- testicular pain - sudden, severe, unilateral, intermittent
- N&V
- abdominal pain and fever
- reactive hydrocoele
- high-riding testicle - affected testicle may appear higher
What is found on examination in testicular torsion? (4)
- negative Prehn sign - no pain relief on elevation of testes
- absent cremasteric reflex (diagnostic) - elevation of testicle and scrotum in response to stroking of ipsilateral inner thigh
- tenderness
- scrotal swelling, oedema, erythema
What is the Prehn sign like in testicular torsion?
Negative Prehn sign - no pain relief on elevation of testes
Distinguishes between testicular torsion and epididymitis
What is the cremasteric reflex and describe it in testicular torsion.
Absent cremasteric reflex - elevation of the testicle and scrotum in response to stroking of the ipsilateral inner thigh
What examination is diagnostic for testicular torsion?
Absent cremasteric reflex
What is characteristic of testicular torsion?
In acute testicular pain, a unilateral swollen and retracted testicle, with loss of the cremasteric reflex, is characteristic of testicular torsion
What are some risk factors for testicular torsion? (7)
- age <25
- neonate
- Bell clapper deformity
- cryptorchidism (undescended testicle)
- trauma
- intermittent testicular pain
- cold weather
What is the first-line investigation for testicular torsion?
Duplex US of scrotum (grey-scale US or colour Doppler US)
Do not delay surgery, only do if diagnosis in doubt
What does duplex US show in testicular torsion? (4)
- enlarged scrotum
- twisting of spermatic cord
- reduced/absent blood flow in affected testicle
- whirlpool sign (spiral-like pattern) - limited utility in neonates
What other investigations can we do in testicular torsion?
Urinalysis, FBC, CRP - rule out epididymitis (should all be normal in testicular torsion)
What score can we calculate in testicular torsion?
TWIST score - Testicular Workup for Ischaemia and Suspected Torsion
When is duplex US for testicular torsion done?
Only if diagnosis in doubt - do not delay surgery
What are some differential diagnoses for testicular torsion? (13)
- testicular appendix torsion - gradual onset, blue dot sign on scrotal skin, US shows increased blood flow
- epididymitis/orchitis - chronic, frequent/painful micturition
- hydrocoele - scrotal transillumination
- varicocele - painless, bag of worms, enlarged veins during Valsalva is diagnostic
- testicular cancer - no pain, gradual
- scrotal haematoma
- Fournier’s gangrene
- inguinal hernia
- renal colic
- Henoch-Schonlein purpura
- acute appendicitis
- spermatocoele
- idiopathic testicular infarction
When must treatment be done for testicular torsion?
Within 6 hours of symptom onset to save testes
What is the first-line management for testicular torsion and when is it done?
Emergency scrotal exploration (radical inguinal orchidopexy) - both testes fixed to posterior wall (to prevent torsion of other testes), untwists the testes
Ideally within 6h of presentation
What is the second-line management for testicular torsion and when is it done?
Manual testicular detorsion - if surgery is not available in 6h or attempted prior to surgery for pain relief
What other management (non-surgical) is there for testicular torsion? (2)
- pain relief - morphine sulfate
- antiemetics
How do we manage intermittent testicular torsion?
Refer for consideration of orchidopexy
What are some complications of testicular torsion? (5)
- infarction of testicle (worse if >10h)
- infertility due to loss of testicle
- cosmetic deformity
- recurrent torsion
- impaired pubertal development
Describe the prognosis of testicular torsion.
- from onset, testicle may only survive for up to 6h
- most testicles salvaged with prompt surgical intervention (quicker the surgery = better prognosis)
