Testicular Torsion: Urological Emergencies

Question 1

How can testicular torsion be defined?

Answer 1

Testicular torsion refers to the twisting of the spermatic cord within the scrotum. This leads to occlusion of testicular venous return and subsequent compromise of the arterial supply, resulting in ischaemia of the testis.

Testicular torsion is a urological emergency. Permanent ischaemic damage may occur within 4-8 hours and urgent surgical intervention is required.

Question 2

Aetiology of testicular torsion

Answer 2

two main causes intravaginal and extravaginal

Question 3

Intravaginal cause of testicular torsion

Answer 3

Intravaginal torsion occurs due to a lack of fixation of the posterolateral section of the testis to the inner wall of the scrotum.

This occurs due to a higher than usual attachment point of the tunica vaginalis to the testis and epididymis within the sac. Hence, the testes swing and rotate freely within the tunica vaginalis. This leads to the formation of the bell-clapper deformity, a free-moving cord inside the scrotum that resembles a ‘clapper in a bell.’

Question 4

recap on testicular anatomy?

Answer 4

The testes lie within the scrotum in a vertical position with the help of the spermatic cord, which arises from the abdomen.

The spermatic cord carries a collection of vessels, nerves and ducts to supply the testes. The tunica vaginalis is a closed sac from the parietal peritoneum which encloses and holds the posterolateral portion of the testes and epididymis in place. Similarly, the gubernaculum fixes the testes but does so at the base of the scrotum

Question 5

extravaginal causes of torsion

Answer 5

Extravaginal torsion is rare but more commonly seen in neonates before the gubernaculum can fixate the testes to the bottom of the scrotum embryologically. This leads to torsion of the testis, the tunica vaginalis and the spermatic cord together. This typically occurs in or just below the inguinal canal.

Whether the mechanism is intravaginal or extravaginal, the torsion of the spermatic cord will increase venous pressure and congestion, which then leads to a decrease in arterial blood flow and subsequent ischaemia.6

Question 6

signs and symptoms of testicular torsion

Answer 6

• sudden onset of testicular pain
• may radiate to back/loin
• most common from ages of 10-30
• can be associated with local trauma
• nausea and vomiting

Question 7

Examination findings for testicular torsion

Answer 7

• extremely tender testicle
• high riding fixed testicle
• abnormal horizontal lie of testicle
• swelling
• discolouration of the scrotal skin
• ***blue dot sign in kids can be indicative of tordid hyatid of morgagni
• absent cremanteric reflex