Torsion of testes

Question 1

Clinical features - epidemiology and history

Answer 1

Peak age 7-14 years (up to 25), but also a perinatal form
Left side>right side
Acute swelling of scrotum
Sudden, severe pain in one testis
Lower abdo pain
Often comes on during sport/physical exercise
May be history of previous brief similar episodes
Easing pain not necessarily resolution - may also be necrosis

Question 2

Clinical features - examination

Answer 2

Reddening of scrotal skin
Swollen, tender, retracted testis
Lifting testis over symphysis increases pain
Testes may be in ‘bell-clapper position’
If prenatally, baby born with firm, hard, non-transilluminal scrotal mass, no symptoms, scrotal skin often attached to necrotic testis

Question 3

Investigations

Answer 3

US with colour Doppler
(MRI and near-infrared imaging)
Urinalysis in borderline cases to exclude UTI and epididymitis

Question 4

Management

Answer 4

Manual reduction. Note: left testis tortes anticlockwise, right tortes clockwise - reverse to treat. Doppler to confirm successful, and prompt orchidopexy
If unsuccessful or unsure (within 24 hours), exploration of scrotum, detorsion and orchidopexy
After 24 hours, chance that orchiectomy is best option as suggestion that increases function of other testis
Contralateral testis should undergo orchidopexy
Prenatal torsion: removal of affected testis and orchidopexy of contralateral side

Question 5

Complications

Answer 5

Torsion occludes the testicular vessels, leading to infarction and subsequent atrophy, infection and cosmetic deformity
Best prognosis if duration of torsion less than six hours