Overview
Definition:
Testicular torsion is a surgical emergency characterized by the twisting of the spermatic cord, which suspends the testicle
This twisting obstructs the blood supply to the testicle, leading to ischemia and potential necrosis if not promptly treated.
Epidemiology:
It most commonly affects neonates and adolescents, with bimodal peaks at birth and during puberty
The incidence is estimated at 1 in 4,000 males per year
Approximately 50% of cases occur between the ages of 10 and 20
Bilateral testicular torsion is rare but carries a high risk of future infertility.
Clinical Significance:
Timely diagnosis and surgical intervention are critical to salvaging testicular function and preventing infertility
Delays in treatment significantly increase the risk of testicular atrophy and loss, impacting the patient's long-term reproductive health and psychological well-being
Understanding the salvage window and recognizing diagnostic challenges are paramount for pediatricians and surgical residents preparing for DNB and NEET SS exams.
Clinical Presentation
Symptoms:
Sudden onset of severe, acute scrotal pain
Nausea and vomiting are common
The pain may radiate to the groin or abdomen
In neonates, presentation may be subtle, with irritability, a firm scrotal mass, or a bluish discoloration of the scrotum.
Signs:
Affected testicle is often exquisitely tender, swollen, and may lie higher in the scrotum than the contralateral testicle
The cremasteric reflex is typically absent
A horizontal lie of the testicle is a classic sign
Edema and erythema of the scrotal skin may be present
In cases of intermittent torsion, symptoms may be transient and recurrent.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the acute onset of severe scrotal pain, swelling, and absence of cremasteric reflex
Imaging confirmation, particularly ultrasound, is often used
Exploratory surgery is the definitive diagnostic and therapeutic intervention in ambiguous cases or when torsion is highly suspected.
Diagnostic Approach
History Taking:
Detailed history of pain onset and duration is crucial
Ask about any preceding trauma or strenuous activity
Inquire about previous episodes of similar pain, suggestive of intermittent torsion
Assess for associated symptoms like nausea, vomiting, fever, or urinary symptoms
For neonates, observe for nonspecific signs of distress.
Physical Examination:
A thorough and gentle physical examination of the scrotum is essential
Palpate for testicular position, tenderness, swelling, and the cremasteric reflex
The absence of the cremasteric reflex is a strong indicator of torsion
The "bell clapper" deformity, where the testicle hangs horizontally, should be sought
Examine the contralateral testicle for symmetry and ensure bilateral scrotal pathology is ruled out.
Investigations:
Doppler ultrasound is the imaging modality of choice, demonstrating decreased or absent testicular blood flow
Look for increased testicular volume and abnormal intratesticular echogenicity
However, normal flow on Doppler does not definitively rule out torsion, especially in intermittent torsion or very early stages
Serum markers like urine analysis or CBC are generally not helpful in diagnosing acute torsion but can rule out other causes like infection.
Differential Diagnosis:
Epididymitis/orchitis: usually associated with fever, dysuria, and a palpable enlarged epididymis
often has a normal cremasteric reflex
Torsed appendage of testis or epididymis: typically presents with a smaller, localized tender nodule and may have a normal testicular perfusion on Doppler
Incarcerated inguinal hernia: a bulge in the groin with scrotal swelling
Trauma: history of injury
Cellulitis: diffuse scrotal erythema and tenderness, often with systemic signs of infection.
Salvage Time Window
Historical Perspective:
Historically, the salvage window was considered to be very narrow, with estimates suggesting loss of the testicle after 4-6 hours
However, contemporary data suggest that testicular viability can be preserved for longer periods, especially with early recognition and intervention.
Current Evidence:
Studies indicate that testicular salvage rates remain high (over 90%) if surgery is performed within 6 hours of symptom onset
Beyond 6 hours, salvage rates begin to decline significantly
After 12-24 hours, the likelihood of testicular survival is very low, and orchiectomy is often necessary
Intermittent torsion may have a different time course, with testes being surgically untwisted and fixed electively.
Factors Influencing Salvage:
Key factors include the degree of torsion, the duration of ischemia, the presence of collateral circulation, and the promptness of medical evaluation and surgical intervention
Early diagnosis by primary care physicians and prompt referral to surgical services are critical
The presence of a normal cremasteric reflex and a higher than normal testicular lie are less reliable indicators of torsion duration than symptom onset time.
Ultrasound Pitfalls
False Negatives:
Normal perfusion on Doppler ultrasound does not exclude torsion
This can occur in early torsion, intermittent torsion, or if the transducer is not correctly positioned
A heterogeneous or enlarged testicle with absent blood flow is highly suggestive, but a normal-appearing testicle with normal flow should not deter suspicion in a clinically torsed patient.
False Positives:
Severe epididymitis or testicular trauma can mimic torsion on ultrasound with absent flow
Doppler can be technically challenging in obese patients or those with significant scrotal edema
Absence of flow can also be seen in patients with previous testicular injury or vascular compromise unrelated to torsion.
Interpretation Challenges:
The interpretation requires expertise
Color Doppler may sometimes be misleading due to artifact or subtle flow
Always correlate ultrasound findings with the clinical picture
If clinical suspicion is high and ultrasound is equivocal or negative, prompt surgical exploration is warranted
Recognize that even in the absence of torsion, findings like a hydrocele or reactive hyperemia can sometimes complicate interpretation.
Management
Initial Management:
Immediate surgical consultation is paramount
While awaiting surgery, pain management with analgesics can be provided
Elevation of the scrotum may offer some comfort but does not resolve the torsion
If torsion is strongly suspected, contraindications to surgery due to patient instability must be addressed.
Surgical Management:
The mainstay of treatment is immediate surgical exploration and detorsion of the spermatic cord
If the testicle is viable, orchiopexy (fixing the testicle to the scrotal wall) is performed to prevent future torsion
The contralateral testicle should also undergo orchiopexy as it is at high risk for torsion due to anatomical predisposition (e.g., bell clapper deformity)
If the testicle is necrotic, orchiectomy (removal of the testicle) is indicated.
Supportive Care:
Postoperatively, patients require pain management, monitoring for complications like infection or hematoma, and wound care
Antibiotics are typically given perioperatively
Psychological support may be necessary, especially if orchiectomy is performed
Follow-up care should include evaluation of the remaining testicle and fertility counseling if indicated.
Complications
Early Complications:
Testicular infarction/necrosis leading to orchiectomy
Hematoma formation
Wound infection
Hemorrhagic infarction of the contralateral testicle if not fixed.
Late Complications:
Infertility due to loss of one or both testicles
Testicular atrophy of the salvaged testicle
Chronic pain
Psychological impact and body image issues
Increased risk of testicular cancer later in life, though this association is complex and debated.
Prevention Strategies:
Prompt surgical intervention within the salvage window is the primary prevention strategy for testicular loss
Bilateral orchiopexy at the time of torsion repair prevents contralateral torsion
Educating young males and parents about the signs and symptoms of testicular torsion and encouraging prompt medical attention is crucial for early diagnosis.
Prognosis
Factors Affecting Prognosis:
The most significant factor is the duration from symptom onset to surgical detorsion
Testicular viability and salvage rates decrease sharply after 6-12 hours
Early recognition, prompt diagnosis, and rapid surgical intervention lead to better outcomes.
Outcomes:
If treated within the critical salvage window (ideally < 6 hours), testicular salvage rates are very high, and fertility is generally preserved
If orchiectomy is performed, the remaining testicle can often maintain adequate testosterone production and fertility
However, a significant percentage of patients, even after salvage, may experience some degree of subfertility or altered testicular function.
Follow Up:
Regular follow-up is essential after torsion management
This includes monitoring for complications, assessing testicular size and consistency, evaluating hormonal function (testosterone levels), and discussing fertility options with the patient and family
A baseline semen analysis may be considered later in adolescence if fertility is a concern.
Key Points
Exam Focus:
Remember the bimodal age distribution (neonates and adolescents)
The key differentiator from epididymitis is the absence of the cremasteric reflex
Doppler US is crucial but not infallible
clinical suspicion overrides a normal US
Bilateral orchiopexy is mandatory.
Clinical Pearls:
Always assume torsion in acute scrotal pain in a male child unless proven otherwise
Do not delay surgery for definitive imaging if clinical suspicion is high
Ask about intermittent episodes of pain as this may point towards intermittent torsion
The "bell clapper" deformity is a anatomical predisposition
Neonatal presentation is often non-specific.
Common Mistakes:
Mistaking torsion for epididymitis or other less emergent conditions
Delaying surgical exploration due to reliance on a normal Doppler ultrasound
Failing to perform bilateral orchiopexy
Not considering torsion in neonates with unusual scrotal findings.