Overview
Definition:
Orchiopexy for intermittent testicular torsion is a surgical procedure performed to fix the testis within the scrotum, preventing future episodes of torsion
Intermittent testicular torsion is characterized by recurrent, transient episodes of severe scrotal pain, often resolving spontaneously, which occurs when the spermatic cord twists partially or completely around its axis, compromising blood flow to the testis.
Epidemiology:
Testicular torsion is most common in adolescent males, with a bimodal peak incidence in neonates and between ages 12-18 years
Intermittent torsion is less common than acute torsion but accounts for a significant proportion of symptomatic presentations
The underlying anatomical predisposition, often a "bell-clapper" deformity where the testis is free to rotate within the tunica vaginalis, is a key factor.
Clinical Significance:
Failure to surgically correct intermittent torsion can lead to irreversible testicular damage, atrophy, and potential infertility due to recurrent ischemia
Prompt recognition and surgical intervention are crucial to preserve testicular function and fertility
This topic is highly relevant for DNB and NEET SS examinations, testing diagnostic acumen and surgical management skills.
Clinical Presentation
Symptoms:
Recurrent, self-limiting episodes of severe, sudden onset scrotal pain, typically in one testis
Pain may radiate to the groin or lower abdomen
Nausea and vomiting may accompany episodes
Absence of a preceding inciting event like trauma
Pain often resolves spontaneously, leading to delayed presentation
Some patients may present with chronic scrotal discomfort.
Signs:
During an episode: Acute severe scrotal pain, tenderness, and swelling
The affected testis may be found to be higher in the scrotum and lie transversely compared to the contralateral testis
Cremasteric reflex is often absent on the affected side
Edema and erythema of the scrotum may be present
Between episodes: The testis may appear normal, but subtle abnormalities in position or mobility may be noted
Testis may be freely mobile within the tunica vaginalis.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the characteristic history of recurrent, self-limiting scrotal pain
Imaging may support the diagnosis but is not always definitive for intermittent torsion, especially between episodes
A high index of suspicion in adolescents with recurrent scrotal pain is paramount.
Diagnostic Approach
History Taking:
Detailed history of pain episodes: onset, duration, severity, radiation, associated symptoms (nausea, vomiting)
Frequency and pattern of recurrence
Any precipitating factors
Previous urological history or trauma
Family history of testicular issues
Inquiry about undescended testis or previous scrotal surgery
Red flags include persistent severe pain, testicular fixation, or signs of infection.
Physical Examination:
Careful examination of the scrotum and testes, ideally in a warm environment to relax the cremasteric muscle
Palpation to assess testicular position, size, consistency, and tenderness
Assess for the presence of the cremasteric reflex on both sides
Evaluate for scrotal edema, erythema, or any palpable masses
Examination of the contralateral testis and its position is also crucial.
Investigations:
Scrotal Ultrasound with Doppler: Primarily useful to rule out acute torsion and assess blood flow, particularly during an episode
Between episodes, it may show normal findings or subtle changes like increased testicular echogenicity or abnormal position
However, normal Doppler findings do not exclude intermittent torsion
Laboratory tests are generally not indicated unless infection is suspected.
Differential Diagnosis:
Epididymitis/Orchitis: Usually associated with fever, urinary symptoms, and localized tenderness of the epididymis
Torsion of the hydatid of Morgagni: Small, appendage on the testis that can twist, causing localized pain and a palpable nodule
Incarcerated inguinal hernia: Painful mass in the groin that can extend into the scrotum
Trauma: History of injury
Varicocele: Bag of worms appearance, typically painless or dull ache
Hydrocele: Fluid accumulation in the tunica vaginalis, usually painless.
Management
Initial Management:
While intermittent torsion may not require emergency intervention if symptoms have resolved, any patient presenting with acute scrotal pain must be evaluated promptly for acute torsion
If acute torsion is suspected, immediate surgical exploration is indicated
For confirmed or highly suspected intermittent torsion, surgical management is the definitive treatment.
Medical Management:
Primarily symptomatic management for pain relief during episodes, typically with NSAIDs or acetaminophen
No long-term medical management is effective for preventing intermittent torsion
Antibiotics are indicated if infection (epididymitis/orchitis) is suspected as the cause of pain.
Surgical Management:
Bilateral orchiopexy is the gold standard for intermittent testicular torsion
The procedure involves surgically fixing both testes to the scrotal wall to prevent rotation
Indications include a history of intermittent torsion, a clinically palpable "bell-clapper" deformity, or a strong suspicion of intermittent torsion based on recurrent symptoms
The technique involves surgically opening the tunica vaginalis of the affected testis, reducing any torsion, and then anchoring the testis within the scrotum using sutures
The contralateral testis is also fixed as it shares the same anatomical predisposition in most cases
This prevents future torsion on either side.
Supportive Care:
Postoperative care includes pain management, wound care, and monitoring for complications
Patients are typically advised to avoid strenuous activity for a period
Follow-up appointments are essential to assess healing and monitor testicular function.
Complications
Early Complications:
Bleeding or hematoma formation at the surgical site
Wound infection
Pain and swelling post-operatively
Injury to the testis or spermatic cord structures during surgery.
Late Complications:
Testicular atrophy due to prior ischemic damage or surgical complications
Infertility due to reduced sperm production from chronic or acute ischemia
Recurrence of torsion if fixation is inadequate or if the contralateral testis was not fixed
Chronic scrotal pain.
Prevention Strategies:
Thorough surgical technique with secure fixation of the testis to prevent migration
Bilateral orchiopexy in cases of suspected intermittent torsion to address the common underlying anatomy
Prompt surgical intervention upon diagnosis
Careful postoperative care and activity restrictions.
Prognosis
Factors Affecting Prognosis:
Duration and severity of ischemic episodes prior to surgery
Timeliness of surgical intervention
Technical adequacy of the orchiopexy
Presence of underlying anatomical abnormalities
Successful preservation of testicular vascularity.
Outcomes:
With timely surgical intervention, the prognosis for preventing further torsion and preserving testicular function is generally excellent
Most patients experience resolution of pain and maintain fertility
However, if torsion has been prolonged or severe, testicular atrophy and subsequent infertility may occur.
Follow Up:
Regular follow-up appointments are recommended, typically at 1 week, 1 month, and 6 months postoperatively, to assess wound healing, monitor for complications, and evaluate testicular size and consistency
Long-term monitoring may include assessment of testicular function and fertility, especially in cases with a history of significant ischemia.
Key Points
Exam Focus:
The "bell-clapper" deformity is the most common anatomical abnormality predisposing to torsion
Intermittent torsion is characterized by recurrent, self-resolving scrotal pain
Bilateral orchiopexy is the standard of care for intermittent torsion
The cremasteric reflex is often absent on the affected side during torsion
Doppler ultrasound is useful for acute torsion but may be normal in intermittent torsion between episodes.
Clinical Pearls:
Always consider torsion in any adolescent male with acute or recurrent scrotal pain, even if the pain resolves spontaneously
Do not dismiss recurrent pain as benign
The contralateral testis should always be surgically fixed due to the high incidence of bilateral predisposing anatomy
A high index of suspicion is key, as imaging can be misleading in intermittent torsion.
Common Mistakes:
Delaying surgical exploration for suspected acute torsion
Failing to consider intermittent torsion in patients with recurrent pain
Performing unilateral orchiopexy in cases of intermittent torsion
Misdiagnosing intermittent torsion as epididymitis or trauma
Not adequately fixing the contralateral testis.