Overview
Definition:
Testicular torsion is a surgical emergency characterized by the twisting of the spermatic cord, which supplies blood to the testicle, leading to ischemia and potential infarction if not promptly treated.
Epidemiology:
Primarily affects adolescents and young adults, with a bimodal distribution peaking between ages 12-18 years and another smaller peak in neonates
Incidence is approximately 1 in 4,000 males annually
Predisposing factors include an undescended testis and a "bell-clapper" deformity of the tunica vaginalis.
Clinical Significance:
Prompt diagnosis and surgical intervention are crucial to salvage the ischemic testicle
Delayed management can result in testicular loss, impacting fertility and causing significant psychological distress
Understanding torsion is vital for all surgical residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Sudden onset of severe, acute unilateral scrotal pain
Pain may radiate to the groin, abdomen, or flank
Nausea and vomiting are common
Previous intermittent episodes of pain (intermittent torsion) may have occurred
Absent or high-riding testis with a horizontal lie.
Signs:
Marked scrotal edema and tenderness
The affected testis is often elevated and exquisitely tender to palpation
Cremasteric reflex is typically absent on the affected side (reflex is elicited by stroking the inner thigh, causing the testicle to retract upwards)
A thickened, edematous spermatic cord may be palpable
Swelling may extend to the groin
Vital signs may show tachycardia and hypotension if significant pain or ischemia is present.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the characteristic history and physical examination findings
While no formal diagnostic criteria exist, the presence of acute, severe scrotal pain with absent cremasteric reflex and a high-riding testis is highly suggestive.
Diagnostic Approach
History Taking:
Detailed history of pain onset, duration, severity, and character
Location of pain and any radiation
Associated symptoms like nausea, vomiting, fever
Previous episodes of similar pain
History of trauma or recent physical activity
Past surgical history, especially of the groin or testes
Family history of testicular abnormalities
Red flags include sudden, severe, unilateral scrotal pain with absent cremasteric reflex.
Physical Examination:
Gentle but thorough examination of the scrotum and testes
Assess for swelling, tenderness, erythema, and temperature
Palpate the testes for position, size, consistency, and tenderness
Assess for the presence of the cremasteric reflex on both sides
Examine the entire spermatic cord for a thickened "cord of silk" sign
Palpate for the epididymis and rule out epididymitis
A digital rectal exam may be considered to rule out other causes of pelvic pain.
Investigations:
Radionuclide scintigraphy (99mTc-pertechnetate) is highly sensitive and specific for torsion, showing decreased or absent blood flow to the affected testis
Doppler ultrasound is the imaging modality of choice, demonstrating absence of intratesticular blood flow or significantly reduced flow on the affected side
Sensitivity and specificity are high but operator-dependent
Urinalysis is usually normal in torsion, helping to differentiate from urinary tract infections
Serum human chorionic gonadotropin (hCG) levels are not typically used diagnostically but may be considered in cases of suspected malignancy.
Differential Diagnosis:
Epididymitis, orchitis, testicular trauma, inguinal hernia, hydrocele, spermatocele, varicocele, thigh abscess, urinary tract infection, appendicitis (in younger boys), kidney stone
Key differentiator is the acute onset and severity of pain with absent cremasteric reflex in torsion.
Management
Initial Management:
Immediate surgical exploration is indicated for suspected testicular torsion
While awaiting surgery, pain control with analgesics (e.g., IV morphine or fentanyl) is essential
Nausea and vomiting should be managed with antiemetics (e.g., ondansetron)
Hydration with intravenous fluids is important.
Surgical Management:
The cornerstone of management is emergency scrotal exploration and detorsion
If the testis is viable after detorsion, bilateral orchiopexy (fixation of both testes to the scrotal wall) is performed to prevent future torsion
The affected testis is fixed anteriorly and inferiorly at two points, and the contralateral testis is fixed similarly, typically high in the scrotum
If the testis is non-viable (necrotic), orchiectomy (removal of the testis) is performed, followed by orchiopexy of the contralateral testis
Surgical detorsion involves untwisting the spermatic cord counterclockwise if the torsion is on the right, and clockwise if on the left (based on anatomical position of the testis).
Supportive Care:
Postoperatively, patients require pain management, monitoring for signs of infection or bleeding, and wound care
Antibiotics are generally not required unless there is suspicion of concomitant infection or the patient underwent orchiectomy with contamination
Psychological support is important, especially following orchiectomy.
Complications
Early Complications:
Testicular necrosis requiring orchiectomy, testicular atrophy, scrotal hematoma, wound infection, pain recurrence.
Late Complications:
Infertility (due to loss of testis or impaired spermatogenesis in the salvaged testis), chronic pain, cosmetic asymmetry, psychosocial issues, potential for delayed development of secondary sexual characteristics if bilateral orchiectomy is required in prepubertal boys.
Prevention Strategies:
Bilateral orchiopexy during the initial surgical intervention is the primary strategy to prevent recurrence
Patient education regarding symptoms of torsion and the importance of immediate medical attention is crucial
Prompt surgical management is key to preventing testicular loss.
Prognosis
Factors Affecting Prognosis:
The duration of ischemia is the most critical factor
Testes are generally salvageable if detorsed within 6-8 hours of symptom onset
Older age at presentation and the degree of testicular rotation also influence outcome
The presence of viable testicular tissue after detorsion is a positive prognostic indicator.
Outcomes:
If surgically treated within 6 hours, the salvage rate for the testis is high (over 90%)
Beyond 12 hours, the salvage rate decreases significantly, and orchiectomy becomes more common
Fertility may be compromised even after testicular salvage due to potential damage to testicular vasculature and hormonal function
Long-term follow-up is necessary.
Follow Up:
Regular follow-up is required to monitor for testicular atrophy, assess hormonal function (testosterone levels), evaluate spermatogenesis (semen analysis, typically not before puberty), and assess for psychosocial adjustment
Follow-up visits should include physical examination of both testes and assessment of wound healing
Patients should be advised to seek immediate medical attention for any recurrence of scrotal pain.
Key Points
Exam Focus:
Testicular torsion is a surgical emergency
Key signs: acute severe unilateral scrotal pain, absent cremasteric reflex, high-riding testis
Doppler ultrasound is imaging of choice
Surgical exploration and detorsion are mandatory
Bilateral orchiopexy is essential to prevent recurrence
Salvage rates decrease significantly after 6-8 hours.
Clinical Pearls:
Never assume scrotal pain is benign in a male patient, especially an adolescent
Even in the presence of epididymitis-like signs, torsion must be ruled out urgently
The "bell-clapper" deformity predisposes to intravaginal torsion
Always perform bilateral orchiopexy
Don't delay surgery for imaging if clinical suspicion is high.
Common Mistakes:
Delaying surgical exploration due to reliance on imaging alone or misdiagnosing torsion as epididymitis
Failure to perform bilateral orchiopexy, leading to recurrent torsion in the contralateral testis
Inadequate pain management in the acute phase
Not considering torsion in neonates with scrotal masses or discoloration.