Testicular Torsion
Testicular torsion is the sudden twisting of the spermatic cord due to a poorly secured testis. Commonly occurs in neonates and adolescent men (10-25 yo). It is a true surgical EMERGENCY. There is a strangulation of the blood supply, and the rate of viability significantly reduces after 6 hours. Late or absent surgical intervention can lead to infertility due to disruption of the blood-testis barrier. Testicular torsion is a clinical diagnosis.
Affects the Left testis > Right testis. It can occur when sleeping or being active.
Classification (related to the tunica vaginalis)
| Classification | Characteristics | Association |
|---|---|---|
| Intravaginal torsion | Tunica vaginalis fixes proximally on the testis (bell-clapper deformity) leaving the testis free to rotate inside the sac | Adolescent |
| Extravaginal torsion | Vaginalis does not adhere to the dartos or gubernaculum leaving the cord and vaginalis free to move as a unit | Neonates |
| Long mesorchium | An elongated mesorchium causes torsion of the testis along it. | Cryptorchidism |
- Predisposing factors
- Cold temperatures and Changes in temperature (affects the cremasteric reflex)
- Rapid testicular growth (in puberty)
- Testicular malignancy (in adults)
- Iatrogenic (incorrect positioning of testes following procedure)
- Signs and symptoms
- Sudden onset suprapubic/groin pain
- Intermittent: incomplete torsion. Testis retorts and rotates
- Constant: complete torsion
- Testicular swelling
- Nausea/Vomiting
- Tender, firm testicle
- Abnormal positioning of the testis
- High-riding testis (Deming sign)
- Horizontal lie (Angell’s sign)
- Absent testis (”Vanishing testis” in neonates)
- Absent cremasteric reflex
- Negative Prehn sign (no pain relief with elevation of the testis. Positive Prehn sign is seen with epididymitis)
- Thick spermatic cord
- Posteriorly positioned epididymis (abnormal positioning, should be anterior)
- Sudden onset suprapubic/groin pain
- Differentials
- Torsion of appendage (appendix, epididymis): blue-dot sign
- Epididymitis: positive prehn sign
- Orchitis
- Hydrocele
- Traumatic rupture
- Investigations
- Color Doppler US: gold standard
- Absent/reduced blood flow to the testes
- Radionuclide scan: use in unequivocal findings, and to r/o epididymitis
- “Cold spots” and asymmetric blood flow (”Hot spots” are seen in epididymitis)
- CBC: leukocytosis
- Urinalysis: r/o epididymitis
- Color Doppler US: gold standard
- Treatment
- Manual detorsion (keep in mind that 2/3 of torsions occur towards the midline)
- Emergent surgical exploration **ideally within 6 hours
- Orchidopexy for viable testis. Can also be performed for the contralateral testes
- Orchidectomy for gangrenous (non-viable) testes
- Complications of testicular torsion
- Infertility: can occur even with normal opposite testes. Infertility may be due to:
- Disruption of the immunological blood testis barrier
- Exposure to antigens from germ cells and sperm to the general circulation
- Development of anti-sperm antibodies
- Infertility: can occur even with normal opposite testes. Infertility may be due to:
Torsion of the Appendix Testis (hydatid of Morgagni)
The hydratid of Morgagni (paradydymis) tends to rotate. It is an embryological remnant on the upper pole of the testis/epididymis (remnant of the Müllerian duct). It is typically seen in boys 7-14 years old.
- Signs and symptoms
- Localized testicular pain
- Blue dot sign (infarction of the hydatid of Morgagni seen as a blue dot in light-skinned scrotum)
- Unlikely to be elevated (Deming sign)
- No horizontal lie (negative Angell’s sign)
- Investigations
- Color Doppler US: to assess testicular perfusion
- Enlarged testicular appendix
- Mild hydrocele
- Preserved testicular blood flow
- Urinalysis: to rule out epididymitis
- Color Doppler US: to assess testicular perfusion
- Treatment
- Conservative:
- Manage pain – NSAIDs
- Consult urology
- Conservative:
