Topic Editor: Grant E. Fraser, M.D., FRACGP, FACRRM, ASTEM
Review Date: 9/30/2012
Definition
Testicular torsion is a urologic surgical emergency caused by twisting of a testicle on the spermatic cord leading to disruption of vascular flow, with time critical ischemia and potential of necrosis of testicular tissue.
Description
- Testicular torsion is a urologic surgical emergency in which compromised blood supply to a testicle results in testicular death if blood flow is not promptly restored (within 4-6 hours)
- Because normal fully descended testes are usually completely anchored, testicular torsion is uncommon
- Testicular torsion should be suspected in all prepubertal and young adult males with acute scrotal or abdominal pain. This diagnosis should also be suspected in male infants presenting with non-specific distress
- Torsion of the spermatic cord will compromise blood flow to the testis and epididymis. The degree of rotation of the testis varies from 180-720°, with older patients tending to have a higher degree of rotation
- Both the number of rotations and the duration of ischemia affect testicular viability
- Treatment within 4-6 hours of onset of symptoms improves the likelihood of a viable testis. In the event torsion has lasted more than 10-12 hours, ischemia and irreversible testicular damage usually occurs, with loss of the affected testicle
- Types of testicular torsion:
- Extravaginal torsion: Rare entity which occurs during fetal development as the teste descends and rotates around the spermatic cord
- Intravaginal torsion: Most common type of testicular torsion which occurs due to the tunica vaginalis having an abnormally high attachment with the spermatic cord. In this setting, the testis is able to rotate within the scrotum
Epidemiology
Incidence/Prevalence
- Testicular torsion affects one in 4,000 males, mostly between 9 and 25 years of age
Age- Peak incidences in infancy and adolescence
Risk factors
- Most common between age 9-15 years with a median age of 13 or 14 years. Can occur in men at least until their 30s but is rare beyond 25 years of age
- Can occur in neonates
- More likely if a 'Bell clapper deformity' is present. This deformity is a failure of the normal posterior anchoring the testis, gubernaculum, and epididymis
- Possible increased risk during cold weather
- Inversion of the testis, where the testis is rotated and lies transversely or upside down
- Separation of the epididymis
- Trauma/exercise
- Intermittent testicular pain
- Undescended testicle
Etiology
- Exact etiology of extra-vaginal torsion is unknown, and an anatomical defect is not usually identified
- Bell clapper deformity is the most common anatomical defect associated with the development of intra-vaginal testicular torsion
- Trauma, possibly causing separation of the epididymis or inversion of the testis
History
- Absence of symptoms related to urinary infection such as dysuria, frequency, and urgency
- Low-grade fever (rarely associated with torsion)
- Nausea and vomiting
- Often history of minor trauma to the testicle preceding the onset of pain
- Pain in the inguinal or lower abdominal area (less common)
- Scrotal swelling and erythema
- Sudden onset of unilateral testicular pain (in younger boys/infants may present as lower abdominal pain or non-specific pain)
- Symptoms can vary with the degree of torsion
- Up to 40% of patients may describe previous similar episodes that remitted spontaneously (represents spontaneous torsion and de-torsion)
- Young males with abdominal pain require a testicular examination, as torsion may present as abdominal pain. In male neonates, generalized fussiness or non-specific pain requires a testicular examination
Physical findings on examination
- Absent cremasteric reflex on the affected side is suggestive of torsion
- High-riding testicle (affected testicle may appear higher than the unaffected testicle)
- Tenderness and a horizontal lie of the affected testicle
- Thickening of the tender twisted spermatic cord can be palpated
- Scrotal swelling
- Usually no pain relief upon elevation of the scrotum (may experience worsening of pain with elevation)
- With time a reactive hydrocele, scrotal wall erythema, and ecchymosis develops
Blood test findings
- Blood tests are typically not useful in the diagnosis of testicular torsion. Although some Urologists/Surgeons may request basic blood tests such as CBC/BMP, these play no role in the diagnosis, evaluation or treatment of this condition
Other laboratory test findings
- Urinalysis should be performed as it may be abnormal in cases of epididymo-orchitis, urethritis or urinary tract infection. It should be noted that up to 20% cases of torsion show pyuria
Radiographic findings
- Color Doppler ultrasound (Duplex) should be obtained promptly if possible. When torsion is present at the time of the ultrasound, there will be absent or decreased blood flow to the affected testicle with decreased flow velocity and increased resistive indices in the intra-testicular arteries. It should be noted that some torsion is intermittent, and it is essential to correlate ultrasound findings with clinical and historical data
- Duplex scan showing normal flow does not rule out torsion as the cause of the patient's symptoms, but does rule out torsion at the time of the ultrasound scan
- Epididymo-orchitis typically results in increased blood flow to the testis involved
General treatment items
- Rapid examination should occur in a patient with suspected testicular torsion. This examination should review whether a mass is present and whether the presentation is consistent with testicular torsion. In most cases; urgent urological review is indicated; irrespective of ultrasound findings (urology consultation should not be delayed but should be concurrent with requesting ultrasound)
- Analgesics should be administered to promote patient comfort and for the necessary clinical/ultrasonography examinations to occur
- Intrauterine torsion of testes should be treated as an emergency and requires early recognition, expeditious exploration and simultaneous contralateral orchidopexy, as anatomical abnormality is bilateral
- Immediate exploration (performed by scrotal incision) is recommended in a newborn with normal testis at birth that subsequently undergoes torsion
- Surgical treatment usually involves evaluation of the testis for viability, with a necrotic testis (as a result of torsion for 10-12 hours or more) being removed to avoid prolonged debilitating pain and tenderness as retention of a necrotic testis may exacerbate the potential for subfertility. In such cases, the viable gonad(s) is fixed to the scrotal wall to prevent subsequent torsion
- Usually in the 1-2 hours of onset of symptoms, it may be possible to untwist the testis by manual de-torsion (see procedure below). If manipulation is successful, the pain subsides and the testis is usually out of danger in the short term. However, operative arrangements should be made to avoid recurrent torsion.
- If definitive care is likely to be delayed beyond 4-5 hours from the onset of torsion, manual detorsion may be attempted. However, all patients who undergo manual de-torsion must be surgically explored for early operative fixation to avoid recurrent torsion
- Manual de-torsion can be performed, knowing that most torsion results from internal rotation of the testis. The procedure is referred to 'an open book maneuver,' with the healthcare provider standing at the patient's feet, grasping the affected testis and rotating it outwards as though opening a book. It should be noted that the degree of rotation can be anywhere between 180 and 720o. Rotation of the testis until there is symptomatic relief is a useful guide. However, manual de-torsion does have the risk of making things worse as a small percent of torted testis may be externally rotated and this maneuver could worsen ischemia and worsen the degree of rotation in those cases
Medications indicated with specific doses
Analgesics
Opioid agonists
[note that multiple doses may need to be administered in the first 30-60 minutes to achieve adequate analgesia]
- Fentanyl [IM/IV]
- Fentanyl [Intranasal]
- Hydromorphone
- Morphine
Disposition
Admission criteria
- Admit patient when there is a confirmed torsion, as urgent scrotal exploration and bilateral orchiopexy is generally indicated
- Scrotal exploration is highly recommended in cases with a suspicious history and inconclusive flow studies
- Admission for urgent surgery is indicated in cases with typical presentation of torsion with absent or delayed availability of ultrasonography
- Cases where spontaneous de-torsion appears to have occurred or a manual de-torsion was successful, a less urgent urological/surgical review is needed as bilateral orchiopexy is usually recommended
