High Yield Topics

Testicular Torsion

By admin



Ovid: 5-Minute Sports Medicine Consult, The


Testicular Torsion
Anne M. Garrison
Vikram Narula
Matthew P. Boyd
Basics
Testicular torsion is a surgical emergency. Prompt diagnosis with restoration of blood flow within 6 hr is required to save testicular viability.
Description
  • Testicular torsion results from twisting of the spermatic cord causing ischemia to the testicle by obstructing venous return.
  • Rotation generally occurs medially and ranges from incomplete (eg, 90–180 degrees) to complete (540–720 degrees) torsion.
  • Depending on the degree of torsion, vascular occlusion occurs, and the result is infarction of the testicle after 6 hr.
  • Testicular infarction leads to atrophy and ultimately may decrease fertility.
Epidemiology
Incidence
  • The annual incidence of testicular torsion for males under the age of 25 is about 1/4,000 (1).
  • 90% are caused by a congenital malformation of the process vaginalis (1)
  • The peak age of occurrence is 14 yrs of age, with 2/3 of torsions noted in males between 10 and 20 yrs of age (2).
  • The 2nd most common group is neonates (2).
  • Testicular torsion rarely occurs after age 30 (2).
Risk Factors
  • Congenital malformation of the tunica vaginalis inserted high on the spermatic cord, known as the “bell-clapper deformity”
  • Increased testicular size often related to puberty
  • Testicular tumor
  • Testicles with a horizontal lie
  • Spermatic cord with long intrascrotal portion
  • Cryptorchidism
General Prevention
  • No known primary prevention measures
  • Secondary prevention: Ipsilateral orchidopexy can prevent recurrent torsion. This is often done on the contralateral testicle at the same time to prevent potential future torsion (2)[C].
Etiology
  • Most patients have a congenital abnormality of the genitalia with a high insertion of the tunica vaginalis on the spermatic cord and a redundant mesorchium that permits increased mobility and twisting of the testicle on its vascular pedicle.
  • The anatomic abnormality generally is bilateral, so both testicles are susceptible to torsion.
  • Only 4–8% of torsions are the result of trauma; most occur without a precipitating event (1).
Diagnosis
  • The presentation of an “acute scrotum” in a child or adolescent requires rapid assessment and strong consideration for consultation with an urologist (3)[C].
  • Patients who present clinically with testicular torsion should go immediately to surgery.
  • If the diagnosis of torsion is uncertain, then Doppler US can be done rapidly to assess the blood flow in the testis.
  • 25–30% of these patients ultimately will prove to have testicular torsion.
History
  • Sudden onset of severe scrotal pain or trauma: Unilateral testicular pain and tenderness followed by scrotal swelling and erythema
  • Less commonly, torsion may present with pain in the inguinal or lower abdominal area.
  • 1/3 of patients have had a previous episode of testicular pain (2).
Physical Exam
  • Nausea and vomiting occur in 50% of patients, and low-grade fever occurs in 25% (2).
  • Symptoms of urinary infection (ie, dysuria, frequency, and urgency) are absent.
  • In distinguishing torsion from epididymitis, localization of tenderness is helpful early in the course. However, once significant scrotal swelling occurs, the anatomy becomes indistinct, and some form of testicular flow study or surgical exploration is required.
  • The affected testicle may ride higher than the contralateral testicle.
  • The affected testicle may be found to lie transversely as opposed to the normal vertical lie.
  • The cremasteric reflex is the most sensitive (99%) physical finding (1).
    • Reflex is elicited by stroking the medial thigh, which causes the cremaster muscle to contract, elevating the testis.
    • Reflex is considered positive if the testicle moves at least 0.5 cm.
  • The classic Prehn sign, which consists of relief of pain on elevation of the testicle in epididymitis, and worsening or no change in the pain with torsion, is considered unreliable (2).
  • Torsion of the appendix testis may present with a palpable hard, tender nodule 2–3 mm in diameter in the upper pole of the testicle. Blue discoloration in this area is called the “blue dot sign” (1).
Diagnostic Tests & Interpretation
  • Radionuclide scan: The criterion standard imaging modality traditionally has been 99m TC-pertechnetate radionuclide scan, which shows decreased flow in the torsed testicle compared with the unaffected side (1).
    • Epididymitis will reveal increased flow owing to inflammation.
    • This technique has an overall sensitivity and specificity of 98% and 100%, respectively.
  • US: Because of the frequent time delays in obtaining nuclear scans and the importance of a rapid and accurate diagnosis, use of Doppler US to assess testicular blood flow has essentially replaced nuclear scanning as a less invasive, more readily available test with comparable accuracy (1,2)[C].
    • Overall sensitivity and specificity for color-flow Doppler range from 86–100% and 97–100%, respectively, although the accuracy tends to be lower in infants owing to the smaller anatomy.
    • US does not expose the patient to ionizing radiation.
    • There are limitations of all flow studies in that they reflect only the current state of perfusion. Consequently, a spontaneously detorsed testicle may show normal or even increased flow and yet still be at high risk for recurrent torsion.
Lab
  • Generally laboratory tests are not helpful.
  • Urinalysis is usually normal; some patients with torsion may have pyuria.
  • Elevated WBC count with a left shift is present in 50% of patients.
  • There are no laboratory tests specific for testicular torsion.
Differential Diagnosis
  • Epididymitis/orchitis
  • Torsion of the appendix testis
  • Testicular trauma or rupture of the testicle
  • Incarcerated inguinal hernia
  • Testicular tumor
  • Acute hydrocele
  • Henoch-Schönlein purpura
  • Other intra-abdominal conditions (eg, appendicitis, pancreatitis, renal colic) rarely may present with testicular pain.

P.577


Treatment
Pre-Hospital
  • Acute onset of testicular pain should prompt immediate referral for further evaluation.
  • If transportation will be delayed and torsion is suspected, manual detorsion should be attempted.
ED Treatment
  • If history and physical exam findings are consistent with the diagnosis of torsion, surgical care should not be delayed for imaging studies (1,2)[C].
  • If the diagnosis is uncertain, imaging and/or consultation with a specialist is appropriate (1,2)[C].
  • US generally is the imaging study of choice: US is faster and more readily available, but it is less sensitive than radionuclide scanning.
  • In situations in which definitive care is likely to be delayed beyond 4–5 hr after the onset of torsion, manual detorsion may be attempted (1,2)[C].
    • Do not delay surgical consultation to attempt manual detorsion.
    • Surgical exploration is still necessary even with successful detorsion.
    • Attempt usually requires anesthesia: IV sedations or local anesthesia
    • Manual detorsion is accomplished by externally rotating the affected testicle laterally (away from midline, as if opening as book, because 2/3 of torsions are medial) until pain is relieved or normal anatomy is restored. All patients who undergo manual detorsion still should have blood flow documented and orchidopexy to prevent recurrences.
    • Rotation in the opposite direction, toward the midline, should be attempted if lateral rotation is not successful.
Surgery/Other Procedures
  • Surgical consultation should be obtained in all suspected cases of testicular torsion (1,2,3)[C].
  • Surgical exploration of the affected and contralateral testes is recommended in all cases (1,2,3)[C].
    • Orchiopexy, fixation of the testicle within the scrotum, is the surgical procedure of choice.
    • The procedure is performed prophylactically on the contralateral side.
    • Nonviable testes should be removed.
In-Patient Considerations
Initial Stabilization
  • IV fluid
  • Analgesics as appropriate
Admission Criteria
  • Any patient with confirmed testicular torsion must be admitted for scrotal exploration and bilateral orchiopexy.
  • Flow studies that are inconclusive or technical failures mandate further investigation by surgical exploration of the scrotum.
  • Admission for urgent surgical exploration of an acute scrotum is mandatory if there will be any potential delay in obtaining a flow study.
Discharge Criteria
  • Patients with negative scrotal exploration or normal flow studies can be discharged with appropriate urologic follow-up.
  • Appropriate parameters for return to ED must be discussed because of the possibility of intermittent torsion.
  • Patients with an obvious diagnosis other than testicular torsion (eg, a nonincarcerated inguinal hernia) can be referred for elective care.
Ongoing Care
  • Patients may return to full activity once the surgical wounds have healed and pain has resolved.
  • Patients who have a testicle removed should be advised of the risk of injury to the remaining testicle and strongly consider protective equipment for contact sporting activity.
Complications
Delayed recognition and treatment may lead to testicular atrophy, decreased fertility, and possibly the need to remove the affected testicle.
References
1. Ringdahl E, Teague L. Testicular torsion. Am Fam Physician. 2006;74:1739–1743.
2. Lavallee ME, Cash J. Testicular torsion: evaluation and management. Curr Sports Med Rep. 2005;4:102–104.
3. Leslie JA, Cain MP. Pediatric urologic emergencies and urgencies. Pediatr Clin North Am. 2006;53:513–527, viii.
Additional Reading
Gatti JM, Murphy JP. Acute testicular disorders. Pediatr Rev. 2008;29:235–241.
Codes
ICD9
  • 608.20 Torsion of testis, unspecified
  • 608.21 Extravaginal torsion of spermatic cord
  • 608.22 Intravaginal torsion of spermatic cord
Clinical Pearls
  • Obtain surgical consultation early in suspected cases of testicular torsion.
  • Do not delay surgical intervention for imaging studies when clinical suspicion is high.
  • US can be useful in cases where clinical suspicion is low because it can evaluate for torsion as well as other pathology.


Continue Reading
You might also like More from author

This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Accept Read More