You are in: eMedicine Specialties > Urology > Common Problems of the Testicle Testicular TorsionArticle Last Updated: Feb 9, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Eugene Minevich, MD, Assistant Professor, Department of Surgery, Division of Pediatric Urology, University of Cincinnati Eugene Minevich is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, and American Urological Association Coauthor(s): Leslie Tackett, MD, Fellow, Departments of Surgery and Pediatrics, Division of Pediatric Urology, Children's Hospital Medical Center at Cincinnati Editors: Raymond Rackley, MD, Professor of Surgery, Cleveland Clinic Lerner College of Medicine at CWRU; Co-Section Head, Section of Voiding Dysfunction and Female Urology, Glickman Urological Institute, Cleveland Clinic Foundation; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Shlomo Raz, MD, Professor, Department of Surgery, Division of Urology, University of California at Los Angeles School of Medicine; J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center; William J Cromie, MD, MBA, President and Chief Executive Officer, Health Care, Capital District Physicians' Health Plan Author and Editor Disclosure Synonyms and related keywords: testicular torsion, intravaginal testicular torsion, extravaginal testicular torsion, torsion of the spermatic cord, torsion of the testis, epididymitis, orchitis, epididymo-orchitis, pyuria, bacteriuria, leucocytosis, contralateral orchidopexy, orchiectomy, testicular necrosis, testicular atrophy, scrotal swelling, intermittent testicular torsion, acute scrotum, bell-clapper deformity INTRODUCTIONSection 2 of 11
  Torsion of the testis, or more correctly, torsion of the spermatic cord, is a surgical emergency because it causes strangulation of gonadal blood supply with subsequent testicular necrosis and atrophy. Acute scrotal swelling in children indicates torsion of the testis until proven otherwise. In approximately two thirds of patients, history and physical examination are sufficient to make an accurate diagnosis. History of the ProcedurePatients often complain of acute-onset scrotal discomfort, which may occur at rest or may relate to sports or physical activities. They may describe similar previous episodes, which may suggest intermittent testicular torsion. Patients deny voiding problems or painful urination but may describe nausea and vomiting. ProblemTesticular torsion refers to twisting of the spermatic cord structures, either in the inguinal canal or just below the inguinal canal. The following are the 2 most common types of testicular torsion (see Image 1):
Frequency
Etiology
PathophysiologyTorsion of the spermatic cord may interrupt blood flow to the testis and epididymis. The degree of torsion may vary from 180-720°. Increasing testicular and epididymal congestion promotes progression of torsion. The extent and duration of torsion prominently influence both the immediate salvage rate and late testicular atrophy. Testicular salvage most likely occurs if the duration of torsion is less than 6-8 hours. If 24 hours or more elapse, testicular necrosis develops in most patients. ClinicalPrenatal torsion manifests as a firm, hard, scrotal mass, which does not transilluminate in an otherwise asymptomatic newborn male. The scrotal skin characteristically fixes to the necrotic gonad. In older boys, the classic presentation of testicular torsion is the sudden onset of severe testicular pain followed by inguinal and/or scrotal swelling. Pain may lessen as the necrosis becomes more complete. Approximately one third of patients also have gastrointestinal upset with nausea and vomiting. In some patients, scrotal trauma or other scrotal disease (including torsion of appendix testis or epididymitis) may precede the occurrence of subsequent testicular torsion. A physical examination may reveal a swollen, tender, high-riding testis (see Image 2). The absence of the cremasteric reflex in a patient with acute scrotal pain supports the diagnosis of torsion. In time, a reactive hydrocele, scrotal wall erythema, and ecchymosis become more striking. Differential diagnosis:
INDICATIONSSection 3 of 11
If clinical evaluation reveals testicular torsion, transfer the patient to the operating room for urgent scrotal exploration, regardless of the number of hours since the onset of presenting symptoms. RELEVANT ANATOMYSection 4 of 11
For normal development and sperm production, the testis must descend from its original position near the kidney into the scrotum. Researchers propose that various mechanisms, including gubernacular traction and intra-abdominal pressure, are responsible for testicular descent; however, endocrine factors of the hypothalamic-pituitary-testicular axis also play a major role in this process. Between the 12th and 17th week of gestation, the testis undergoes transabdominal migration to a location near the internal inguinal ring. The testis does not migrate transinguinally to its final position until the seventh month of gestation. The testes are paired ovoid structures that are housed in the scrotum and positioned so that the long axis is vertical. The anterolateral two thirds of the organ is free of any scrotal attachment. The epididymis, connective tissue, and vasculature cover the posterolateral aspect of the organ. The capsule of the testis is termed the tunica albuginea. WORKUPSection 5 of 11
Lab Studies
Imaging Studies
TREATMENTSection 6 of 11
Medical therapyManual detorsion of the torsed testis may be attempted but is usually difficult because of acute pain during manipulation. This nonoperative detorsion is not a substitute for surgical exploration. If successful (ie, confirmed by color Doppler sonogram in a patient with complete resolution of symptoms), perform definitive surgical fixation of the testes before the patient leaves the hospital as an urgent—rather than emergent—procedure. Surgical therapyTreatment of testicular torsion varies according to patient age.
Intraoperative detailsSigns of a viable testis after detorsion (see Image 3) include a return of color, return of Doppler flow, and arterial bleeding after incision of tunica albuginea. Postoperative details
COMPLICATIONSSection 7 of 11
Torsion of the spermatic cord continues to be one of the few emergencies in urologic practice. Delay of more than 6-8 hours between onset of symptoms and the time of surgical (or manual) detorsion reduces the salvage rate to 55-85%. A correlation may exist between the duration of torsion and abnormal semen parameters, and some authorities suggest that retention of an injured testis can induce pathologic changes to the contralateral testis. OUTCOME AND PROGNOSISSection 8 of 11
Success in the management of spermatic cord torsion is measured by immediate testicular salvage and incidence of late testicular atrophy, which are, in turn, directly related to the duration and degree of testicular torsion. Delaying surgical intervention worsens the intraoperative testicular salvage and incidence rate and the extent of subsequent testicular atrophy. The delay between the onset of symptoms and the time of surgical or manual detorsion is obviously of utmost importance in achieving a viable testis. FUTURE AND CONTROVERSIESSection 9 of 11
Recent studies show that exocrine and endocrine function is substandard in men with a history of unilateral torsion. The following 3 theories explain the contralateral disease noted in torsion:
To explain the decreased fertility observed in unilateral torsion of the spermatic cord, several specialists suggest an autoimmune mechanism. This hypothesis is based upon the following:
MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Article Last Updated: Feb 9, 2007 | ||||||||||||||||||||||||||
