eMedicine Specialties > Pediatrics: Surgery > Urology

Testicular Torsion

Author: Krishna Kumar Govindarajan, MCh, FEBPS, MRCS Ed, DNB, MS, MBBS, Specialist Registrar, Department of Pediatric Surgery, Birmingham Children's Hospital, UK
Coauthor(s): Caleb P Nelson, MD, MPH, Instructor in Surgery, Department of Urology, Harvard Medical School; Consulting Staff, Division of Pediatric Urology, Department of Urology, Children's Hospital Boston
Contributor Information and Disclosures

Updated: May 22, 2009

Introduction

Testicular torsion is an acute vascular event in which the spermatic cord becomes twisted on its axis, such that the blood flow to and/or from the testicle becomes impeded. This results in ischemic injury and infarction. The condition may result in loss of the testis.

Testicular torsion is one of the more common acute pediatric surgical conditions, although few studies have documented the actual incidence. In 1976, a study from the United Kingdom reported the annual incidence of testicular torsion as 1 case per 4000 in males younger than 25 years.¹ Testicular torsion has a bimodal incidence; one group presents in the perinatal period (perinatal testicular torsion), and the other group presents in early puberty (although torsion can present at any age, well into adulthood [see Testicular Torsion]). Another condition that mimics testicular torsion in presentation is torsion of the appendix testis (appendix epididymis), which is most commonly seen in older prepubertal boys.

Because testicular torsion is a potentially reversible condition when diagnosed and treated early, the emphasis should be on prompt evaluation of children who present with acute scrotum. General public awareness and awareness in referring pediatricians and general practitioners is key to improving outcomes in these boys.²

History of the Procedure

Testicular torsion was first described by Delasiauve in 1840. It was not widely regarded as a significant problem until 1907, when Rigby and Russell published their work on torsion of the testis in Lancet. The first description of neonatal torsion was by Taylor in 1897. Subsequently, Colt reported torsion of the appendage testis in 1922.^3,4

The initial use of Doppler ultrasonography was reported in 1975; Nadel et al reported sodium pertechnetate testicular scintigraphy in 1973.⁵

Etiology

A rotational twisting of the spermatic cord is the basis of all torsion events. When the twist is sufficient to obstruct arterial inflow, testicular ischemia results. If the duration of ischemia is long enough, infarction results. Lesser degrees of cord twisting may result in obstruction of venous outflow, causing congestion and swelling of the testis without frank infarction.

Unfortunately, no reliable indicator for risk of torsion has been identified. Numerous factors have been observed in association with torsion, but none can be used to predict torsion risk in a clinical setting.⁶

• Bell clapper deformity: In this anatomic variant, the testis hangs freely within parietal tunica vaginalis secondary to an extension of the tunica high onto the spermatic cord. This extension allows the testis to rotate easily within the tunica because of the lack of normal fixation of the posterior testis to the scrotal tissues. The bell clapper deformity is often noted at the time of exploration in older children and adolescents with testicular torsion. The anomaly is seen in 12% of males in cadaveric studies and is often bilateral.⁷
• Pubertal changes: The observation that the risk of torsion is increased around the time of puberty has led to speculation regarding the role of pubertal changes in torsion risk. Increased testosterone levels at puberty result in an increased testicular volume and mass. These increases could predispose the testis to torsion because of increased movement around the axis of the cord. The cord’s torsional rigidity and other resistances, which tend to limit the angle of rotation, may increase less markedly with growth and development. Thus, normal physical activity may result in angular momentum sufficient to easily overcome the opposing resistances, allowing complete testicular torsion.⁸
• Anatomical abnormalities: Various anatomical abnormalities of the testis are associated with torsion. Most significant of these is cryptorchidism. Cryptorchid testes are at significantly higher risk of torsion than scrotal testes.⁹ Other anatomic abnormalities that may predispose to torsion include a horizontal lie of the testes, polyorchidism,¹⁰ and epididymal anomalies.¹¹
  
  

  

  Torsion of undescended testis.

  [ CLOSE WINDOW ]

  

  Torsion of undescended testis.

• Physical activities: In some cases, specific physical activities, including sports, weight training, or trauma, appear to induce an episode of torsion, perhaps due to a sudden cremasteric reflex. Epidemiological studies have shown that testicular torsion is more common in winter months and in northern latitudes, prompting speculation that cold-induced cremasteric contraction may play a role in the development of torsion.¹²
• Tunica and scrotal tissue adhesion: In the newborn, the scrotal parietal tunica vaginalis has not yet fully adhered to the outer tissues of the scrotum. Thus, the entire testes, tunica vaginalis, and gubernaculum may twist together within the scrotum, resulting in an extravaginal torsion. This is the most common form of torsion in the perinatal period. Because the adhesion between the tunica and scrotal tissues is bilaterally deficient, these infants are at risk for bilateral torsion events (either synchronous or metachronous).^8,13

Pathophysiology

Testicular torsion can take place either inside (intravaginal) or outside (extravaginal) the tunica vaginalis. The distinction is important because these conditions are associated with different ages of presentation and etiologies; hence, they differ in management. Intravaginal testicular torsion is far more common and represents almost all torsion events in older boys, whereas extravaginal testicular torsion is commonly seen in perinatal torsion. The tunica vaginalis takes about 6 weeks after birth to adhere to the surrounding tissues, possibly explaining the preponderance of the condition in neonates. Large birth weight, difficult labor, breech presentation, and overreactive cremasteric reflex have been proposed as possible causes for perinatal torsion.^8,14

Testicular torsion is classically described as involving a medial rotation; however, in up to one third of cases, a lateral rotation has been described.^15,16 When manual detorsion is contemplated, the testis is typically rotated laterally ("opening the book"); however, if the testis is already laterally rotated, this maneuver worsens the condition.

Presentation

Testicular torsion presents as an acute onset of severe scrotal pain, commonly with associated scrotal swelling and erythema. Nausea and vomiting are common, as are local scrotal redness and pain. Although the pain is usually severe, with a rapid onset, patients occasionally present with a history of pain lasting many hours or even days.

Upon examination, the classic findings of testicular torsion include an exquisitely tender, high-riding testis with an abnormal (transverse) orientation. Scrotal swelling and edema are common. The cremasteric reflex is generally absent in cases of testicular torsion. In one series, the absence of cremasteric reflex was 100% sensitive for testicular torsion but was only 66% specific (because many boys have absent or decreased cremasteric reflex at baseline).^17,18 An intact cremasteric reflex in the setting of torsion has been reported; thus, the presence of the reflex should not be used to rule out torsion in a patient whose presentation is otherwise suspicious for torsion.¹⁸

Torsion of the appendix testis may present similarly to testicular torsion. The age of the patient may be helpful, as torsion of the appendix testis is more common in prepubertal boys.¹⁴ These boys are less likely to have nausea and vomiting than boys with testicular torsion. Upon examination, a classic "blue-dot sign" may be seen; this finding on the upper scrotum is a typical finding in torsion of the appendix testis. However, in the acute setting, differentiating testicular torsion from torsion of the appendix is often impossible, and scrotal exploration should be performed whenever the diagnosis is uncertain.

Intermittent torsion that persists with recurrent attacks of pain requires a careful examination to reveal subtle signs, such as excess testicular mobility and transverse testicular orientation. An elective scrotal exploration may be planned to look for a bell clapper deformity and to avoid a dead testicle.

Torsion of the cryptorchid testis can be very challenging to diagnose. This condition may be mistaken for incarcerated hernia, appendicitis, or other causes of acute abdomen. Intra-abdominal testicular torsion is often associated with malignant degeneration.¹⁹ Testicular torsion can occur in boys who have undergone prior orchidopexy, although this is unusual. Hence, testicular torsion should be suspected and considered in the differential diagnoses of acute scrotum in this group.^12,20

Differential diagnoses

• Torsion appendage testis
• Hydatid of Morgagni
• Idiopathic scrotal edema (dermatitis, insect bite)
• Trauma
• Epididymitis
• Orchitis
• Scrotal abscess/cellulitis
• Epididymal torsion
• Tumor
• Acute hydrocele
• Obstructed/incarcerated hernia
• Furuncle
• Hemangioma
• Varicocele
• Abdominal trauma with hemiscrotum
• Perforated appendicitis
• Splenogonadal fusion
• Adrenal neuroblastoma
• Adrenal hemorrhage
• Meconium peritonitis
• Antenatal Meckel diverticulum perforation
• Henoch-Schönlein purpura
• Hernial sac torsion
• Pyocele
• Ventriculoperitoneal shunt migration

Indications

Neonate with acute scrotum at birth

Recommendations are controversial. Although most authorities recommend exploration of the ipsilateral side and fixation of the contralateral testis, some have suggested that observation is acceptable because of the negligible salvage rate of the ischemic testis and the low incidence of contralateral torsion. The risk of anesthesia in children younger than 1 year may also factor into decision-making process.

Neonate with acute scrotum a few days after birth

The recommendations are the same as those for the neonate with acute scrotum at birth.

Prepubertal boy with acute scrotum

Exploration with salvage of ipsilateral testis is recommended, if possible. If testicular torsion is confirmed, contralateral orchiopexy is recommended. Differential diagnoses to consider include torsed appendix epididymis ("blue-dot sign") and epididymitis. If a clear-cut "blue dot sign" is identified and confirmed with Doppler ultrasonography findings, a conservative approach is justified.

Adolescent with acute scrotum

Exploration with salvage of ipsilateral testis is recommended, if possible. If torsion is confirmed, contralateral orchiopexy is recommended. If the testis has not been salvaged, ipsilateral orchiectomy is usually performed.

Relevant Anatomy

The normal testis lies suspended in the scrotum, with the visceral tunica vaginalis wrapping the anterior, inferior, superior, and mediolateral margins, leaving the posterior surface adherent to the surrounding scrotal soft tissues. The testicular arteries arise from the abdominal aorta and pass inferolaterally through the retroperitoneum to the internal inguinal ring, where they meet the vasa deferentia and enter the inguinal canal. The spermatic cord (artery, vein, vas, and supporting structures) passes through the canal, out the external inguinal ring, over the pubic tubercle, and into the scrotum, where it meets the testis.

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