Introduction
Background
Testicular torsion is a true urologic emergency and must be differentiated from other complaints of testicular pain because a delay in diagnosis and management can lead to loss of the testicle. Though testicular torsion can occur at any age, including the prenatal and perinatal periods, it most commonly occurs in adolescent males; it is the most frequent cause of testicle loss in that population.
A Doppler sonogram of an avascular testicle is shown below.
Transverse power Doppler image of both testes illustrates an enlarged, avascular left testicle.
Pathophysiology
The testicle is covered by the tunica vaginalis, a potential space that encompasses the anterior two thirds of the testicle and where fluid from a variety of sources may accumulate. The tunica vaginalis attaches to the posterolateral surface of the testicle and allows for little mobility of the testicle within the scrotum.
In patients who have an inappropriately high attachment of the tunica vaginalis, the testicle can rotate freely on the spermatic cord within the tunica vaginalis (intravaginal testicular torsion). This congenital anomaly, called the bell clapper deformity, can result in the long axis of the testicle being oriented transversely rather than cephalocaudal. This congenital abnormality is present in approximately 12% of males, 40% of whom have the abnormality in the contralateral testicle as well.1 The bell clapper deformity allows the testicle to twist spontaneously on the spermatic cord. Torsion occurs as the testicle rotates between 90° to 180°, causing compromised blood flow to the testicle.
Complete torsion usually occurs when the testicle twists 360° or more; incomplete or partial torsion occurs when the twisting is less than this. The twisting of the testicle causes venous occlusion and engorgement as well as arterial ischemia and infarction of the testicle. How tightly the testicle is twisted appears to correlate with how quickly the testicle becomes nonviable from ischemia.
In the neonatal age group, the testicle frequently has not yet descended into the scrotum, where it becomes attached within the tunica vaginalis. This mobility of the testicle predisposes it to torsion (extravaginal testicular torsion). Inadequate fusion of the testicle to the scrotal wall typically occurs within the first 7-10 days of life.
Frequency
United States
Incidence of torsion in males younger than 25 years is approximately 1 in 4000.2 Torsion more often involves the left testicle.
Of the cases of testicular torsion that occur in the neonatal population, 70% occur prenatally and 30% occur postnatally.
Mortality/Morbidity
This urologic emergency requires prompt diagnosis, immediate urologic consultation, and rapid definitive operative treatment for salvage of the testicle.
A salvage rate of 90-100% is found in patients who undergo detorsion within 6 hours of pain; the viability rate fell to between 20% and 50% after 12 hours; and 0 to 10% viability if detorsion is delayed greater than 24 hours.3,2
Age
Testicular torsion most often is observed in males younger than 30 years, with most aged 12-18 years. The peak age is 14 years, although a smaller peak also occurs during the first year of life.
Clinical
History
- History includes a sudden onset of severe unilateral scrotal pain.
- Onset of pain can occur more slowly, but this is an uncommon presentation of torsion.
- Torsion can occur with activity, can be related to trauma in 4-8% of cases,2 or can develop during sleep.
- The historical features suggestive of testicular torsion include the following:
- Acute onset of unilateral scrotal pain
- Scrotal swelling
- Nausea and vomiting: In the pediatric population, nausea and vomiting more commonly accompany acute testicular torsion and have a positive predictive value of greater than 96%.4
- Abdominal pain (20-30%)
- Fever (16%)
- Urinary frequency (4%)
- Many patients have a history of recurrent scrotal pain that has resolved spontaneously. This history is highly suggestive of intermittent torsion and detorsion of the testicle. Patients who complain of what sounds like torsion-detorsion should be referred promptly to a urologist since patients with symptoms of intermittent torsion who electively have surgical exploration are less likely to develop subsequent torsion and loss of the testicle.5 Creagh et al reported that acute torsion developed in 10% of patients with intermittent torsion while they waited for surgery.6
Physical
- The physical examination may be difficult to perform, as the testicle is typically very tender and patients are often in significant discomfort.
- The involved testicle is painful and is frequently elevated in position when compared with the other side.
- Horizontal lie of the testicle
- Enlargement and edema of the testicle; edema involving the entire scrotum
- Scrotal erythema
- Ipsilateral loss of the cremasteric reflex - The cremasteric reflex is almost always absent in patients with testicular torsion, and its presence may help to distinguish other causes of acute scrotal pain from testicular torsion.7,8
- Usually, no relief of pain upon elevation of scrotum (elevation may improve the pain in epididymitis [Prehn sign])
- Fever (uncommon)
Causes
- Congenital anomaly; bell clapper deformity
- Undescended testicle
- Sexual arousal and/or activity
- Trauma
- Testicular tumor
- Exercise
More on Testicular Torsion |
 Overview: Testicular Torsion |
| Differential Diagnoses & Workup: Testicular Torsion |
| Treatment & Medication: Testicular Torsion |
| Follow-up: Testicular Torsion |
| Multimedia: Testicular Torsion |
| References |
| Next Page » |
References
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Further Reading
Keywords
testicular torsion, testicular torsion symptoms, testicular torsion treatment, testicular torsion causes, testicular pain, scrotal pain, torsion of testis, torsion of the testes, testicle pain, severe unilateral scrotal pain, scrotal swelling, scrotal erythema, undescended testicle, testicular trauma
