Testicular torsion is a condition due to twisting of the testis resulting in interference with the arterial blood supply. It is an emergency.
It is usually due to sudden contraction of the cremasteric muscle, which inserts onto the cord in a spiral manner. One may have torsion of the cord or appendages. Incidence is highest between 10-25 years of age.
Risk factors
- Undescended testis
- Bell clapper deformity
- Separation of the epididymis from the body of the testis
- Inversion of the testis.
- Testicular cancer
Precipitating factors
- Straining on stool
- Sexual activity
- Sports
- Lifting of heavyweights
Clinical presentation
Signs and symptoms:
- Sudden testicular pain &swelling that radiates to the lower abdomen
- Nausea and vomiting
- Fever -rarely
- History of a similar episode.
On physical exam:
- The testis is Swollen, painful, and high-riding.
- Erythematous scrotum if left for long.
- Negative Prehn’s sign- Elevation of the scrotum doesn’t relieve the pain
- Absent of cremasteric reflex on the affected side
TWIST SCORE
Criteria = score
- Testicular swelling = 2
- Hard testicle = 2
- Absent cremasteric reflex = 1
- Nausea and vomiting = 1
- High riding testis = 1
Maximum score =7
Interpretation;
- <2 = testicular torsion unlikely (100% negative predictive value)
- 3-4 = testicular ultrasound with flow
- 5-7= emergent urologic consult and surgery to save the testicle
Investigations
- Testicular Ultrasound With Flow
- Urinalysis – Rule Out The Presence Of An Infection
- Full Hemogram – WBC May Be Elevated
- MRI Or Radionuclide Imaging If Clinical Findings Are Inconclusive
Differential diagnosis
- Epididymo-orchitis
- Mumps orchitis
- Torsion of a testicular appendage
- Strangulated inguinal hernia
- Testicular tumor
- Trauma
- Hydrocele
- Varicocele
- Urolithiasis
- Fournier’s gangrene
- Idiopathic scrotal edema
Management
- If there is an acute painful scrotum, explore it because if left untreated, infarction of the testis will result.
- Untwisting should be carried on within 6 hrs of symptoms.
- In adults, surgery is done via a testicular incision, whereas in children, surgery is done using an inguinal incision because it is usually associated with a hernia.
- Emergency exploration of the testis and untwisting of the testis if viable
- Orchidopexy of the affected testis by anchoring it to the scrotal septum
- If the other testis is abnormal, fix it.
- If infracted, orchiectomy of the affected one and perform orchidopexy of the other testis.
- Adequate analgesia
Prevention
- Orchidopexy after an episode of testicular torsion
- Proper wear for protection when playing sports
Complications
- Testicular infarction and orchiectomy
- Testicular atrophy
- Infertility
- Cosmetic deformity
