Testicular torsion – 7 Interesting Facts

Interesting Facts

  1. Testicular torsion results from twisting of the spermatic cord and its contents, causing loss of blood supply to the involved testis
  2. Causes acute scrotal pain (unless torsion occurs prenatally), scrotal edema, nausea, and vomiting
  3. Classic examination findings include painful testis, scrotal edema, ipsilateral scrotal induration and erythema, and loss of ipsilateral cremasteric reflex; findings in neonates include a painless, firm scrotal mass that cannot be transilluminated
  4. Suggestive history and physical examination should prompt urgent surgical consultation for scrotal exploration
  5. Contrast-enhanced color duplex Doppler ultrasonography is useful when physical examination findings are equivocal
  6. Manual detorsion is indicated if surgery delayed
  7. All patients require operative management and orchiopexy to prevent recurrence

Pitfalls

  • Since testicular torsion may present with abdominal pain, all male patients presenting with abdominal pain should have their testicles examined
  • Torsion is more common with an undescended testis. Diagnosis should be strongly considered in patients with painful inguinal mass and an empty hemiscrotum
  • Surgical exploration and orchiopexy are required for all patients with testicular torsion, even if successfully detorsed manually

Urgent Action

  • Urgent consultation with a urologist is required if testicular torsion is clinically suspected
  • Manual detorsion should be performed if there is delay to surgery, as pain lasting 4 to 8 hours is highly associated with testicular death 1

Terminology

Clinical Clarification

  • Testicular torsion is acute twisting of the spermatic cord and its contents, resulting in disruption of blood supply to testis 1

Classification

  • Extravaginal torsion (twisting proximal to the tunica vaginalis) seen in the perinatal period 2
    • Occurs in utero or shortly after birth; accounts for up to 10% of all testicular torsions 3
  • Intravaginal torsion (twisting within the tunica vaginalis) seen in older children and adults 2

Diagnosis

Clinical Presentation

History

  • Acute scrotal pain that is severe in intensity
  • Pain often radiates to lower abdomen and groin
  • Pain often causes impaired gait
  • Onset of pain common during sleep or upon sexual arousal
  • Left testicle is more commonly affected than right testicle
  • Nausea and vomiting
  • Lethargy
  • Restlessness may be seen in neonates who are otherwise asymptomatic
  • Less commonly, symptom onset reported:
    • During or after physical activity
    • With sudden temperature changes (eg, diving into cold water)
    • After direct trauma (4%-8% of cases) 4

Physical examination

  • Since testicular torsion may present with abdominal pain, all male patients presenting with abdominal pain should have their testicles examined
  • Massive local swelling makes examination difficult after several hours
  • Scrotum may be elevated on the affected side
  • Painful palpation (88% of boys with testicular torsion) 4
  • Scrotal edema (44% of boys with testicular torsion) 4
  • Ipsilateral scrotal induration and erythema
  • Absence of ipsilateral cremasteric reflex
    • Finding approaches 100% sensitivity and 66% specificity for torsion 5
  • Medial position of testicle
  • Abnormal horizontal (as opposed to vertical) testicular lie
  • In utero torsion can result in neonatal finding of firm scrotal mass that cannot be transilluminated
    • Scrotal skin has blue appearance or no discoloration
    • Nontender scrotum; loss of innervation from prolonged torsion and ischemia

Causes and Risk Factors

Causes

  • Most common cause is congenital malformation
    • Tunica vaginalis improperly wraps around spermatic cord
      • Inhibits testis attachment to posterior scrotum
      • Creates bell clapper deformity, allowing increased mobility of testis
      • Causes medial position of testicle
  • Long intrascrotal spermatic cord
  • Testicular mass (less common)

Risk factors and/or associations

Age
  • Occurs in 1 per 4000 males younger than 25 years 4
  • Rare in men older than 35 years 6
  • Bimodal occurrence in children: small peak in neonates with a larger peak in peripubertal children 7
Genetics
  • An affected male relative is noted in 10% of cases 8
  • High rate of bilateral testicular torsion within families studied (37%) 8
Other risk factors/associations
  • History of cryptorchidism

Diagnostic Procedures

  • From Phillips GS et al: Essentials of genitourinary disorders in children: imaging evaluation. Sem Roentgenol. 47(1):56-65, 2012, Figure 8.Testicular torsion in a 17-year-old boy with severe left testicular pain. – Transverse ultrasonographic image of the right and left testicle demonstrates no detectable color Doppler flow within the enlarged left testicle. The echotexture of both testes are homogeneous.

Primary diagnostic tools

  • History and physical examination may be sufficient to diagnose testicular torsion and indicate which patients should be taken to immediate surgery 2
    • Presence together of scrotal pain, nausea and vomiting, ipsilateral scrotal skin changes, and absence of ipsilateral cremasteric reflex strongly suggests testicular torsion
  • Imaging with color Doppler ultrasonography is only necessary if history and physical examination are equivocal but it is often performed in clinical practice 1 6
    • Absent or diminished testicular perfusion and/or twisting of spermatic cord confirms torsion
  • Use MRI or scintigraphy if ultrasonography not rapidly available
  • Surgical exploration confirms diagnosis and should be urgently performed 2

Imaging

  • Contrast-enhanced color duplex Doppler ultrasonography of the scrotum 4
    • Recommended in children and adults if needed to confirm diagnosis
    • Specific findings include:
      • Absent or diminished testicular perfusion
        • Early findings often show decreased perfusion; however, findings can occasionally be misleading
          • Common early findings on color Doppler ultrasonography include increased resistive index with decreased diastolic flow and decreased arterial velocity
          • Rarely normal or increased testicular vascularization can be visualized in early torsion 5
        • Confirm diagnosis by loss of detectable flow in the affected testis and epididymis
          • Absence of intratesticular flow is 86% to 100% sensitive and 100% specific for complete testicular torsion 3 9
      • Twisting of spermatic cord
        • Large, echogenic extratesticular mass cranial to testis containing twisted cord segment and epididymis
        • With high-frequency transducer, it is possible to identify exact torsion site and spiral portion of twisted cord (ie, whirlpool-shaped, snail shell–shaped)
        • Visualization of an abnormal spermatic cord twist is up to 96% sensitive for testicular torsion; visualization of a normal linear cord is 99% specific for lack of torsion 6
      • Power Doppler ultrasonography is recommended for small children and newborns owing to its increased sensitivity for detecting diminished blood flow in small (prepubertal) testicles when compared to color Doppler ultrasonography
    • Nonspecific findings can include the following:
      • Enlarged testis visualized by grayscale imaging; diffuse hypoechogenicity is typical and sometimes lobar architecture is well identified
      • Hemorrhagic infarction visualized by hyper- and hypoechogenicities
      • Enlarged epididymis demonstrated by heterogeneous echogenicity
      • Gradual increase in thickening of peritesticular tissues, caused by edema
  • Scintigraphy 4
    • Alternative imaging modality if Doppler ultrasonography is unavailable
    • Highly sensitive in early stages to detect absence of flow by lack of local radionuclide uptake
    • Limitations include exposure to radiation and time required for imaging (takes several hours to perform)
  • MRI (with and without contrast material) 4
    • Alternative imaging modality if Doppler ultrasonography is unavailable
    • May be used after ultrasonography to obtain additional information (eg, presence of hemorrhagic necrosis) if surgery not immediately planned
    • Whirlpool pattern and knot in the spermatic cord may be detected by conventional T1 and T2 images
    • Ischemia caused by torsion is detectable with contrast enhancement

Differential Diagnosis

Most common

  • Epididymitis
    • Most common reason for acute scrotal pain
    • Gradual pain onset; localized posterior to testis
    • Differentiated from testicular torsion by:
      • Presence of lower urinary tract symptoms (eg, dysuria, frequency, urgency, hematuria, fever)
      • Testis in normal anatomic position
      • Presence of cremasteric reflex or Prehn sign (ie, relief of pain with testicular elevation)
    • Doppler ultrasonography can aid in differentiating this condition from testicular torsion; obtain if history and physical examination are equivocal for testicular torsion
  • Torsion of testicular or epididymal appendages (remnants of paramesonephric and mesonephric ducts, respectively)
    • Benign condition; may be experienced multiple times owing to multiple appendages
    • Presents with scrotal pain
    • Differentiated from testicular torsion by:
      • Painless testicular palpation
      • Presence of cremasteric reflex
      • Development of bluish nodule over superior portion of testicle (occurs in up to 40% of patients)
    • Diagnosis aided by Doppler ultrasonography; obtain if history and physical examination are equivocal for testicular torsion
  • Orchitis
    • Often an extension of epididymal infection
    • Abrupt onset of pain
    • Differentiated from testicular torsion by:
      • Presence of lower urinary tract symptoms
      • Testis in normal anatomic position
      • Presence of cremasteric reflex
    • Doppler ultrasonography can aid in differentiating this condition from testicular torsion; obtain if history and physical examination are equivocal for testicular torsion
  • Incarcerated hernia
    • Inability to reduce an inguinal hernia in setting of acute abdominal pain is diagnostic of an incarcerated hernia
    • Causes acute onset of pain
    • Differentiated from testicular torsion by:
      • Possible involvement of a scrotal mass
      • Previously fluctuant groin mass that may extend into scrotum
    • Doppler ultrasonography and urgent surgical consultation is often required to differentiate incarcerated hernia from testicular torsion; obtain ultrasonography if history and physical examination are equivocal for testicular torsion
  • Trauma
    • History of trauma or known mechanism of injury
    • Ecchymosis may be present

Treatment

  • From Fowler GC: Manual testicular detorsion. In: Fowler GC et al, eds: Pfenninger and Fowler’s Procedures for Primary Care. 4th ed. Philadelphia, PA: Elsevier; 2020: 771-2, Figure 112.1.Manual detorsion of a testicle. – The arrows represent direction that will successfully detorse two-thirds of testicles. Reverse direction is needed in the remaining one-third.

Goals

  • Detorse and return adequate blood supply to affected testis
  • Pain lasting 4 to 8 hours is highly associated with testicular death 1
  • Return affected testis to normal anatomic position and prevent recurrence of torsion

Disposition

Recommendations for specialist referral

  • Urgent surgical referral is necessary for all patients who present with suspected or confirmed testicular torsion
  • Newborn infants with suspected torsion require immediate referral for urologic evaluation

Treatment Options

Urgent surgical detorsion is necessary for all patients 5 7

Presurgical manual detorsion should be performed if surgery is delayed 5 7

Nondrug and supportive care

Outside of the newborn period, manual detorsion is attempted when there is a delay to surgery 7

Surgical revision is ultimately necessary for all cases of torsion to detorse if needed and prevent recurrence 7

Procedures
Manual detorsion 7

General explanation

  • Detorsion requires analgesia or anesthesia (eg, spermatic cord block)
  • Performed with ultrasonographic guidance if emergently available
  • Typically performed while awaiting transport to the operating room; 10 sometimes performed emergently without ultrasonic guidance
  • Torsion is in the medial direction in two-thirds of patients; 4 may require more than 1 turn as torsion may be more than 360°
  • Once grasped, testicle is pulled down and turned laterally like opening a book; if symptoms worsen, turn in the opposite (medial) direction
  • Physically untwisting cord is associated with 68% to 86% success rate; pain is relieved and ultrasonogram shows return of blood flow 2

Indication

  • Testicular torsion outside neonatal period
  • If surgery is delayed to such an extent that the torsion would exceed 6 hours duration; however, does not replace surgery

Contraindications

  • Within neonatal period
  • When duration of torsion exceeds 6 hours

Interpretation of results

  • Symptom worsening may indicate presence of lateral torsion
  • Success is determined by relief of pain
Surgical revision 7

General explanation

  • Testicular salvage rates are increased with prompt surgical exploration
  • If affected testis appears necrotic or nonviable, orchiectomy is performed
  • Viable testis is detorsed
  • Orchiopexy (ie, fixation of testes) is performed for salvaged testicle and contralateral testicle
    • Prevents future recurrence as anatomic defect that allowed torsion is likely to be bilateral

Indication

  • All patients with testicular torsion, including those in perinatal period 4

Comorbidities

  • Torsion is more common with an undescended testis. Diagnosis should be strongly considered in patients with painful inguinal mass and an empty hemiscrotum

Complications and Prognosis

Complications

  • Testicular infarction and necrosis will occur if detorsion is not rapidly performed
  • Defects in spermatogenesis can occur despite testis viability after detorsion
    • Abnormal sperm analysis has been noted in over 50% of patients, which correlated with the duration of torsion 11

Prognosis

  • Salvage rates are related to duration of torsion and ischemia
    • 90% to 100% salvage rate if torsion resolved within 6 hours of onset 7
    • 50% salvage rate at 12 hours 7
    • 10% salvage rate at 24 hours 7
  • Overall salvage rates are 62% to 85% in descended testes and 29% to 40% in undescended testes 4

Sources

DaJusta DG et al: Contemporary review of testicular torsion: new concepts, emerging technologies and potential therapeutics. J Pediatr Urol. 9(6 Pt A):723-30, 2013

Cross Reference