Testicular torsion
Encyclopedia
Testicular torsion is when the spermatic cord
to a testicle
twists, cutting off the blood supply. The most common symptom is acute testicular pain
and the most common underlying cause is a congenital malformation known as a "bell-clapper deformity". The diagnosis is often made clinically but if it is in doubt an ultrasound
is helpful in ruling in or out the condition. Emergency diagnosis and treatment is required in order to save the viability of the testicle.
and tenderness of less than 6 hours of duration. There is often an absent or decreased cremasteric reflex
. Many of the symptoms of testicular torsion are similar to the infection epididymitis
.
known as the "bell-clapper deformity" accounts for 90% of all cases. In this condition, rather than the testes attaching posteriorly to the inner lining of the scrotum by the mesorchium
, the mesorchium terminates early and the testis is free floating in the tunica vaginalis
.
though a classic physical exam finding has not been found to be reliable in distinguishing torsion from other causes of testicular pain such as epididymitis
. In cases of true torsion the cremasteric reflex
is typically absent, the scrotum is generally not very swollen, and the affected testis may have a horizontal lie.
of the scrotum is nearly 100% accurate at detecting torsion. It is identified by the absence of blood flow in the twisted testicle, which distinguishes the condition from epididymitis
.
, and is one of the causes of an infant being born with monorchism
(one testicle).
Testicular torsion is a surgical emergency
that needs immediate intervention. If treated within 6 hours, there is an excellent chance (90%) of saving the testicle. Within 12 hours the rate decreases to 50%, within 24 hours is 10%, and after 24 hours the rate approaches 0. Once the testicle is dead it must be removed to prevent gangrenous
infection.
Spermatic cord
The spermatic cord is the name given to the cord-like structure in males formed by the ductus deferens and surrounding tissue that run from the abdomen down to each testicle.-Contents of spermatic cord:...
to a testicle
Testicle
The testicle is the male gonad in animals. Like the ovaries to which they are homologous, testes are components of both the reproductive system and the endocrine system...
twists, cutting off the blood supply. The most common symptom is acute testicular pain
Testicular pain
Testicular pain or scrotal pain is when part or all of either one or both testicles hurt. Pain of the scrotum is often included. It may be either acute, subacute or chronic depending on its duration. Causes rank from benign muscular skeletal problems to emergent condition such as Fournier's...
and the most common underlying cause is a congenital malformation known as a "bell-clapper deformity". The diagnosis is often made clinically but if it is in doubt an ultrasound
Ultrasound
Ultrasound is cyclic sound pressure with a frequency greater than the upper limit of human hearing. Ultrasound is thus not separated from "normal" sound based on differences in physical properties, only the fact that humans cannot hear it. Although this limit varies from person to person, it is...
is helpful in ruling in or out the condition. Emergency diagnosis and treatment is required in order to save the viability of the testicle.
Signs and symptoms
Testicular torsion usually presents with an acute onset of diffuse testicular painTesticular pain
Testicular pain or scrotal pain is when part or all of either one or both testicles hurt. Pain of the scrotum is often included. It may be either acute, subacute or chronic depending on its duration. Causes rank from benign muscular skeletal problems to emergent condition such as Fournier's...
and tenderness of less than 6 hours of duration. There is often an absent or decreased cremasteric reflex
Cremasteric reflex
The cremasteric reflex is a superficial reflex observed in human males.This reflex is elicited by lightly stroking the superior and medial part of the thigh...
. Many of the symptoms of testicular torsion are similar to the infection epididymitis
Epididymitis
Epididymitis is a medical condition in which there is inflammation of the epididymis . This condition comprises gradual onset of testicular pain that can vary from mild to severe, and the scrotum may become red, warm and swollen...
.
Congenital
Conditions that allow the testicle to rotate predispose to torsion. A congenital malformation of the processus vaginalisProcessus vaginalis
The processus vaginalis is an embryonic developmental outpouching of the peritoneum.It is present from around the 12th week of gestation, and commences as a peritoneal outpouching.-Gender differences:...
known as the "bell-clapper deformity" accounts for 90% of all cases. In this condition, rather than the testes attaching posteriorly to the inner lining of the scrotum by the mesorchium
Mesorchium
The testes, at an early period of fetal life, are placed at the back part of the abdominal cavity, behind the peritoneum, and each is attached by a peritoneal fold, the mesorchium, to the mesonephros.-See also:* mesentery* mesovarium...
, the mesorchium terminates early and the testis is free floating in the tunica vaginalis
Tunica vaginalis
The tunica vaginalis is the serous covering of the testis.It is a pouch of serous membrane, derived from the processus vaginalis of the peritoneum, which in the fetus preceded the descent of the testis from the abdomen into the scrotum....
.
Size
A larger testicle either due to normal variation or a tumor increases the risk of torsion.Temperature
Torsions are sometimes called "winter syndrome". This is because they often happen in winter, when it is cold outside. The scrotum of a man who has been lying in a warm bed is relaxed. When he arises, his scrotum is exposed to the colder room air. If the spermatic cord is twisted while the scrotum is loose, the sudden contraction that results from the abrupt temperature change can trap the testicle in that position. The result is a testicular torsion.Diagnosis
Immediate testing for torsion is indicated when the onset of testicular pain is sudden and/or severe. In general a doppler ultrasound should be obtained only in low suspicion cases to rule out torsion while in those cases with a convincing history and physical exam immediate surgical detorsion (Derotation) is reasonable.Clinical exam
Prehn's signPrehn's sign
Prehn's sign is a medical diagnostic indicator that was once believed to help determine whether the presenting testicular pain is caused by acute epididymitis or from testicular torsion...
though a classic physical exam finding has not been found to be reliable in distinguishing torsion from other causes of testicular pain such as epididymitis
Epididymitis
Epididymitis is a medical condition in which there is inflammation of the epididymis . This condition comprises gradual onset of testicular pain that can vary from mild to severe, and the scrotum may become red, warm and swollen...
. In cases of true torsion the cremasteric reflex
Cremasteric reflex
The cremasteric reflex is a superficial reflex observed in human males.This reflex is elicited by lightly stroking the superior and medial part of the thigh...
is typically absent, the scrotum is generally not very swollen, and the affected testis may have a horizontal lie.
Imaging
A doppler ultrasound scanUltrasound
Ultrasound is cyclic sound pressure with a frequency greater than the upper limit of human hearing. Ultrasound is thus not separated from "normal" sound based on differences in physical properties, only the fact that humans cannot hear it. Although this limit varies from person to person, it is...
of the scrotum is nearly 100% accurate at detecting torsion. It is identified by the absence of blood flow in the twisted testicle, which distinguishes the condition from epididymitis
Epididymitis
Epididymitis is a medical condition in which there is inflammation of the epididymis . This condition comprises gradual onset of testicular pain that can vary from mild to severe, and the scrotum may become red, warm and swollen...
.
Pathophysiology
Torsion is due to a mechanical twisting process. It is also believed that torsion occurring during fetal development can lead to the so-called neonatal torsion or vanishing testisVanishing testis
Vanishing testis refers to the disappearance of one or other testis during embryonic or foetal development.It is one of the causes of monorchism, and is thought to be due to intrauterine testicular torsion....
, and is one of the causes of an infant being born with monorchism
Monorchism
-Causes:This can be due to:* One testicle not descending into the scrotum during normal embryonic or fetal development , also known as: undescended testis or cryptorchidism. In this case the testis is within the abdominal cavity, somewhere along the normal route of descent — most commonly,...
(one testicle).
Treatment
With prompt diagnosis and treatment the testicle can be saved in a high number of cases. In some cases the testicle can untwist on its own or it can be manually untwisted, which can be attempted with pain relief as the guide for successful detorsion. Manual detorsion is successful in 26.5% to greater than 80% of patients based upon a number of reviewed studies.Testicular torsion is a surgical emergency
Surgical emergency
Surgical emergency is a medical emergency which requires immediate surgical intervention .The following conditions are surgical emergencies:* Acute trauma* Accidental amputation* Acute appendicitis...
that needs immediate intervention. If treated within 6 hours, there is an excellent chance (90%) of saving the testicle. Within 12 hours the rate decreases to 50%, within 24 hours is 10%, and after 24 hours the rate approaches 0. Once the testicle is dead it must be removed to prevent gangrenous
Gangrene
Gangrene is a serious and potentially life-threatening condition that arises when a considerable mass of body tissue dies . This may occur after an injury or infection, or in people suffering from any chronic health problem affecting blood circulation. The primary cause of gangrene is reduced blood...
infection.
Epidemiology
Torsion is most frequent among adolescents with about 65% of cases presenting between 12 – 18 years of age. It occurs in about 1 in 160 males or 1 in 4000 males per year before 25 years of age.External links
- Photos of swollen, excised, and detorsed testicles of patient who sought treatment within four hours of onset of pain.