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Testicular Torsion

Testicular torsion is the twisting of the spermatic cord within the scrotum, causing impaired blood flow and possible tissue death. It most commonly occurs in infants and adolescents. Manual detorsion or surgical exploration within 6 hours of symptoms has the highest chance of testicular salvage. Surgery involves untwisting the cord and fixing the testis to prevent recurrence, with orchiectomy if the testis is nonviable. Delayed treatment risks infertility due to testicular ischemia and necrosis.

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Darshan Singh
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412 views20 pages

Testicular Torsion

Testicular torsion is the twisting of the spermatic cord within the scrotum, causing impaired blood flow and possible tissue death. It most commonly occurs in infants and adolescents. Manual detorsion or surgical exploration within 6 hours of symptoms has the highest chance of testicular salvage. Surgery involves untwisting the cord and fixing the testis to prevent recurrence, with orchiectomy if the testis is nonviable. Delayed treatment risks infertility due to testicular ischemia and necrosis.

Uploaded by

Darshan Singh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Shri Dhanwantry Ayurvedic

College and Hospital


DEPARTMENT OF SHALYA TANTRA

TESTICULAR TORSION

Submitted to: Submitted


by :
Dr. Aditi Anshum
(Asst. Prof) Arshdeep
Madhav
TESTICULAR TORSION
TORSION OF TESTIS
Definition:
It is the sudden twisting of spermatic cord within the scrotum.
It is associated with poorly secured testis.
It is considered as urological emergency because of the risk of
ischemia and possible infarction of testis

Occurrence:
It is most commonly found in infants and young men.
Peak incidence is in the neonatal age(first 30 days) and during
puberty 10-18 years of age.
Etiology of testicular torsion
Predisposing causes:
• Inversion of testis : It is the most common cause where testis
lies horizontally or upside down.
• High investment of tunica vaginalis : (BELL CLAPPER
DEFORMITY)
• Sudden contraction of spirally attached cremasteric muscle
leads to rotation of testis around the vertical axis during
straining at stools, lifting heavy weight, coitus.
• A long redundant spermatic cord allows twisting of testis on its
own axis.
• In cases where the body of testis is separated from the
epididymis.
• Testicular malignancy especially in adults.
BELL CLAPPER DEFORMITY
Types and pathophysiology
Two types of testicular torsion :
1. INTRAVAGINAL TORSION
2. EXTRAVAGINAL TORSION
• Three mechanism of testicular torsion may be identified:
• Intravaginal torsion: This type of torsion occurs due to
congenital abnormality of tunica vaginalis attached to superior
pole of testis(bell-clapper deformity) – increased mobility of
testis within the tunica vaginalis which leads to possible
abnormal transverse lie of testis.
• Extravaginal torsion: Lack of fixation of the tunica vaginalis to
the gubernaculum leads to torsion of testis and tunica
vaginalis(along with the spermatic cord).
• Long mesorchium: (thick band of connective tissue between
the efferent ductules of epididymis and the posterior surface of
testis - leads to testicular torsion.
Torsion results in venous engorgement with consequent
1. arterial compromise
2. Tissue ischemia
3. Possible infarction
Irreversible damage occurs after 6-12 hours of torsion.
CLINICAL FEATURES
• Nausea
• Vomiting
• Sudden agonizing pain in the groin and lower abdomen.
• Typically, swollen and tender testis or lower abdominal
tenderness.
• Scrotum is empty and oedematous at the side of lesion.
• Acute inflammation with swollen, erythematous or blue
discoloured in venous engorgement.
• DEMING’s sign: Tender lump at the external abdominal ring –
the testis is positioned high.
• PREHN’s sign: Elevation of scrotum increases pain in torsion of
completely descended testis.
• ANGELL’s sign: The opposite testis lies horizontally because of
the presence of mesorchium.
TWIST SCORE
Testicular workup for ischemia and suspected torsion score
CLINICAL FEATURE SCORE IF PRESENT

Swelling of scrotum 2

Testis firm to palpation 2

Cremasteric reflex absent 1

Scrotal elevation(High riding testis) 1

Nausea or vomiting 1
RISK CATEGORIES
According to twist score-

• Low risk: 0-2

• Moderate risk: 3-4

• High risk: more than 5


• If the score is more than 5 refer the patient to surgery/
exploration.
DIAGNOSIS
• On the basis of clinical features:
• On the basis of clinical twist score:
• Imaging :
• Scrotal doppler: to confirm the diagnosis
• Contrast CT scan:
• Duplex ultrasound of scrotum: Either formal ultrasound or
POCUS can be used to diagnose torsion.
CHARACTERSTIC FINDINGS
1. Enlarged testis
2. Whirlpool sign: Twisting of spermatic cord.
3. Reduced or absent blood flow to/from the affected
testis(COLD SPOTS)
4. Heterogenous appearance of testicular parenchyma indicates
testicular necrosis.
5. Testicular torsion.
MANAGMENT
Initial management : management of testicular torsion is time
sensitive.
• Perform rapid clinical evaluation of patient with acute scrotal
pain as soon as possible.
• Record time from symptom onset.
• Consider differential diagnosis of scrotal pain.
• Consider using TWIST SCORE to supplement clinical judgement.
• Obtain IV access and start pain management; consider
spermatic cord block.
• If surgery is not immediately available, manual testicular
detorsion should performed. For best results- if detorsion occur
within 4 hours of pain.
1. In the first hour untwist the testis manually.
2. If this is not successful urgent exploration of scrotum and
undo the torsion and viable testis should be fixed to scrotum
to prevent recurrence.
3. Gangrenous testis should be removed
4. Opposite side testis should be fixed at an early date to prevent
torsion as it also has higher risk of undergoing torsion
TREATMENT
Testicular torsion is a medical emergency and should be treated
with 4-6 hours of onset of symptoms for the best chance of
testicular salvage.
Manual detorsion in the emergency department may be
attempted prior to surgery for immediate pain relief, but should
not delay transferring the patient to the operating room.
MANUAL TESTICULAR DETORSION: May be attempted prior to
surgery for immediate pain relief or if surgery is not immediately
available.
PROCEDURE:
1. Rotate the testis laterally towards the thigh; two-thirds of
torsion occur toward the midline.
2. If the lateral rotation does not provide symptom relief, rotate
the testis towards the midline; one-third of torsions occur
MANUAL ROTATION OF TESTIS
SURGERY
SURGERY should still be performed in all patients to resolve any
degree of remaining torsion and to prevent the recurrence.
• Because of the risk of infertility surgery exploration of the
scrotum is recommended in any patient, suspected of having
testicular torsion even if manual detorsion has been attempted.
• EXPLORATORY SURGERY:
• Indication: Suspected testicular torsion
• Timing: Ideally, within 6 hours of symptom onset.
• Procedure: Immediate surgical exploration of the scrotum with
reduction(untwisting) and orchidopexy of the affected testis.
• ORCHIDOPEXY of the contralateral testis is recommended
because the risk of testicular torsion of the contralateral side
increases with previous or current testicular torsion.
Orchiectomy should be done if the testis grossly necrotic or
nonviable.

PROGNOSIS
Testicular salvage rate depends on the interval of the time
between the symptom onset and restoration of testicular blood
flow
Within 6 hours: 90-100%
More than 12 hours: 20-60%
More than 24 hours: upto 20%
Late or absent surgical intervention – leads to
1. Testicular ischemia(with/without necrosis)
2. Disruption of blood testis barrier
3. lead to antisperm antibodies

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