Testicular Torsion

In Agony 2
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Diagnosis and reasoning

This middle aged man has presented with an acute scrotum, a urological emergency. Important causative etiologies to consider include scrotal trauma, incarceration of an inguinal hernia, testicular tumors, acute epididymitis, testicular torsion, and torsion of a testicular appendix. A systematic clinical approach is key towards differentiation; in this respect note the absence of a history of trauma. Neither are there signs or symptoms suggestive of an inguinal hernia, while the absence of a testicular mass argues against a testicular tumor. Acute epididymitis is a possibility, given the examination findings, and history of similar but milder episodes in the past; however, the onset of symptoms is usually more subacute. Note that the absence of associated urinary symptoms or fever does not necessarily exclude this diagnosis. Torsion of a testicular appendix can also present in this manner; however, in such patients, the torsed appendix is often palpable at the upper pole of the testis, and if ecchymotic, can be seen through the skin (this is termed the 'blue-dot' sign); furthermore, the testis itself is usually palpable and non-tender, with a normal lie. Testicular torsion is another consideration, as symptoms are typically abrupt in onset, while inflammatory hemiscrotal changes may be present in the early stages. However, the condition is rather uncommon over 40 years of age. Thus, in summary, the clinical findings are somewhat equivocal, with acute epididymitis and testicular torsion being the main considerations. Where clinical findings are indeterminate, color doppler sonography (or power doppler sonography) of the scrotum is the gold standard investigation; the absence of blood flow seen here is diagnostic of testicular torsion. Note that testicular scintigraphy was the preferred diagnostic test prior to the advent of scrotal doppler sonography; in the modern setting, it is probably only indicated if sonographic findings are equivocal. In addition, an ultrasound scan of the abdomen and urine cultures will yield little useful information and are not indicated in this patient. Testicular torsion is a urological emergency; immediate surgical exploration of the scrotum with detorsion of the affected testis, and orchidopexy of both testes is the treatment of choice. Furthermore, as these patients are usually in severe pain, strong analgesia (preferable with an opioid) is essential. While all patients should be warned that an orchidectomy might be necessary if the affected testis is non-viable, this is highly unlikely in this specific patient, given the very early presentation. Levofloxacin is a Fluoroquinolone widely used to treat complicated urinary tract infections and acute pyelonephritis; it is not indicated in this specific patient.


Discussion

Testicular torsion is a urological emergency where twisting of the spermatic cord results in interruption of blood supply to the testicle; if left untreated, irreversible loss of testicular function results. The condition is estimated to occur in 1 in every 4000 men less than 25 years of age; overall, it shows a bimodal distribution, with the first peak occurring during the neonatal period, and the second (and higher) peak during puberty. Note that torsion is uncommon over the age of 40. There are two key forms of testicular torsion: extravaginal torsion and intravaginal torsion. Extravaginal torsion mainly occurs in neonates, and is believed to be due to poor fixation of neonatal tissues. Intravaginal torsion is the more common type; in these patients, abnormal fixation of the tunica vaginalis results in increased mobility of the testes (this is also termed a 'bell-clapper deformity'). Note that the remainder of this text focuses exclusively on intravaginal torsion, as this accounts for almost all cases in adults and older children. While testicular torsion can occur spontaneously, a precipitating event such as trauma or strenuous exercise may be identified in certain patients. When torsion occurs, the spermatic cord undergoes rotation ranging from 90° to 720°; initially this impairs venous drainage, resulting in testicular engorgement and edema; these in turn give rise to arterial occlusion resulting in testicular ischemia. Note that tissue viability rapidly declines with time; salvage is realistic only in the first 4 to 8 hours. While the condition usually affects a single testis, bilateral torsion can occur both synchronously or asynchronously. Furthermore, unilateral torsion can result in bilateral testicular injury due to extensive apoptosis in the germinal epithelium of the contralateral testis. Affected individuals typically present with sudden severe unilateral testicular pain, which is often associated with nausea and vomiting. Fever and urinary symptoms may also be present, potentially confounding the diagnosis. Certain patients may also provide a history of preceding testicular trauma or strenuous physical activity. There may also be a history of recurrent testicular pain from time to time, potentially due to episodes of low-grade torsion in the past. During examination, comparison of the affected and unaffected sides is often helpful. In the affected hemi-scrotum, inflammatory changes may be visible, and a high riding testicle with an abnormal horizontal orientation may be palpable (indicating a twisted and foreshortened spermatic cord). The cremasteric reflex may be absent, while elevation of the affected testis will not abolish the pain experienced by the patient (Prehn's Sign). Note that these findings are supportive but not diagnostic of torsion. Where clinical findings are clear-cut, prompt surgical intervention is essential; imaging studies should be reserved for cases where the diagnosis is ambiguous. Scrotal doppler ultrasonography is the imaging modality of choice in such a scenario; this evaluates the size, shape, echogenicity and perfusion of both testes. Note that power doppler imaging has a superior sensitivity and specificity (88.9% and 98.8% respectively) to color doppler imaging. Scrotal scintigraphy is an alternative to doppler ultrasound, and can be considered in patients in whom sonographic findings are ambiguous. Exploration and surgical detorsion of the affected testis, followed by orchidopexy (to prevent future episodes of torsion) is the mainstay of management. Time is critical here, with 96% of testes being salvageable if operated within the first 4 hours. Contralateral orchidopexy is also advisable, as the 'bell-clapper deformity' is usually present on both sides. Note that if the testis found to be non viable upon exploration, orchidectomy should be performed instead, along with contralateral orchidopexy. While waiting for surgical intervention, certain studies have suggested that manual detorsion of the testis may help restore some degree of blood flow. This is performed by rotating the testis from the medial to the lateral side, as if opening a book; alleviation of pain suggests a successful maneuver. However, this should never delay or replace surgery. Note that newly introduced surgical techniques include making a vertical incision over tunica albuginea (similar to a fasciotomy) so as to counteract testicular compartment syndrome, which may occur following reperfusion. Furthermore, where orchidectomy proves to be necessary, subsequent placement of a testosterone testicular prosthesis (at a latter date) may help alleviate the resultant hormonal and psychological effects. The main complication of the testicular torsion is loss of the affected testis, with potential sub fertility. Other complications include cosmetic issues, and the psychological impact on the patient, following loss of the testis. The prognosis mainly depends the timing of intervention; while 96% of testes can be salvaged if operated on within the first 24 hours, this diminishes to almost zero after 24 hours.


Take home messages

  1. Testicular torsion may present with intermittent or atypical symptoms and must be considered in all cases of scrotal pain or swelling.
  2. Testicular pain and tenderness, while usually present at the start, decline over time.
  3. Doppler imaging of the scrotum is the diagnostic technique of choice, where clinical findings are equivocal.
  4. Urgent scrotal exploration and bilateral testicular fixation should be performed in all cases of testicular torsion.

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  1. DAJUSTA DANIEL G., GRANBERG CANDACE F., VILLANUEVA CARLOS, BAKER LINDA A.. Contemporary review of testicular torsion: New concepts, emerging technologies and potential therapeutics. Journal of Pediatric Urology [online] 2013 December, 9(6):723-730 [viewed 04 April 2015] Available from: doi:10.1016/j.jpurol.2012.08.012
  2. DAVID JE, YALE SH, GOLDMAN IL. Urology: Scrotal Pain Clin Med Res [online] 2003 Apr, 1(2):159-160 [viewed 27 March 2015] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1069041
  3. GABRIEL EN. Testicular torsion: Needless testicular loss can be prevented. Niger J Clin Pract [online] 2012 December [viewed 04 April 2015] Available from: doi:10.4103/1119-3077.97311
  4. GORDHAN CG, SADEGHI-NEJAD H. Scrotal pain: Evaluation and management Korean J Urol [online] 2015 Jan, 56(1):3-11 [viewed 26 March 2015] Available from: doi:10.4111/kju.2015.56.1.3
  5. KESSLER CS, BAUML J. Non-Traumatic Urologic Emergencies in Men: A Clinical Review West J Emerg Med [online] 2009 Nov, 10(4):281-287 [viewed 27 March 2015] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791735
  6. KUTIKOV ALEXANDER, CASALE PASQUALE, WHITE MICHAEL A., MEYER WESLEY A., CHANG ANDY, GOSALBEZ RAFAEL, CANNING DOUGLAS A.. Testicular Compartment Syndrome: A New Approach to Conceptualizing and Managing Testicular Torsion. Urology [online] 2008 October, 72(4):786-789 [viewed 31 March 2015] Available from: doi:10.1016/j.urology.2008.03.031
  7. RAKHA E, PULS F, SAIDUL I, FURNESS P. Torsion of the testicular appendix: importance of associated acute inflammation J Clin Pathol [online] 2006 Aug, 59(8):831-834 [viewed 27 March 2015] Available from: doi:10.1136/jcp.2005.034603
  8. SHARP VJ, KIERAN K, ARLEN AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician [online] 2013 Dec 15, 88(12):835-40 [viewed 04 April 2015] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24364548
  9. TYDEMAN C, DAVENPORT K, GLANCY D. Suspected testicular torsion - urological or general surgical emergency? Ann R Coll Surg Engl [online] 2010 Nov, 92(8):710-712 [viewed 27 March 2015] Available from: doi:10.1308/003588410X12771863937007
  10. YUSUF GT, SIDHU PS. A review of ultrasound imaging in scrotal emergencies J Ultrasound [online] , 16(4):171-178 [viewed 26 March 2015] Available from: doi:10.1007/s40477-013-0033-x