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Review literature: (Cuckow and Frank, 2000) (Frank and O'Brien, 2002) (Visser and Heyns, 2003)
Definition of Testicular Torsion
Testicular torsion is a mostly spontaneous torsion of the testicle around the spermatic cord with consecutive ischemia. Testicular torsion can be separated intro intravaginal torsion (torsion of the spermatic cord within the tunica vaginalis) and extravaginal torsion (torsion of the spermatic cord outside the tunica vaginalis).
Epidemiology of Testicular Torsion
Testicular torsion is possible at any time of life. Testicular torsion is most frequent in children (before the second year of life) and adolescents (between 15–20 years of age).
Etiology and Pathophysiology of Testicular Torsion
Causes of Testicular Torsion
Testicular torsion is caused by an abnormal mobility of the testicle. Cremasteric contraction causes an rotational force to the testes and can induce testicular torsion, as also manipulation or testicular trauma may trigger a torsion.
Ipsilateral Testicular Damage after Torsion
After torsion of the testis with a complete disruption of testicular circulation, the testicular tissue is irreversibly damaged after 8 hours. With complete hemorrhagic necrosis, preservation of the testis is not rational. Due to an incomplete torsion, the ischemic damage may significantly slower and testis preservation may be feasible after longer time intervals.
Contralateral Testicular Damage after Torsion
Testicular torsion with subsequent ischemia destroys the blood-testis barrier and allows the formation of autoantibodies, which cause a contralateral testicular damage. Furthermore, reflectory vasoconstriction can cause a contralateral testicular damage.
Pathology of Testicular torsion
Untreated testicular torsion leads to a hemorrhagic necrosis of the testicular tissue, since the venous supply is first compressed by the torsion of the spermatic cord.
Signs and Symptoms of Testicular Torsion
- Sudden testicular pain
- Abnormal high position of the testes in the scrotum, with abnormal transverse direction
- Radiation of testicular pain to the ipsilateral lower abdomen
- Nausea and vomiting possible
- Missing cremasteric reflex
- Prehn's sign is negative: same or greater pain with elevation of the testis. The Prehn's sign is unreliable.
- Precursors of testicular torsion are similar less painful events
- Scrotal swelling and infection in advanced testicular torsion
Diagnosis of Testicular Torsion
- Urine analysis
- Complete blood count, CRP
Testicular Ultrasound with Doppler-Sonography
Doppler ultrasound of the testis can detect a lack of blood flow in the testis: 90% sensitivity and 99% specificity, 1% false positive results. Some studies found worse results, the detection of a testicular blood flow should be questioned, when patients present with typical signs and symptoms of testicular torsion.
Crucial for the proper assessment is the Doppler study of intratesticular vessels, the study of capsule or scrotum vessels is irrelevant. If an arterial Doppler signal in the testis disappears by compressing the spermatic cord at the external inguinal ring, testicular blood flow is proved. If the signal is not influenced by compression of the spermatic cord, an irrelevant scrotal vessel is detected. Testicular vessels have a high end-diastolic blood flow, normally the resistive index (RI) is below 0.7. Higher RI values (decreasing diastolic blood flow) are signs of a partial testicular torsion.
In advanced stages of testicular torsion, conventional ultrasound imaging shows inhomogeneities of the testicular tissue.
Scintigraphy of the Testis
Comparative studies found similar results between scintigraphy of the testis and Doppler ultrasound imaging. Disadvantages of the testicular scintigraphy are a longer time period to carry out the investigation and a difficult interpretation in young children with small scrotum.
Surgical Exploration of the Scrotum
When in doubt, immediate surgical exploration should be offered to the patient (or parents) to enable timely orchidopexy or to exclude testicular torsion.
Differential Diagnosis of Testicular Torsion
- Torsion of testicular appendage
- Testicular trauma
- Inguinal hernia
- Germ cell tumor
Treatment of Testicular Torsion
Surgical Detorsion and Orchidopexy
Immediate surgical exploration, detorsion and orchidopexy should be offered in suspected testicular torsion, even if the diagnosis is only possible. Scrotal exploration is done either with bilateral transverse incisions or one median raphe incision [fig. surgical exploration in suspected testicular torsion]. With a transverse incision, a dartos pouch can be done before opening the tunica vaginalis of the testis. After detorsion of the testis, the organ is examined for viability. Orchidopexy is done, when the testis shows a recovery and is judged to be viable. Orchidopexy is done either with a dartos pouch as in cryptorchism treatment, or fine nonadsorbable sutures are used for direct vision sutures of the tunica vaginalis to the tunica dartos. Testes, which appear necrotic after several minutes of warming, should be removed.
In cases of indeterminate blood flow, further management is controversial. If necrotic testes are not removed, there is a risk of contralateral testicular damage with reduced fertility. In general, however, organ preservation is sought in cases with indeterminate blood flow.
Immediate prophylactic fixation of the opposite testis is recommended after a confirmed testicular torsion. In cases of severe necrosis of the twisted testis, the contralateral fixation should be postponed until ipsilateral wound healing is complete.
Manual Detorsion of a Testicular Torsion
Testicular torsion can be attempted, when scrotal swelling is moderate and the patient tolerates the manipulation (after local anesthesia of the spermatic cord). Most often, the left testis is rotated counterclockwise and the right testis is rotated clockwise. Manual detorsion is achieved with rotation of the ventral circumference laterally (to the thigh) to compensate the most frequent rotation direction. Manual detorsion is not a safe procedure, since testicular torsion is also possible to the opposite direction. The success of the manual detorsion should lead to clinical improvement and visible testicular perfusion in Doppler ultrasound imaging. After successful manual detorsion, scrotal orchidopexy of both sides should be done within the next days.
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- Cuckow und Frank 2000 CUCKOW, P. M. ; FRANK, J. D.:
- Torsion of the testis.
In: BJU Int
86 (2000), Nr. 3, S. 349–53
- Frank und O’Brien 2002 FRANK, J. D. ; O’BRIEN, M.:
- Fixation of the testis.
In: BJU Int
89 (2002), Nr. 4, S. 331–3
- Visser und Heyns 2003 VISSER, A. J. ; HEYNS, C. F.:
- Testicular function after torsion of the spermatic cord.
In: BJU Int
92 (2003), Nr. 3, S. 200–3
Deutsche Version: Hodentorsion