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Testicular Torsion: Diagnosis and Treatment

Definition of Testicular Torsion

Testicular torsion is a mostly spontaneous torsion of the testicle around the spermatic cord with consecutive ischemia (Cuckow and Frank, 2000) (Frank and O'Brien, 2002) (Visser and Heyns, 2003).

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

The torsion of the testis leads to a complete or incomplete blockage of the venous drainage and to a hemorrhagic necrosis of the testicular tissue. The testicular tissue is irreversibly damaged after eight hours complete torsion. The ischemic damage may significantly lower after incomplete torsion and testis preservation may be feasible after longer time intervals. Detorsion leads to an additional reperfusion injury of the tissue through the induction of oxidative stress.

Contralateral Testicular Damage after Torsion

Subfertility may develop after testicular torsion, the prevalence and mechanisms are unclear and controversial. Possible mechanisms are reflectory sympathetic vasocontriction with subsequent ischemia and damage to the blood-testis barrier with formation of anti-sperm antibodies. In addition, testicular torsion may be a form of congenital testicular dysgenesis, explaining the bilateral risk of torsion and reduced testicular function found in patients after torsion (Jacobsen et al., 2020).

Pathology of Testicular torsion

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). 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 sign is negative: same or greater pain with elevation of the testis. The Prehn sign is unreliable.
• Precursors of testicular torsion are similar less painful events
• Scrotal swelling and infection in advanced testicular torsion

Diagnosis of Testicular Torsion

Laboratory Tests

• Urine analysis
• Complete blood count, CRP

Testicular Ultrasound Imaging

In untreated old testicular torsion, conventional ultrasound imaging shows inhomogeneities of the testicular tissue. Differentiation from a testicular tumor might become difficult. Imaging of the spermatic cord can visualize the cord twist as a snail-shaped mass.

Testicular ultrasound imaging of a serveral days old testicular torsion on the right side with inhomogeneity of the testicular parenchyma, which is especially striking in comparison with the unaffected side (right figure). See also fig. macroscopic findings of a missed testicular torsion of the same patient. With kind permission, J. Menzinger, München.

Testicular 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.

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
• Epididymitis
• Orchitis
• Testicular trauma
• Inguinal hernia
• Germ cell tumor
• Hydroceles
• Spermatocele
• Varicocele
• Hematocele

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.

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 as an provisional emergency aid, 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.

References

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