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Testicular torsion

Section: Urology Curriculum: Curriculum, page 28

Definition

  • Twisting of the testicle and spermatic cord resulting in compromised vascular supply

Epidemiology

  • 1 in 4000 <25 y/o males and more predominant on the left

Aetiology

  • Bell-clapper deformity - high-riding tunica vaginalis/covers the whole testis causing a more horizontal lie and lack of fixation of cord structures
  • Long mesorchium (= ligament attaching epididymis to testicle, if long can lead to torsion and is associated to cryptorchidism - elongated epididymis)
  • Horizontal lie

Classification

  • Intravaginal - twisting within the tunica vaginalis
  • Extravaginal - twisting is outside a low inserting tunica vaginalis

Pathophysiology

  • Normal testicular suspension prevents twisting via fixation of epididymis/testicle posteriorly
  • Bell-clapper - high attachment of tunica vaginalis means the testicle can rotate freely on the cord within the tunica vaginalis
  • Rotation over 180 degrees causes venous occlusion/engorgement, arterial ischaemia and infarction

Clinical

  • Progressive testicular pain/lower abdominal pain and nausea
  • Absence of cremasteric reflex, abdo pain, tenderness
  • High riding, horizontal lie

Investigations

  • Bloods to R/O infection
  • Urine to R/O infection
  • USS to assess flow/timing past 24 hours or R/O infection
  • Unusual hx or signs not in keeping with torsion
  • Torsion features
    • Absent/decreased flow
    • Decreased flow velocity and increased flow resistance within testicle

Differential Diagnosis

  • Appendix torsion
    • Hydatid of Morgagni
    • Appendix testis = remnant of Mullerian (Paramesonephric) duct
    • Tender lump at top of testicle +/- blue dot - through skin or translumination
    • Can excise just this
    • Only explore if dx uncertainty
  • Epididymo-orchitis

Management

  • Principles - rapid confirmation of dx with low threshold for exploration
  • Restoration of blood flow
  • Salvage vs resection
  • Analgesia
  • Surgery - Scrotal exploration + bilateral orchidopexy
  • Future prosthesis after 6 months - inflammation etc

Prognosis

  • Salvage
    • <6hrs - >90%
    • 12-24 hrs - 20-50%

    • 24 hrs - <10%

  • Complications
    • Surgery
      • Bleeding, infection, recurrence, pain, orchitis, cosmesis, orchidectomy
    • Delay to surgery
      • Infarction and orchidectomy
      • Contralateral infarction?

Graph View

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