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Testicular Torsion
2
Testicular Torsion
Lauren, Sarah O, Sarah B, Jessica, Caitlin, Erin
Testicular torsion is when the spermatic cord (and related blood vessels) twist and cut off blood flow to the testicle.
History
Doctors don’t always know what causes testicular torsion, it may be related to anatomical risk factors, inherited conditions, movement, or weather.
Testicular torsion is a medical emergency, since pain lasting more than 4 to 8 hours is highly associated with testicular death if no intervention occurs. Blood flow needs to be restored to the testicle in the first 6 hours. Approximately 4 out of every 10 men with testicular torsion will lose their testicle as a result.
(FirstMed, 2019)
This can happen at any age, but is most
common in boys aged 12-18, and in newborns.
According to the Canadian Men's Health Foundation, testicular torsion occurs in around 1 in 4,000 males under the age of 25; however, it can also occur in older males. Testicular torsion is more likely to occur within males who's testicles move more freely within the scrotum.
Who's Affected?
Two types of testicular torsion occur:
1. Extra-vaginal (supravaginal)
- torsion occurs outside of the scrotum at the level of the inguinal canal
- observed in neonates
2. Intra-vaginal
- more common
- mostly due to bell clapper deformity
- observed most in adolescents and young adults
(Bombiński, P., et. al, 2016)
BELL CLAPPER DEFORMITY
ANATOMICAL
RISK FACTORS
An anatomical predisposition known as ‘bell clapper deformity,’ is when the testis and epididymis are not properly attached within the scrotum.
It is the most common cause of/anatomical risk factor for testicular torsion.
A long mesorchium and cryptorchidism have been associated with testicular torsion as well.
Clinical Presentation
Clinical Presentation
Symptoms
- The hemiscrotum (either testicles) may be swollen or erythematous (red)
- Sudden testicular pain that is not relieved by elevation of the scrotum.
- No fever or urethral discharge
- Physical examination may reveal elevation or transverse position of a of a testicle, absence of the cremasteric reflex, anterior rotation of the epididymis, and pain relief by manual detorsion.
- Symptoms may be intermittent due to spontaneous detorsion.
- In these cases, short periods of pelvic/lower quadrant pain along with nausea and vomiting are common.
Clinical consequences
Testicular torsion without treatment can lead to:
- Venous occlusion (blocking of blood drainage),
- Arterial ischemia (blocking/interruption of blood supply)
- Edema
- Testicular infarction (necrosis of testicular parenchyma)
Diagnostic Tests
(Furst, 2019)
Investigations
- Patient History
- Previous testicular torsion
- Recent blunt trauma
- Bell clapper deformity
- Age
- Neonatal
- Between 12 to 18
- Physical Examination
- Presentation of symptoms
- Physical appearance
- Urine or blood tests
- Cremasteric reflix (CR)
- Absent CR is not singularly reliable as diagnostic tool
- Greyscale and Colour Doppler Ultrasound
- Used when physical examination is unclear
- Evaluates size, shape, echogenicity, and perfusion of testicles
- Incomplete Torsion
- Limited blood flow
-Complete Torsion
- Absent blood flow
(Davis, 2012)
Sonographic Findings
Sonographic Findings
Depend on extent of torsion and time elapsed.
Gray-scale and Doppler evaluation both
routinely performed.
Gray-Scale Imaging: early stages (<4 hrs), testis looks normal, associated with high salvage rate. With time, testis and epididymis appear swollen and hyperechoic and/or less uniformly echogenic. Infarctions causing heterogenous echotexture may be present. Scrotal skin may appear thicker along with swelling and hydrocele formation. Spermatic cord appears as somewhat round, twisted lump with epididymis partially encircling it. Once significant swelling, infarctions, and increased vascularity of scrotal wall have been noted, salvage rate is low.
Examining spermatic cord at external inguinal ring can also demonstrate twisting of cord.
Doppler: Initially, venous blood flow will be affected, then arterial. In partial torsion, blood flow impeded, but arterial flow still marginally present with increased resistive index (flow may decrease or reverse in diastole). In complete, no blood flow present.
Even if Doppler ultrasound comes back normal, torsion should not be ruled out. If still suspected, ultrasound should be performed again after 1-4 hours
https://pubs.rsna.org/doi/full/10.1148/rg.255045109#R7
https://www.slideshare.net/shaffar75/doppler-ultrasound-of-acute-scrotum-23607822
https://pubs.rsna.org/doi/full/10.1148/rg.255045109#R7
https://link.springer.com/article/10.1007/s00247-018-4093-0
https://www.slideshare.net/shaffar75/doppler-ultrasound-of-acute-scrotum-23607822
Images
https://www.slideshare.net/shaffar75/doppler-ultrasound-of-acute-scrotum-23607822
https://pubs.rsna.org/doi/full/10.1148/rg.255045109#R7
https://www.slideshare.net/shaffar75/doppler-ultrasound-of-acute-scrotum-23607822
Differential Diagnosis
Differential Diagnosis and Treatment
Due to the emergent nature of Testicular Torsion (TT) it is important to determine diagnosis as soon as possible and rule out other possible causes.
TT, TAT, epidydimitis and orchitis are the most common causes of acute scrotal pain seen in emergency department
Epididymo-orchitis/Epididymitis/Orchitis
• Tender swollen epididymis and/or testis
• Infection (genitourinary procedures or sexual activity)
• Presents with gradually increasing, dull unilateral scrotal pain
• Doppler ultrasound will show increased blood flow
• Tx with antibiotics
Torsion of the Appendix Testicle (TAT)
• Appendage of normal tissue on superior portion of testis
• Torsion of appendix can result in a hard tender nodule under upper pole of testicle, pain and scrotal edema
• Blue discoloration visible in area “blue dot sign”
• Affected testis is comparable in size to unaffected
• Tx is pain management, cooling, and reduced activity, surgery not usually required
Testicular abscess
- Complication of untreated or severe epididymo-orchitis
- Symptoms are testicular pain, swelling, fever
- Can become a scrotal abscess if the tunica albuginea ruptures
- Small percentage of cases develop from bacterial infection
- Avascular region and altered echogenic region
Idiopathic Scrotal Edema
• Edema of skin and dartos fascia no involvement of deeper layers, testes or epididymis
• Not necessary painful
• On ultrasound, thickening and edema of scrotal wall, normal appearance of testes, hyper vascularity of scrotal wall characterized by ‘fountain sign’ (TRV image of scrotal with Doppler showing increased vascularity)
• Tends to resolve itself in 3-5 days
Varicocele
• Dilation of pampiniform plexus of veins found in spermatic cord
• Scrotal mass, swelling, pain, infertility
• Aggravated pain and swelling with standing throughout day
• Dx with ultrasound, Valsalva maneuver showing vein >2-3mm diameter
• Tx surgery
Also Px presenting with scrotal pain could be a result trauma, incarcerated hernia, and tumors
Differential Diagnosis Continued
Complications with Sono images
Epididymo-orchitis: inflammed epididymis (epididymitis) with inflammed testis
- Increased intravascular pressure
- Hydrocele
Mimics incomplete testicular torsion and spontaneous detorsion
Complications with Sono Images
Testicular abscess: complication of epididymo-orchitis
- Avascular region of the testis
- Heterogenous echotexture
Mimics complete testicular torsion with necrosis
Treatment
Surgical exploration
- If surgery performed within six hours, there is a 90-100% testicular salvage rate
- If surgery performed between 12-24 hours, there is a 20-50% salvage rate
- If surgery is performed over 24 hours after onset, there is a 0-10% chance of salvage
Manual detorsion - usually in an outward direction, may be attempted in the initial examination
- Can also be attempted if surgery is not immediately available or while waiting for surgical preparations
Treatment
References
References
American Urological Association, 2019; Karaguzel, Kadihasanoglu, & Kutlu, 2014; Radiopaedia, 2019
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Bandarkar, A. N., & Blask, A. R. (2018). Testicular torsion with preserved flow: key sonographic features and value-added approach to diagnosis. Pediatric radiology, 48(5), 735–744. doi:10.1007/s00247-018-4093-0
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