Testicular torsion

In testicular torsion the spermatic cord that provides the blood supply to a testicle is twisted, cutting off the blood supply, often causing orchalgia. Prolonged testicular torsion will result in the death of the testicle and surrounding tissues.

It is also believed that torsion occurring during fetal development can lead to the so-called neonatal torsion or vanishing testis, and is one of the causes of an infant being born with monorchism.

Risk factors

In most males, the testes are attached posteriorly to the inner lining of the scrotum by the mesorchium. When the mesorchium terminates early and does not attach the testis, this is called a bell clapper deformity as the testis is free floating in the tunica vaginalis, only attached to the spermatic cord, like a bell clapper. A bell clapper deformity is a predisposing factor for testicular torsion in non-neonates. Currently there is no recommended clinical examination for a bell clapper deformity.

Torsions are sometimes called "winter syndrome". This is because they often happen in winter, when it is cold outside. The scrotum of a man who has been lying in a warm bed is relaxed. When he arises, his scrotum is exposed to the colder room air. If the spermatic cord is twisted while the scrotum is loose, the sudden contraction that results from the abrupt temperature change can trap the testicle in that position. The result is a testicular torsion.

Prevalence

While torsion is more frequent among adolescents, it should be considered in all cases where there is testicular pain. Torsion occurs more frequently in patients who do not have evidence of inflammation or infection. Two risk factors are trauma and strenuous physical activity.

Diagnosis

Emergency testing for torsion may be indicated when the onset of pain is sudden and/or severe, or the test results available during the initial examination do not enable a diagnosis of urethritis or urinary tract infection to be made. A doppler ultrasound scan of the scrotum, if available, is of help in the diagnosis by showing the presence or absence of blood flow to the testicle. However, if suspicion is high, immediate untwisting is advised in order to prevent infarction and subsequent testicular loss with or without sterility(i.e. incidental and unfortunate testiculectomy). Dizziness and nausea are often present when there is an absence of blood supply to the testicle, as well as a tremendous amount of pain. If the diagnosis is questionable, an expert should be consulted immediately, because testicular viability may be compromised. If physical examination suggests a compromised blood supply and the patient has had such symptoms for a significant period of time, medical personnel may choose to bring the patient directly to surgery without an ultrasound since the time required for ultrasound testing could affect testicular viability.

Color Doppler sonography is used to identify the absence of blood flow typically found in a twisted testicle, which distinguishes the condition from epididymitis. [cite journal | author = Arce J, Cortés M, Vargas J | title = Sonographic diagnosis of acute spermatic cord torsion. Rotation of the cord: a key to the diagnosis. | journal = Pediatr Radiol | volume = 32 | issue = 7 | pages = 485–91 | year = 2002 | pmid = 12107581 | doi = 10.1007/s00247-002-0701-z]

Urinalysis (analyzing chemical composition of urine) can be used to rule out bacterial infections.

Surgical exploration may be necessary if diagnosis cannot be made using other methods. If there is the slightest hint of a torsion of the testicle, then doctors will perform surgery; even if the testicle turns out not to have twisted, they will still protect it by attaching the testicle to the scrotum wall.

Treatment

With prompt diagnosis and treatment the testicle can be saved in a high number of cases. [cite journal | author = Cattolica E, Karol J, Rankin K, Klein R | title = High testicular salvage rate in torsion of the spermatic cord. | journal = J Urol | volume = 128 | issue = 1 | pages = 66–8 | year = 1982 | pmid = 7109074]

Testicular torsion is a medical emergency that needs immediate treatment. If treated within 6 hours, there is nearly a 100% chance of saving the testicle. Within 12 hours this rate decreases to 70%, within 24 hours is 20%, and after 24 hours the rate approaches 0. (eMedicineHealth) Once the testicle is dead it must be removed to prevent gangrenous infection.

A simple and minimally invasive surgery pioneered in Dallas by Dr. Dean Moheet in 1952 effectively corrects and further prevents future testicular torsion. It can be done in an emergency situation after determination that the testicle is cut off from blood supply or as an outpatient procedure for patients who have experienced frequent episodes with testicular torsion. If necessary, the surgeon will first untwist the testicle(s). The surgeon will then permanently suture the testicles to the inner lining of the scrotum. If only one testicle has been problematic, the surgeon may suture both testicles as a preventative effort.

References

External links

"Adapted from the public domain document Centers for Disease Control and Prevention. 1998 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR 1998;47(No. RR-1) at http://wonder.cdc.gov/wonder/STD/STD98TG/STD98T12.HTM and other sources."

Photos of swollen, excised, and detorsed testicles of patient who sought treatment within four hours of onset of pain. http://www.vesalius.com/graphics/archive/archtn.asp?VID=1235&nrVID=1234