Testicular Torsion

Learning Objectives

1. List the differential diagnosis for an acutely painful scrotum.
2. Understand the anatomical basis of testicular torsion.
3. List common presenting signs and symptoms of testicular torsion.
4. Describe both initial and definitive management of testicular torsion.
5. Explain why torsion is an emergent condition and discuss the time for salvage of the testicle.

Some cases to start with:

1. 14 year male presents with testicular pain  upon awakening that morning. He has had several episodes of similar pain that resolved spontaneously in the past, but this time the pain is persisting.
2. 23 year man complains of three days of painful urination and a swollen testicle.

Acute Scrotum

Emergent	Non-emergent
Testicular torsion	Appendage torsion
Fournier’s gangrene	Acute epididymitis
Abdominal aortic aneurysm	Testicular/scrotal abscess
Traumatic testicular rupture	Testicular cancer with bleeding
Peritonitis with patent processus vaginalis	Renal colic
Incarcerated inguinal hernia	Hydrocele
	Varicocele
	Henoch-Schonlein Purpura
	Orchitis

By age:

Infant

• Hernia
• Hydrocele

Child

• Hernia
• Torsion
• Epididymitis

Adolescent

• Epididymitis
• Torsion
• Trauma

Adult

• Epididymitis
• Hernia
• Trauma
• Tumor torsion

Commonest causes:

• Responsible for 0.5% of total ED visits.
• 85-90% cases: Appendage torsion + Testicular torsion + Acute epididymitis
• 75% cases: Testicular torsion + Acute epididymitis
• 25% cases: Testicular torsion (1:4000 males; peak age ~14 yrs)
• M/C cause: Acute epididymitis

Special signs and Techniques

1. Cremasteric reflex

• Stroking ipsilateral inner thigh – reflex elevation of testicle
• Absence of ipsilateral reflex – think testicular torsion
• Presence – 96% NPV for torsion

2. Prehn’s sign

• Relief of pain with scrotal elevation
• Thought to be positive in epididymitis (not reliable)

3. Blue dot sign

• Infarcted appendage (blue dot) seen through scrotal skin
• Think of appendage torsion

Relevant Anatomy

Normal Testicular fixation in Scrotum:

1.Tunica vaginalis to Scrotal ligament (Gubernaculum)

2.Posterior part of testis (not layered by tunica vaginalis) to scrotum by mesorchium

Increased mobility of testis:

1. Defect in normal fixation mechanism
2. Long mesorchium
3. Exercise or Trauma
4. Puberty: Increased weight and vascularity

Cremasteric spasm:

Rapid cremaster contraction → elevation +/- rotation of testicle

• Cremaster = Internal oblique muscles
• Inserts into spermatic cord in spiral fashion
• Abdominal muscle contraction = Cremaster contraction
• Association with blunt abdominal trauma and straining

Winter syndrome: During winter when males are in bed

• Scrotum relaxed in warmth → Testicles freely mobile → Testicles twist à Sudden exposure to cold → Contracts quickly → Torsion

Sleep: Strong cremasteric reflex associated with nocturnal erections

Types of Testicular Torsion

1. Extravaginal (perinatal period)

• Scrotal ligament not developed
• Prenatal = “vanishing” testis

2. Intravaginal (after perinatal period) – more common

• Bell-clapper deformity (in upto 12% asymptomatic men)
• Long mesorchium

Pathophysiology of Testicular Torsion

Mikuz Histologic Grading of Testicular Torsion

Grade	Features	Time
1	Intertubular edema, limited blood extravasation, desquamation of germ cells	<4 hours
2	Diffuse intertubular hemorrhage, focal necrosis of the germ cells	4-8 hours
3	Diffuse infarction of parenchyma	>12 hours

Features Suggestive of Testicular Torsion

• Severe acute testicular pain +/- nausea & vomiting (26-60%)
• Prophetic pain (self-limiting previous episodes)
• Affected testicle lies high up (Deming’s sign; 26-80%)
• Horizontal lie of contralateral testicle (Angell’s sign; 25-90%)
• Anterior position of epididymis rather than posterior
• Absent cremasteric reflex (40-100%)
• Reactive hydrocele (52%); Fever (infarction; 8-41%)

In adolescent boys with lower abdominal pain examine external genitalia to rule out scrotal or testicular pathology. Non-scrotal/abdominal pain accounts for 5-25% cases in cases of acute testicular torsion.

TWIST score

Finding	Points
Testicular swelling	2
Hard testicle	2
Absent cremasteric reflex	1
Nausea or vomiting	1
High-riding testicle	1

PPV 100% when >5 points (Suggesting stat urological consult)

NPV 100% when <2 points (Suggesting clinical clearance)

Scores from 2-5 patients require U/S for further assessment

Time is Testicle

Duration	Salvage rate
<6 hrs	90-100%
12-24 hrs	20-50%
>24 hrs	0-10%

Torsion	Infarction onset
3	2 hours
1	12-24 hours
<1	>24 hours

Clinically – Complete vs Incomplete? – Difficult to determine

Surgery – reduces pain and other symptoms’ duration

Don’t rely on symptoms duration. All require emergent urologic evaluation.

Imaging in Testicular Torsion

Indications:

1.Clinical doubt as to the cause

2.Failure to respond to treatment

Clinical setting of testicular torsion – USG shouldn’t delay intervention

Gold-standard: Color Doppler USG

Uncertain perfusion on color Doppler USG: Nuclear medicine scan

Gray-scale USG

Abnormal spermatic cord twist (Whirlpool sign)

• Sensitivity: 96%

Normal linear cord (In patients without torsion)

• Specificity: 99%

Normal homogenous echo pattern = Viable testis

Hypoechoic/Inhomogenous echo pattern = Non-viable testis

Color Doppler USG

Sensitivity: 96-100%; Specificity: 84%-95%

Incomplete torsion:

• Elevated resistive index (>0.75)
• To-and-fro flow

Complete torsion: Absence of blood flow in testis and epididymis

Nuclear Medicine Scan

Tc-99m Pertechnetate

Sensitivity: 80-90%

Specificity: 90-100%

Early: Nubbin sign (Abrupt cut-off of iliac a.)

Late: Halo/Rim/Dough-not sign

Manual Detorsion of Testis

Steps for manual detorsion of testis in testicular torsion has been discussed here.

Definitive Management of Testicular Torsion

• Surgical detorsion and bilateral orchipexy to the scrotum.
• Contralateral orchipexy is obligatory.

Informed consent prior to surgical exploration:

1. Removal or fixation of affected testis depending upon viability
2. Fixation of contralateral testis should the diagnosis of torsion prove correct
3. Testicular atrophy (upto 68%) even following surgery
4. Subfertility – abnormal semen analysis in 50-87%

Answer to the cases we began with:

1. A 14-year-old male presents to ED with complaints of testicular pain upon awakening that morning. He has had several episodes of similar pain that resolved spontaneously in the past, but this time the pain is persisting.

Ans: Testicular torsion

2. A 23-year-old man complains of three days of painful urination and a swollen testicle.

Ans: Epididymo-orchitis

Take Home Messages

Time is Muscle!! (Myocardial infarction)
Time is Brain!! (Stroke)
Time is Testicle!! (Testicular torsion)

Castration by procrastination.

When in doubt, check it out (explore).

MCQs on Testicular Torsion

Comment down the best choices:

1. Regarding testicular torsion, which ONE of the following statements is TRUE?

A. It is mostly due to lateral rotation of the spermatic cord

B. The cremasteric reflex is always absent

C. It can be reliably excluded with scrotal ultrasound scan

D. It can be associated with a fever

---

2. Testicular torsion of at least _____ degrees is necessary for complete arterial occlusion?

A. 180

B. 360

C. 520

D. 720

---

3. What is Angell’s sign?

A. High riding contralateral testis

B. Twisted spermatic cord on affected side

C. Horizontal lie of testis on contralateral side

D. Horizontal life of testis on affected side

---

4. An adult patient presents with recurrent severe testicular pain with spontaneous resolution. Testis was found to have horizontal lie on examination. Urine analyses and culture were normal. Doppler reveals hyper-perfused testis. What is the best management for this patient?

A. Antibiotics

B. Conservative management with scrotal support and analgesia

C. Orchiopexy

D. No treatment needed

References:

Halls GD, Dietrich T, Ford D. Diagnosis and Emergency Department Management of Urologic Emergencies in the Male Patient: Part I [Internet]. AHC Media - Continuing Medical Education Publishing. 2002 [cited 2017Dec30]. Available from: https://www.ahcmedia.com/articles/118262-diagnosis-and-emergency-department-management-of-urologic-emergencies-in-the-male-patient-part-i

Jezek D. Atlas on the Human Testis. 1st ed. London: Springer London; 2013.

Sandler M. Diagnostic nuclear medicine. 1st ed. Philadelphia: Lippincott Williams & Wilkins; 2003.

Salem A, H A. An Illustrated Guide to Pediatric Urology. 1st ed. Switzerland: Springer International; 2017.

King C, Henretig F, Young C. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2007.

N, O'Flynn KJ, Pearce I. Testicular torsion: a urological emergency. Trends in Urology; Men's Health. 2010; 1(1): 31-4