Testicular torsion is a common surgical emergency of adolescent males presenting with sudden onset of intense scrotal pain. Anatomically testicular torsion follows a congenital anomaly in predisposed individuals that allows the testis to rotate, twisting the spermatic cord, resulting in loss of blood supply and eventual testicular necrosis. The most common underlying cause is a congenital malformation known as a "bell-clapper deformity" wherein the testis is inadequately affixed to the scrotum allowing it to move freely on its axis and susceptible to induced twisting of the cord and its vessels.
Several types of torsion can be distinguished:
Intermittent testicular torsion
A variant is a less serious but chronic condition called intermittent testicular torsion (ITT), characterized by the symptoms of torsion but followed by eventual spontaneous detortion and resolution of pain. Nausea or vomiting may also occur. Though less pressing, such individuals are at significant risk of complete torsion and possible subsequent orchiectomy and the recommended treatment is elective bilateral orchiopexy. Ninety-seven percent of patients who undergo such surgery experience complete relief from their symptoms.
Extravaginal testicular torsion
A torsion which occurs outside of the tunica vaginalis, when the testis and gubernaculum can rotate freely, is termed an extravaginal testicular torsion. This type occurs exclusively in newborns. Neonates experiencing such a torsion present with scrotal swelling, discoloration, and a firm, painless mass in the scrotum. Such testes are usually necrotic from birth and must be removed surgically.
Torsion of the testicular appendix
This type of torsion is the most common cause of acute scrotal pain in boys ages 7–14. Its appearance is similar to that of testicular torsion but the onset of pain is more gradual. Palpation reveals a small firm nodule on the upper portion of the testis which displays a characteristic "blue dot sign." This is the appendix of the testis which has become discolored and is noticeably blue through the skin. Unlike other torsions, however, the cremasteric reflex is still active. Typical treatment involves the use of over-the-counter analgesics and the condition resolves within 2–3 days.
Early diagnosis and definitive management are the keys to avoid testicular loss. All prepubertal and young adult males with acute scrotal pain should be considered to have testicular torsion until proven otherwise. The finding of an ipsilateral absent cremasteric reflex is helpful, but not diagnostic. Diagnosis of torsion is mainly clinical. If history and examination suggest torsion, urgent testicular exploration is the only best way to proceed. Doppler ultrasound scan can be helpful in suspected cases. The sensitivity of colour doppler ultrasound scan ranges from 89% to 100%. Theoretically the sensitivity of doppler scanning may be lower in incomplete or intermittent testicular torsion, in both of which flow can be normal. Surgical exploration should be the first line of management in suspected cases.
Associated diseases
Complications
Risk factors
A larger testicle either due to normal variation or a tumor increases the risk of torsion. Also conditions that allow the testicle to rotate predispose to torsion: a congenital malformation of the processus vaginalis known as the "bell-clapper deformity" accounts for 90% of all cases. In this condition, rather than the testes attaching posteriorly to the inner lining of the scrotum by the mesorchium, the mesorchium terminates early and the testis is free floating in the tunica vaginalis.
When torsion causes infarction, it leads to death of testis. The reaction of pituitary hormones is that they stimulate the remaining healthy testicular tissue to increase testosterone levels and as the compensation to make more sperms. The result is that sperm count can return to normal and man can remain fertile. But still probably 33% of men still have lower count after torsion which leads to some difficulties in fathering a child.
Sometimes the corrupted testicle could be ruptured and then the sperms are released into blood circulation, which is not their natural medium. Immune cells start to produce anti-sperm antibodies, which could affect remaining sperms in testicles.
Some males have testicles that can rotate in the scrotum as an inherited trait. For them there is only option and it is surgery which attach testicles to the scrotum.
Testicular torsion usually presents with sudden, severe, testicular pain (in groin and lower abdomen) and tenderness. There is often associated nausea and vomiting. The testis may be higher than its normal position. Mild pyrexia and redness of overlying area may be found.
Some of the symptoms are similar to epididymitis though epididymitis may be characterized by discoloration and swelling of the testis, often with fever, while the cremasteric reflex is usually present. Testicular torsion, or more probably impending testicular infarction, can also produce a low-grade fever. There is often an absent or decreased cremasteric reflex.
There is no self or alternative therapy for this condition.
Pharmacotherapy
No drugs can be used to fix testicular torsion.
Surgical therapy
Testicular torsion is a medical emergency requiring quick and urgent action. Usually orchiopexy is performed to resolve a testicular torsion. If caught early enough and the blood supply can be restored to the testicle, this operation can be performed to prevent further occurrence of torsion. If the blood supply has been interrupted for too long, an orchiectomy must be performed. Sometimes orchiopexy is also done preventively in adults in cases in which the patient has the bell-clapper deformity, retractile testicles or intermittent torsion.
In the case of cryptorchidism one or both testes are absent from the scrotum. It is is the most common etiologic factor of azoospermy in the adult.
Antibodies that bind to sperm, inhibiting their movement, stopping recognition and entry into the egg.
An accumulation of clear fluid in the tunica vaginalis, the most internal of membranes containing a testicle.
The inability of the testicles to produce sperm or testosterone.
An inflammation of epididymis.
The condition of only one testicle present in the scrotum.
An endocrine gland, about the size of a pea, whose secretions control the other endocrine glands and influence growth, metabolism, and maturation.
Male gonads which produce both sperm and androgens, such as testosterone, and are active throughout the reproductive lifespan of the male.
The cell in seminiferous epithelium responsible for nutrition and development of germ (sperm) cells.
A male reproductive cell which is able to fertilize the counterpart female gamete - the oocyte.
An undifferentiated male germ cell with self-renewing capacity representing the first stage of spermatogenesis.
FSH is a hormone secreted by the anterior pituitary gland. It regulates the development, growth, pubertal matur and reproductive functions of the body
Steroid hormone produced primarily in the testes of the male; responsible for the development of secondary sex characteristics in the male.
Process in which spermatozoa are produced from male primordial germ cells in testicles by way of mitosis and meiosis.
A not-temporary condition in which the testes diminish in size and may be accompanied by loss of function.
Body temperature usually not exceeding 38 degrees of Celsius.
Pain that occurs in low area of abdomen, below the umbilicus.
A sensation of unease and discomfort in the stomach with an involuntary urge to the forceful expulsion of the contents of stomach through the mouth.
Increased temperature and redness of one or both testicles.
An infection of the testicleals.
A discomfort felt in the testicles (testes) or scrotum.
Excessive accumulation of any fluid in the area of testicles.
Process by which a woman donates eggs for purposes of assisted reproduction or biomedical research.
Surgical removal of one or both testes.
Surgery to move an undescended testicle into the scrotum used as a treatment of cryptorchidism.
The procedure in which a man (sperm donor) provides his sperm for fertility treatment.
A process in which an egg is fertilised by sperm outside the body: in vitro. Own or donated gametes may be used.
