Positively Painful Private Parts II: Testicular Torsion

It should be no surprise that acute testicular torsion is a surgical emergency. The testicle twists on the spermatic cord which leads to the following sequence:

Venous compression
Edema of testicle and cord
Arterial occlusion
Ischemic testicle

The risk 1/4000 for males < age 25. There is a bimodal distribution, with rates peaking in the neonatal period and again during puberty. For the purposes of this post, we’ll be focusing on older children, as the neonatal form often occurs in utero. Almost two-thirds of cases (65%) occur between ages 12 and 18 years. The pubertal peak is thought to be due to increasing testicular volume (cue endocrinologist with orchidometer in hand).

As noted in part I of the series the bell clapper deformity occurs when the testis is not fixed to the tunica vaginalis posteriorly and it is free to rotate. This leads to an increased risk of torsion. The incidence is in the population is approximately 1/125 and is usually present bilaterally. It goes without saying that though patients may have the deformity, most don’t torse.

The classic presentation begins with the abrupt onset of pain, with most cases being recognized in under 12 hours. There can be associated nausea, vomiting and referred lower abdominal pain.In a retrospective review from Kadish, 1998, only 8% had pain prior to the “main” episode. On exam, the ipsilateral scrotum is edematous. It can be red or dusky in color depending on the length of time since onset of symptoms. The testis is tender, elevated and may have a horizontal lie. The cremaster reflex is absent in many cases – but this isn’t diagnostic.

I can’t reiterate this enough, but testicular torsion should ideally be a clinical diagnosis. If you suspect it call a Urologist ASAP. Most cases where my pre-test probability for torsion were low, did not have torsion. Indeed, an ultrasound isn’t perfect, having a Sensitivity of 69-100% and specificity of 77-100%. the treatment is detorsion of the affected testis (if viable) and fixation (orchiopexy) of both testis. If you remember anything from this post I want you to remember the point below clearly signalled by big, bold red letters:

Viability rates

Within 4-6 hours 100%
12-24 hours 20%
>24 hours 0%

Males with a history of testicular torsion may have increased risk of infertility even when a viable de-torsed testis is left in scrotum because of immune-mediated injury to contralateral testis. Some scientists theorize that anti-sperm antibodies are produced during the period of ischemia. This is far from hard science as other studies have failed to show that anti-sperm antibodies are present. There can be cases of intermittent torsion which are challenging to diagnose. We do know that: