What is testicular torsion?

What is Testicular Torsion

Testicular torsion is a surgical emergency where the spermatic cord twists around its longitudinal axis, cutting off blood supply to the testicle and requiring immediate surgical intervention within 6-8 hours to prevent permanent testicular loss. 1

Definition and Pathophysiology

• Testicular torsion occurs when the testis rotates and twists the spermatic cord, which contains the blood vessels supplying the testicle 2
• This twisting compromises both arterial inflow and venous outflow, leading to immediate circulatory changes and testicular ischemia 3
• The condition can occur either within (intravaginal) or outside (extravaginal) the tunica vaginalis 3
• In infants, torsion is primarily extravaginal and often occurs prenatally or perinatally 4

Epidemiology and Risk Factors

• Testicular torsion has a bimodal age distribution, with peaks occurring in neonates and postpubertal boys 1
• The estimated yearly incidence is 2.9 to 3.8 per 100,000 boys under 18 years of age 1
• The condition occurs more frequently in adolescents than adults, though it can happen at any age 4
• The primary anatomical risk factor is the "bell-clapper deformity," an abnormal attachment of the tunica vaginalis that allows the testicle to rotate freely 2

Clinical Presentation

• The hallmark symptom is sudden onset of severe unilateral testicular pain 1, 5
• Associated symptoms include nausea and vomiting, which are common 5
• Physical examination findings include a red, swollen scrotum, high-riding testicle, and absent cremasteric reflex 6
• A negative Prehn sign (pain is NOT relieved when the testicle is elevated) is a key distinguishing feature 1
• The condition typically presents without preceding trauma 5

Critical Time Window

• Testicular viability is compromised if surgical detorsion is not performed within 6-8 hours of symptom onset 1
• Surgical outcomes are significantly better when intervention occurs within 12 hours 1
• Beyond this window, irreversible ischemic damage and testicular necrosis occur, leading to testicular loss 3, 7
• The salvage rate depends on both the degree of torsion and duration of ischemia 4

Diagnostic Approach

• Duplex Doppler ultrasound is the first-line imaging modality with sensitivity of 69-96.8% and specificity of 87-100% 1
• Key ultrasound findings include decreased or absent blood flow to the affected testicle 1
• The "whirlpool sign" (spiral twist of the spermatic cord) is the most specific ultrasound finding with 96% sensitivity 1, 4
• Additional findings include an enlarged, heterogeneous, hypoechoic testis, ipsilateral hydrocele, and scrotal skin thickening 1
• A critical pitfall: false-negative Doppler evaluations can occur with partial torsion or spontaneous detorsion 1

Management

• Immediate urological consultation and prompt surgical exploration are the definitive treatment 1
• Manual detorsion can be attempted as a temporizing measure before surgery, though it may fail due to patient discomfort or incorrect rotation direction 6
• Surgical management involves detorsion of the affected testicle and bilateral orchidopexy (fixation of both testicles) to prevent recurrence 8
• The contralateral asymptomatic testicle should be fixed prophylactically, as the anatomical predisposition is typically bilateral 8
• Post-operative care includes bed rest, scrotal elevation, and analgesics until inflammation subsides 1

Long-Term Consequences

• Delayed treatment results in germ cell necrosis, arrested spermatogenesis, and diminished testosterone levels 7
• Testicular atrophy rates range from 9.1% to 47.5% even with surgical intervention 8
• Fertility may be compromised due to both direct testicular damage and potential autoimmune effects on the contralateral testicle 7
• Reperfusion injury following detorsion can cause additional damage through oxidative stress and endothelial cell injury 7