Can testicular torsion lead to epididymitis?

Testicular Torsion Does Not Typically Lead to Epididymitis—But the Reverse Can Occur

Testicular torsion and epididymitis are distinct pathological entities that do not have a causal relationship in the traditional sense, though epididymitis can rarely precipitate torsion through testicular enlargement. 1

Understanding the Pathophysiological Relationship

Testicular Torsion Does Not Cause Epididymitis

• Testicular torsion involves twisting of the spermatic cord, which compromises blood flow to and from the testis, leading to ischemia rather than infection or inflammation. 2
• The primary pathology in torsion is vascular obstruction—venous obstruction occurs first, followed by arterial flow obstruction and ultimately testicular ischemia. 3
• The degree of testicular ischemia depends on the extent of torsion (ranging from 180 to 720 degrees or greater), not on inflammatory processes. 3

The Rare Exception: Epididymitis Can Precipitate Torsion

• A documented case report demonstrates that epididymo-orchitis can lead to subsequent testicular torsion, likely through testicular enlargement creating mechanical predisposition to twisting. 1
• In this case, an 18-year-old male developed testicular torsion 5 days after initial presentation with epididymo-orchitis, ultimately requiring orchiectomy. 1
• The enlarged testis from epididymo-orchitis can predispose to torsion, making close follow-up and adequate counseling critical for patients with epididymo-orchitis. 1

Critical Diagnostic Pitfalls

The Challenge of Overlapping Presentations

• The clinical presentations of testicular torsion and epididymitis overlap significantly, making rapid diagnosis challenging and potentially leading to misdiagnosis. 3, 4
• Testicular torsion characteristically presents with abrupt onset of severe scrotal pain, while epididymitis typically has gradual pain onset. 2
• However, two adult patients initially treated with antibiotics for suspected epididymitis were ultimately found to have testicular torsion, with one requiring orchidectomy due to necrosis. 5

Distinguishing Features on Imaging

• Reperfusion after early ischemia from torsion/detorsion can induce reactive hyperemia on color Doppler imaging that is sonographically indistinguishable from the hyperemia seen with acute epididymo-orchitis. 3
• In epididymitis, color Doppler shows increased blood flow corresponding to hyperemia, with sensitivity nearly 100% for detecting scrotal inflammation. 3
• In testicular torsion, Doppler shows decreased or absent blood flow to the affected testicle, though false-negative evaluations can occur with partial torsion or spontaneous detorsion. 3, 2
• The "whirlpool sign" (spiral twist of the spermatic cord) is the most specific ultrasound sign for testicular torsion. 3, 2

Essential Clinical Correlation

• Clinical data including fever, waxing and waning pain, and laboratory markers for infection must be integrated to distinguish between torsion with reperfusion and acute epididymo-orchitis. 3
• Normal urinalysis does not exclude either testicular torsion or epididymitis. 2
• Any patient with acute scrotal complaint and negative scan should receive daily follow-up until symptoms subside. 4

Management Implications

When Torsion is Suspected

• Immediate urological consultation and surgical exploration within 6-8 hours of symptom onset is essential to prevent testicular loss. 2, 6
• Any patient in whom testicular torsion is strongly considered should undergo immediate exploratory surgery without diagnostic studies. 4
• If radiographic studies cannot be arranged and interpreted within 1-2 hours, scrotal exploration should be performed. 4

When Epididymitis is Diagnosed

• Patients diagnosed with epididymo-orchitis require close follow-up and counseling about warning signs of potential subsequent torsion, given the rare but documented risk of torsion secondary to testicular enlargement. 1
• Broad-spectrum antibiotics lead to subsidence of clinical symptoms in epididymitis with no sequelae when appropriately treated. 7