TESTICULAR TORSION

Torsion of Testis
The disease process whereby there is
cessation of blood flow to the testicle
because of an occlusion of arterial blood
supply due to twisting of the spermatic
cord
Lead to testicular loss unless there is
timely intervention. Irreversible ischemic
injury to the testicular parenchyma may
begin as soon as 4 hours after initial
onset.

Epidemiology
Annual incidence of 1 in 4000 amongst those
under 25 years old male.
Adolescents with acute scrotal pain have a 5060% chance of having a twisted testis, but 2535% in children.

Fig 1. Incidence of common causes for acute

scrotal problems in infants and children.

Davenport. BMJ. 1996:435-437

Anatomy

Extravaginal
torsion

Intravaginal torsion

Testicular Torsion

As soon as
4 hours!!

PRESENTATION
Classic manifestation: Sudden onset of unilateral
persistent scrotal pain but in some instances the onset
appears to be more gradual, and in some boys the
degree of pain is minimized

presentation
Acute onset ipsilateral testicular pain in
89%.
34% associated groin, abdominal or
thigh pain, which could be earliest and
predominant symptom.
Urinary symptoms in 5% and vomiting in
39%.
36% have previous testicular pain or
swelling.
Injury in 4%, recent exercise in 7%,
bicycle riding in 3% and 11% were
J. etpain.
al. Br J Surg. 1988:988-92
woken form sleepAnderson
with the

PRESENTATION

Inspection: asymmetric position of the

testicles with the torsed testicle
occupying a high position in the scrotum
(high-riding testicle)

PRESENTATION
Absence of cremasteric reflex. Positive
reflex is testicular retraction when upper
inner thigh is stroked

PRESENTATION

Normal testicle must be palpated first (it

should be in vertical position)
Next the spermatic cord of the affected
testis is palpated. Torsion: painful and
swollen
Finally, the affected testis is palpated

Fever and erythema of the

overlying scrotal skin are late signs,
with low salvage rates.
Lack of relief of pain with caudal
scrotal support (Prehns sign).It was
not reliable in children.

Epididymitis/
Orchitis

Incarcerated
Hernia

Differential
Diagnosis
Varicocele

Torsion of
Appendix Testis

Idiopathic
Scrotal Edema

PRESENTATION
Scrotal ultrasound with color Doppler is
widely used (sensitivity 88.9% and
specificity 98.8%), although some
institutions use technicium-99m
radionuclide scanning to look for blood flow
to testicle (sensitivity 90% and specificity
89%)

PRESENTATION
If imaging modality cannot be obtained in a timely
manner and the index of suspicion is high
intraoperative exploration is mandatory

TREATMENT

Surgical identical for intravaginal and

extravaginal torsion

If testis appears nonviable initially

placed in warm gauze pad appropriate
color and turgor may return, in which
case orchidopexy should be performed;
otherwise orchiectomy is recommended

Rates of testicular salvage by time from start of symptoms.

Davenport, M. BMJ 1996;312:435-437

Copyright 1996 BMJ Publishing Group Ltd.

 Attempt manual detorsion- outward

open the book . Some may be twisted
360, 720 or 1440 degrees

Torsion typically occurs in a medial

direction, manual detorsion should
be attempted initially by rotation
the testis outward toward the thigh.

TREATMENT
Viable testicle orchidopexy with creation of a threepoint nonabsorbable suture fixation. Some authors also
advocate placement of the testicle in to a subdartos
pouch to fix the testicle by tissue as well as by suture

TREATMENT
A median raphe scrotal incision may be used to explore
both sides, or a transverse incision following the skin
creases may be placed in each hemiscrotum
The separate incisions are more appropriate for dartos
pouch placement of the testes
The affected side should be examined first

TREATMENT
The cord should be detorsed to reestablish blood flow to
the testis
A necrotic testis should be removed by dividing the cord
into 2 or 3 segments and doubly ligating each segments
with silk suture
If the testis is to be preserved, it should be placed in the
dartos pouch with suture fixation

TREATMENT
When torsion of the spermatic cord is found, exploration
of the contralateral hemiscrotum must be carried out
In almost all cases a bell-clapper deformity is found
The contralateral testis must be fixed to prevent
subsequent torsion
Even if a patient had a previous orchidopexy, they may
(rarely) develop torsion again

TREATMENT
Contralateral orchidopexy is often performed
(controversy)
Manual detorsion has been reported

CONCLUSION
The most important point: keeping
torsion in the top of the differential
diagnosis when evaluating a scrotal
emergency