Testicular torsion

Testicular torsion refers to sudden twisting of spermatic cord, usually internal rotation. 1/3 of cases are due to external rotation. It's most frequent in childhood and adolescents. It's mostly idiopathic, but in some cases it may be related to bell-clapper deformity. It causes abrupt onset testicular pain and a swollen testicle and is therefore one cause of acute scrotum. The testicle lies transversally in the scrotum rather than longitudinally as usual.

It results in irreversible necrosis within hours. The Sertoli cells die before the Leydig cells.

Diagnosis and evaluation

• Mainly clinical, after differentiated from acute epididymitis
  • Negative Prehn sign (i.e., no relief of pain from lifting the affected testicle.
  • Absent cremaster reflex
• Duplex ultrasound can help in the diagnosis
  • Decreased blood flow in case of torsion

Management

• Should be within 6 hours
• Manual detorquation (manual untwisting, also called detorsion)
  • Externally rotate the testes one or two full 360 degree turns
    • Clockwise for right testicle
    • Counter-clockwise for left testicle
  • Can be tried, but should not delay surgery
  • If there is pain relief, the testis lies lower in the scrotum, and Doppler shows blood flow, it was a success
    • If not, detorqutation in the opposite direction may be tried
• Surgery
  • In all cases!
    • Surgery should be performed even if manual untwisting was performed, to prevent recurrence and to make sure the untwisting is complete
  • Surgical detorqutation
  • Orchidopexy of both testicles = fixation the testis to the scrotum, to prevent recurrence
  • Orchidectomy if necrotic testis