•This calls for early diagnosis and emergency correction of torsion to minimize the risk of testicular infarction.

•The diagnosis of testicular torsion is clinical and if doubt an emergency Doppler ultrasound can be done.

•Testicular torsion commonly develops during puberty but can also be seen in newborns as a result of intrauterine torsion or soon after birth.

•The exact incidence of testicular torsion is not known but it has been estimated to occur in about 1 in 4,000 to 1 in 25,000 males per year before 25 years of age.

•Testicular torsion is most frequent among adolescents with about 65 % of cases presenting between 12 and 18 years of age.

•It has been estimated that in 95 % of men with testicular torsion the testis can be saved if treated within six hours of the onset of pain.

•Other causes of acute scrotal pain that should be ruled out include:

–Orchitis

–Epididymitis, epididymo-orchitis

–Torsion of the testicular or epididymal appendages

–Trauma-related causes of acute scrotum

–Acute hydrocele

–Testicular tumor

–Idiopathic scrotal edema

26.2Etiology and Risk Factors

•The exact etiology of testicular torsion is not known

•The “bell-clapper deformity”

–This is the commonest cause of testicular torsion

–It accounts for 90 % of the cases

–It is a congenital malformation of the processus vaginalis

–In this condition, rather than the testes attaching posteriorly to the inner lining of the scrotum by the mesorchium, the mesorchium terminates early and the testis is free floating in the tunica vaginalis.

–This condition is bilateral and calls for fixation of the other testis when one testis is affected. This is to prevent subsequent torsion of the other side.

•A large mesentery between the epididymis and the testis can also predispose itself to torsion, although this is rare.

•Contraction of the spermatic muscles shortens the spermatic cord and may initiate testicular torsion.

•Other etiologic factors involved in intravaginal testicular torsion include:

–Undescended testicle

–Sexual arousal or activity

–Physical exercise

nosing testicular torsion.

–In testicular torsion, there is no blood flow or the blood flow is markedly decreased.

–In epididymo-orchitis, there is normal or slightly increased blood flow.

–The sensitivity of color Doppler in detecting acute testicular torsion in children is 90–100 %, with specificity being 100 %.

–Other studies have suggested that color Doppler ultrasonography was only 86 % sensitive, 100 % specific, and 97 % accurate in the diagnosis of testicular torsion (Figs. 26.2 and 26.3).

–Doppler ultrasonography has (Figs. 26.4 and 26.5):

•94 % sensitivity.

•96 % specificity.

•95.5 % accuracy.

•89.4 % positive predictive value.

•98 % negative predictive value.

•In doubtful cases, an isotope scan (techne- tium-99 m pertechnetate) can be done. Radionuclide scans have a sensitivity of

bilateral torsion of testes

90–100 % accuracy in detecting testicular blood flow.

–This is the most accurate investigation but it is not readily available

–Add to this the time it requires to organize and do this investigation particularly in cases of torsion where urgency is required

–In testicular torsion, there is no uptake of the uptake is markedly reduced

–In epididymo-orchitis, there is normal uptake and uniformly symmetric activity.

–A urine analysis and culture can be done to roll out infection.

–The complete blood count can be normal. However, the WBC count is elevated in as many as 60 % of patients who have testicular torsion.

•Surgical exploration should not be delayed for the sake of performing imaging studies.

26.4Intermittent Testicular Torsion

•This is a less serious variant of testicular torsion.

•It is a chronic condition characterized by the symptoms of testicular torsion but followed by eventual spontaneous detortion and resolution of pain.

•The attack may be associated with nausea or vomiting

•These patients are however at significant risk of developing complete torsion

•It is important recognize this condition and physicians treating these patients should be aware of this.

•The treatment is elective bilateral orchiopexy.

•This is curative and 97 % of patients who undergo bilateral orchidopexy experience complete relief from their symptoms.

26.5Classification of Testicular Torsion

•Testicular torsion is classified is classified into two types depending on onset:

–Acute testicular torsion

–Intermittent testicular torsion

•Testicular torsion is also classified anatomically into two types:

–Intravaginal torsion

•This is the commonest type

•Commonly develops during puberty

•The torsion occurs within the tunica vaginalis

•Intravaginal torsion comprises approximately 16 % of patients with torsion presenting in emergency departments with acute scrotum.

•Thepeak incidence occurs in adolescents aged 13 years.

•The left testis is more frequently involved.

•Bilateral cases account for 2 % of all testicular torsions.

–Extravaginal torsion (Figs. 26.6, 26.7, 26.8, 26.9, and 26.10)

•This much less common

•Extravaginal torsion comprises approximately 5 % of all testicular torsions.

•This type occurs exclusively in newborns

•The condition is most often a prenatal (in utero testicular torsion) event.

•It is associated with high birth weight.

•Up to 20 % of cases are synchronous, and 3 % are asynchronous bilateral.

•This type of torsion occurs outside of the tunica vaginalis, when the testis and gubernaculum can rotate freely.

•The torsion usually occurs intrauterine and rarely soon after birth

•It is usually unilateral but can also occur bilaterally.

•The newborns with this type of torsion usually present immediately after birth with scrotal swelling, and dark discoloration of the scrotum

•Clinically, the affected testis is usually firm and painless

•The scrotal skin characteristically fixes to the necrotic gonad.

•The affected testis is usually necrotic

•The treatment is orchidectomy and contralateral orchidopexy to obviate the risk of torsion on the other side

Fig. 26.6 A clinical photograph showing a newborn with intrauterine torsion of testis. Note that the patient is healthy and of good weight

26.6Effects of Testicular Torsion

•Torsion of the testes causes venous occlusion and engorgement as well as arterial obstruction and ischemia and subsequent infarction of the testis. The extent of this depends on two factors:

–The degree of torsion:

•Torsion of testis occurs as the testis and the cord rotate between 90° and 180°, compromising blood flow to and from the testis.