EXTRAVAGINAL

TORSION

•Complete testicular torsion usually occurs when the testis twists 360° or more.

•Incomplete or partial torsion occurs with lesser degrees of rotation.

•In some cases, the degree of testicular torsion may extend to 720°.

–The duration of torsion:

•The duration of testicular torsion is the most important factor that prominently influences the salvage rates of the affected testis and late testicular atrophy.

•Testicular salvage is most likely if the duration of torsion is less than 6 h.

•If 24 h or more elapse, testicular necrosis develops in most patients.

The Duration of Torsion and Testicular

Salvage Rate

•<6 h: 90–100 %

•12–24 h: 20–50 %

•>24 h: 0–10 %

•The decreased fertility observed in patients who developed only unilateral torsion of the spermatic cord, was based on an inherent bilateral testicular abnormalities or an autoimmune mechanism affecting the contralateral testis. This hypothesis however was not supported.

26.7Clinical Features

•Although testicular torsion can occur at any age, including the prenatal and perinatal periods, it most commonly occurs in adolescent males.

•Testicular torsion is commonly observed in males younger than 30 years, with a peak at 12–18 years.

•The incidence of testicular torsion in males younger than 25 years is approximately 1 in 4,000.

•Testicular torsion more often involves the left testicle.

•Testicular torsion can occur suddenly, with physical activity or may develop during sleep.

•Torsion can occur:

–Spontaneously

–During sports or physical activity

–In relation to trauma in 4–8 % of cases

–During sleep

•This is an acute emergency and the patient usually present with:

–The classic presentation of testicular torsion is the sudden onset of severe testicular pain followed by inguinal and/or scrotal swelling.

–Gradual onset of pain is an uncommon presentation of testicular torsion.

–The pain may lessen as the necrosis becomes more complete.

–This may be associated with groin and lower abdominal pain and tenderness

–In time, a reactive hydrocele, scrotal wall erythema, and ecchymosis become more striking.

–Scrotal pain that is referred to the lower abdomen may be perceived as not being of scrotal or testicular origin which is one of the causes of delay in seeking early medical advice. Any adolescent boy who complains of lower abdominal pain should also undergo examination of the external genitalia to rule out the possibility of scrotal or testicular pathology.

–The pain is often associated nausea and vomiting. Approximately one third of patients also have gastrointestinal upset with nausea and vomiting.

–In the pediatric age group, nausea and vomiting has a positive predictive value of greater than 96 %.

–Patients rarely report voiding difficulties or painful micturation.

–In some patients, scrotal trauma or other scrotal disease (including torsion of appendix testis or epididymitis) may precede the occurrence of subsequent testicular torsion.

–Patients may describe previous episodes of recurrent acute scrotal pain that has resolved spontaneously. This history is highly suggestive of intermittent torsion and detorsion of the testis.

–Acute testicular torsion developed in 10 % of patients with intermittent torsion while they waited for surgery.

–Clinically, the affected testis will be swollen, and markedly tender

–The affected testis lies high up from its normal position usually with an abnormal transverse lie

–There may be redness of the affected scrotum

–There may be an associated mild fever

•Physical examination may reveal:

–A swollen, tender, high-riding testis.

–Abnormal transverse lie of testis.

–Loss of the cremasteric reflex.

–Edema involving the entire scrotum.

–Enlargement and edema of the testis.

Fig. 26.11 A clinical photograph showing severe epididymo-orchitis with intra-scrotal abscess formation in

achild

–Fever is uncommon.

–Scrotal erythema.

•The cremasteric reflex is almost always absent or diminished on the affected side in patients with testicular torsion. Normally, pinching the inside of the thigh causes the testicles to contract and move up. This reflux may disappear on the affected side

•Prehn’s sign: Relief of pain with elevation of the testis. This is a classic physical examination sign but it is not reliable in distinguishing testicular torsion from other causes of acute scrotal pain.

•Although a negative Prehn sign is classically thought to be a predictor of torsion, this is unreliable for diagnosis.

• The most confusing condition with torsion of testis is epididymo-orchitis. In epididymo-orchitis:

–There is marked redness and swelling of the affected testis

–The patient is often febrile

–The cremasteric reflux is usually present

•Epididymitis, orchitis, epididymo-orchitis (Fig. 26.11):

–These conditions most commonly occur from the reflux of infected urine or from sexually acquired disease caused by gonococci and Chlamydia.

–The patients occasionally develop these conditions following excessive straining or lifting and the reflux of urine (chemical epididymitis).

–These conditions may be secondary to an underlying congenital, acquired, structural, or urologic abnormality and are often accompanied by systemic signs and symptoms associated with urinary tract infection. These include:

•Pyuria

•Bacteriuria

•Leucocytosis

–A complete urological evaluation (ie, renal sonography, urodynamic study) is necessary in prepubertal boys with acute epididymitis.

•In an acute developing hydrocele:

–The swelling is usually painless but there may be some discomfort

–The scrotal contents can be visualized with transillumination

–Incarcerated hernia if suspected may be diagnosed by careful examination of the inguinal canal

•In idiopathic scrotal edema:

–In idiopathic scrotal edema, the scrotal skin is thickened, edematous, and often inflamed.

–The testis is not tender and is of normal size and position.

•Factors predictive of testicular torsion include:

–Acute onset of pain.

–Duration of pain of less than 6 h.

–Fever, nausea and vomiting.

–History of trauma or activities.

–Absence of cremasteric reflex.

–Abnormal transverse direction of testis.

26.8Treatment

•Testicular torsion is an acute surgical emergency and with early diagnosis and prompt treatment the testicle can often be saved.

•The aim is to restore the blood flow to the affected testis as early as possible.

•It has been estimated that about 40 % of testicular torsion cases result in loss of the testicle.

•The success of salvaging the affected testis is time dependent:

–If the affected testis is treated either manually or surgically within 6 h, there is a high chance (approx. 90 %) of saving the testicle.

–If the affected testis is treated at around 12 h from the onset, the success rate of salvaging the testis decreases to 50 %.

–If the affected testis is treated about 24 h from the onset, the success rate of salvaging the testis drops to 10 %.

–If the affected testis is treated after 24 h from the onset, the ability to save the testicle approaches 0.

•Typically when testicular torsion occur, the testis rotates towards the midline of the body.

•Non-surgical correction of testicular torsion (manual detorsion):

–This can sometimes be accomplished by manually rotating the testicle in the opposite direction (i.e., outward, towards the thigh). Rotate the testis in medial to lateral direction.

–This maneuver can be attempted while waiting for proper surgical exploration but no further time should be wasted.

–This is usually difficult because of acute pain during manipulation.

–The procedure for manual detorsion of the testis is similar to the “opening of a book” when the physician is standing at the patient’s feet.

–Most torsions twist inward and toward the midline (anti-clock wise rotation); thus, manual detorsion of the testicle involves twisting outward and laterally (anti-clock wise).

–Torsion closes the book and manual detorsion opens the book.

–Lateral rotation has been described in up to a third of testicular torsions, however, and in such cases further lateral rotation will worsen the condition.

–For manual detorsion in a suspected torsion of the right testicle, the physician is positioned in front of the standing or supine patient and holds the patient’s right testicle with the left thumb and forefinger. The physician then rotates the right testicle outward 180° in a medial-to-lateral direction.

–For the patient’s left testicle torsion, the physician uses the right thumb and forefinger and rotates the patient’s left testicle in an outward direction 180° from medial to lateral.

–Rotation of the testicle may need to be repeated two to three times for complete detorsion.

–Pain relief serves as a guide to successful detorsion, but restoration of blood flow using Doppler ultrasound must be confirmed following the maneuver.

–Other signs suggestive of successful manual detorsion include:

•Resolution of the transverse lie of the testis to a longitudinal orientation

•Lower position of the testis in the scrotum

•Return of normal arterial pulsations detected with a Doppler ultrasound

–Manual detorsion of the affected testicle is not recommended if the duration of torsion is longer than 6 h.

–Following successful manual detorsion, elective bilateral orchidopexy is recommended, to prevent recurrent torsion and protect the contralateral side from torsion.

–The success rate of manual detorsion is variable ranging from 26.5 % to more than 80 %.

–It must be remembered that nonoperative manual detorsion is not a substitute for surgical exploration.

–If manual detorsion is successful (confirmed by color Doppler ultrasound in a patient with complete resolution of symptoms), the patient should undergo definitive surgical fixation of the testes before leaving the hospital, so that the operation can be performed as an urgent rather than emergency procedure.

–A bilateral scrotal orchidopexy is often recommended to treat the torsed testis and prevent torsion of the other testis.

•The treatment of testicular torsion is emergency surgical exploration (surgical detorsion).

–This done through a scrotal approach.

–If the testis is found viable, it should be fixed (orchidopexy) and contralateral orchidopexy should be done at the same time.

–If the testis is found necrotic, orchidectomy should be done and contralateral orchidopexy is done at the same time.

•Patients requiring an orchiectomy because of a nonviable testis may benefit from the placement of a testicular prosthesis.

–Delay performing this procedure, usually for 6 months, until healing is complete and inflammatory changes resolve.

–Perform the prosthetic placement through an inguinal incision.

•Recent studies show that exocrine and endocrine function is subnormal in men with a history of unilateral torsion.

•This is based on the following three theories which explain the contralateral disease noted in patients with testicular torsion:

–Unrecognized repeated injury to both testes

–Preexisting pathologic condition predisposing to both abnormal spermatogenesis and torsion of the spermatic cord

–Induction of pathologic changes in the contralateral testis by retention of the injured testis (autoimmune)

–To explain the decreased fertility observed in unilateral torsion of the spermatic cord, several theories suggest an autoimmune mechanism. This hypothesis is based upon the following:

•Knowledge of the blood-testis barrier, which isolates the luminal compartment of the seminiferous tubule

•Inducing experimental allergic orchitis

•The contralateral testicular disease resembles sympathetic ophthalmia, a cell-mediated immune response