Definition
A.Testicular torsion is twisting of the testicle around the vas deferens, with compromise in the blood supply and possible necrosis to the testicles. Testicular torsion is a urologic emergency and is the most frequent cause of testicle loss in the adolescent male population. Approximately 40% of all cases of acute scrotal pain and swelling are diagnosed with testicular torsion. There is often a history of recurrent episodes of testicular pain before torsion.
B.Testicular torsion is most commonly misdiagnosed as epididymitis:
1.Epididymitis usually presents with gradual onset of pain that is localized posterior to the testis that gradually radiates to the lower abdomen.
2.These symptoms are rare with torsion.
Incidence
A.Incidence in males younger than 25 years old is approximately 1 in 4,000. Although torsion can occur at any age, the largest number of cases occur during adolescence.
B.The bell clapper congenital anomaly is present in approximately 12% of males, and 40% have the abnormality in the contralateral testicle.
Pathogenesis
A.Testicular torsion and torsion of the spermatic cord are caused by abnormal fixation of the testicle to the scrotum, allowing free rotation. The bell clapper deformity allows the testicle to twist spontaneously on the spermatic cord. Venous occlusion and engorgement cause arterial ischemia and infarction of the testicle.
Predisposing Factors
A.Age: More common in adolescence.
B.Trauma to testicle.
C.Spontaneous occurrence.
D.Congenital bell clapper anomaly.
E.Exercise.
F.Undescended testicle.
G.Active cremasteric reflex.
Common Complaints
A.Sudden onset of severe unilateral scrotal pain (less than 24 hours).
B.Swelling of scrotal sac.
C.High position of the testicle.
D.Abnormal cremasteric reflex.
Other Signs and Symptoms
A.Sudden onset of testicular pain, which may radiate to groin.
B.Possible edema.
C.Abdominal pain (20%–30%).
D.Nausea and vomiting (50% of cases).
E.Fever (16%).
F.Urinary frequency (4%).
Subjective Data
A.Review the onset, duration, and course of symptoms.
B.Review for a history of prior episodes of intermittent testicular pain that resolved spontaneously.
C.Review abdominal symptoms such as pain, nausea and vomiting, and fever.
D.Review urethral discharge (possible sexually transmitted infection [STI]) and dysuria.
E.Review the patient’s history for trauma to the scrotum or testicle.
Physical Examination
A.Check temperature (if infection is suspected), blood pressure (BP), pulse, and respirations.
B.Inspect:
1.Observe the patient generally for pain before and during examination.
2.Visualize the scrotal sac for edema, symmetry, lesions, discharge, and color (especially for blue dot superior to the affected testicle). Testis is located high in the scrotum as a result of shortening of the cord by twisting.
3.Check the inguinal and femoral areas for bulges and hernias.
C.Auscultate:
1.Auscultate all four quadrants of the abdomen; note bowel sounds.
2.Assess the scrotum for bowel noise.
D.Palpate:
1.Palpate the abdomen for masses, rebound, and tenderness or guarding.
2.Palpate the groin; check the lymph nodes.
3.Examine for an inguinal hernia.
4.Genital exam:
a.Check warmth, tenderness, swelling, and any nodularity; if a mass is present, check if it is solid or cystic. The testes should be sensitive to gentle compression but not tender. They should feel smooth, rubbery, and free of nodules.
b.Elicit a cremasteric reflex by stroking the inner thigh with a blunt object (reflex hammer or ink pen). The testicle and scrotum should rise on the stroked side. Cremasteric reflex is usually absent in testicular torsion.
c.Elevate the scrotum; there is usually no relief in pain with torsion. Elevation of the scrotum may improve the pain of epididymitis (Prehn’s sign).
Diagnostic Tests
A.Urinalysis: Normal in 90% of cases of testicular torsion.
B.Doppler ultrasonography for blood flow and scrotal ultrasonography.
Differential Diagnoses
A.Testicular torsion: Firm, tender mass of acute onset in an afebrile young man with a history of prior episodes must be considered to represent torsion until proven otherwise.
B.Epididymitis.
C.Orchitis.
D.Hydrocele.
E.Testicular tumor: Usually a hard, enlarged, painless testicle.
F.Acute appendicitis.
G.Scrotal/testicular trauma.
H.Varicocele.
Plan
A.Immediately refer the patient to a urologist and/or emergency room.
B.Symptoms lasting more than 6 hours can indicate testicular necrosis.
C.The opposite testicle is usually stabilized during the same surgery.
Pharmaceutical Therapy
None.
Follow-Up
A.Patient should follow up with the urologist as directed.
Emergent Issues/Instructions
A.Testicular torsion is a urologic emergency requiring surgery. Instruct the patient to go to the emergency department.
Consultation/Referral
A.All patients with suspected testicular torsion need to be immediately evaluated by a physician and referred to a urologist. Testicular torsion may result in an infarction within 6 hours.
Individual Considerations
A.Geriatrics: In older males, rule out epididymitis, especially with new sexual partners or with symptoms of dysuria and urethral discharge. (Refer to section Epididymitis
.)