Testicular Torsion (for Teens) – Nemours KidsHealth

What Is Testicular Torsion?

Testicular torsion is an emergency condition. It happens when the spermatic cord, which provides blood flow to the testicle, rotates and becomes twisted. The twisting cuts off the testicle’s blood supply and causes sudden pain and swelling.

Testicular torsion requires surgery right away to save the testicle. Testicular torsion that goes on for more than a few hours can permanently damage the testicle, and a damaged testicle must be removed.

What Causes Testicular Torsion?

The scrotum is the sack of skin beneath the penis. Inside the scrotum are two testes, or testicles. Each testicle is connected to the rest of the body by a blood vessel called the spermatic cord. Testicular torsion happens when a spermatic cord becomes twisted, cutting off the flow of blood to the attached testicle.

Most cases of testicular torsion (also called testis torsion) affect guys who have a condition called a bell clapper deformity. In most males, the testicles are attached to the scrotum, making it hard for them to twist. In males who have the bell clapper deformity, the testicles are unsecured and can move and twist in the scrotum.

Testicular torsion can happen to boys and men of any age, but is most common in 12- to 18-year-olds. It can happen after strenuous exercise, while someone is sleeping, or after an injury to the scrotum. A lot of times, though, there is no apparent cause.

What Are the Signs & Symptoms of Testicular Torsion?

If you have a testicular torsion, chances are you’ll know it. You’ll feel a sudden, possibly severe pain in your scrotum and one of your testicles. The pain might increase and decrease but generally won’t go away completely. Other symptoms include:

• swelling, especially on one side of the scrotum
• nausea and vomiting
• belly pain
• one testicle appears to be higher than the other

What Should I Do?

If you have a sudden pain in your scrotum, call a doctor and get to a hospital or doctor’s office as soon as you can. Don’t eat or drink anything until you’ve seen a doctor and found out if you’ll need surgery. Testicular torsion is an emergency: When it happens, a guy needs surgery — fast. Saving the testicle becomes more difficult the longer the spermatic cord stays twisted.

 As a general rule:

• within about 4–6 hours of the start of the torsion, the testicle can be saved 90% of the time
• after 12 hours, this drops to 50%
• after 24 hours, the testicle can be saved only 10% of the time

Sometimes, the spermatic cord can become twisted and then untwist itself without treatment. This is called torsion and detorsion, and it can make testicular torsion more likely to happen again. If your spermatic cord untwists and the pain goes away, it might be easy to ignore it, but you should call the doctor anyway. They can check you out and take steps to make another testicular torsion unlikely.

Get Help Right Away

Talking to someone about your private parts might seem a little embarrassing. It’s really important, though, to tell a parent or contact a doctor if you have pain in your scrotum. Ignoring pain for too long or simply hoping it goes away can result in severe damage to your testicle and might lead to your testicle being removed.

Even if a pain in your scrotum goes away on its own, you still need to tell a parent or doctor. A torsion that goes away makes you more likely to have another one later. Doctors can greatly reduce your risk of another torsion by doing a simple surgical procedure that secures your testicles to your scrotum.

How Is Testicular Torsion Diagnosed?

When you arrive at the hospital or doctor’s office and describe your condition, the staff and doctors will assume you have a testicular torsion, even if the pain turns out to be something different.

A doctor will examine your scrotum, testicles, abdomen, and groin and might test your reflexes by rubbing or pinching the inside of your thigh. This normally causes the testicle to contract, which probably won’t happen if you have a testicular torsion.

The doctor also might do tests to see if the spermatic cord is twisted, including:

• Ultrasound. High-frequency (Doppler) waves are used to make an image of the testicle and check the blood flow.
• Urine tests or blood tests. These can find if the pain and symptoms are being caused by an infection instead of a torsion.

Sometimes, doctors will need to do surgery to be sure a problem is testicular torsion. A doctor may also do immediate surgery without any other testing in order to save the testicle. This is more likely if the torsion has been going on for a while or if the doctor suspects a guy has a torsion after examining him.

How Is Testicular Torsion Treated?

Testicular torsion almost always requires surgery to correct. In rare cases, the doctor might be able to untwist the spermatic cord by pushing on the scrotum, but most guys will still need surgery to attach both testicles to the scrotum to prevent torsion from happening again.

Usually, surgery for a testicular torsion doesn’t require a stay in the hospital. If you have a torsion, you’ll go into an operating room at the hospital or doctor’s office. You’ll most likely be given a painkiller and general anesthesia, meaning you’ll be asleep and not feel pain during the surgery.

A surgeon or urologist will make a small cut in the scrotum, untwist the spermatic cord, and stitch the testicles to the inside of the scrotum to prevent future torsions. Then, the doctor will stitch up the scrotum, and you’ll go to a room to recover for an hour or two.

The surgery to attach the testicles to the scrotum takes about 45 minutes. There may be some pain, but it shouldn’t be too bad. It’s much better than the torsion.

Sometimes, if the torsion goes on too long, doctors can’t save the affected testicle. They’ll need to remove it through a type of surgery called an orchiectomy (pronounced: or-kee-EK-teh-mee).

What Happens After Surgery?

Guys need to skip strenuous activities (like sports) and sex or sexual stimulation (like masturbation) for a few weeks after testicular torsion surgery. Talk to your doctor about when it will be safe to go back to your normal activities. 

Even if your torsion led to the loss of a testicle, you can still lead a normal life, just like anyone else. Most guys will still be able to father children later in life and have normal sexual relations with one working testicle. Many also opt for a prosthetic, or artificial, testicle a few months after surgery. This can help make some feel more comfortable about their appearance.

Testicular Torsion – StatPearls – NCBI Bookshelf

Continuing Education Activity

Scrotal complaints are relatively common both in primary care and in the emergency department and comprise at least 0.5 percent of all emergency department visits. Testicular torsion is a true urologic emergency, and early identification is critical to prevent the need for testicular amputation. Ultrasound is the ideal imaging modality to evaluate the scrotal contents. This activity will review the most common causes of testicular torsion, the common presenting signs and symptoms, and the treatment approach according to current evidence. This activity will highlight the role of the interprofessional team in recognizing and treating testicular torsion.

Objectives:

• Describe the epidemiology of testicular torsion.

• Outline the presenting signs and symptoms of testicular torsion.

• Summarize considerations that influence the management of testicular torsion.

• Explain how the facilitation of interprofessional team education and discussion can optimize the effective detection of testicular torsion and inform the need for subsequent evaluations.

Access free multiple choice questions on this topic.

Introduction

Scrotal complaints are relatively common in the emergency department, comprising at least 0.5% of all emergency department visits. Testicular torsion is a time-dependent diagnosis, a true urologic emergency, and early evaluation can assist in urologic intervention to prevent testicular loss. Ultrasound is the ideal imaging modality to evaluate the scrotal contents. [1][2][3] 

Testicular viability significantly decreases 6 hours after the onset of symptoms, hence early diagnosis is key. Testicular torsion is most common in young people, but rarely may be seen in older individuals. Surgery is the only treatment.

Etiology

The majority of cases occur in younger patients (< 25 years old) and are usually due to a congenital abnormality of the processus vaginalis. The history of onset may be spontaneous, exertional, or, in fewer instances, associated with trauma. Testicular torsion accounts for roughly one-quarter of scrotal complaints that present to the emergency department. [4]

Testicular torsion is caused by twisting of the blood supply and spermatic cord. The tunica vaginalis is usually solidly adhered to the posterolateral aspect of the testicle and within it, the spermatic cord is not mobile. If the attachment of the tunica vaginalis is high, then this allows for the spermatic cord to twist inside, leading to intravaginal torsion. This defect is referred to as the bell clapper deformity and is bilateral in at least 2/5th of cases.

On the other hand, neonates tend to develop extravaginal torsion. This occurs because the tunica vaginalis has not adhered to the gubernaculum and thus, both the tunica vaginalis and spermatic cord are prone to torsion. This pathology can occur weeks or months prior to birth and is treated in a different manner. However, it is important to know that neonates can also present with intravaginal torsion.

Testicular torsion has been known to occur in the presence of testicular malignancy in adults.

Epidemiology

The majority of cases occur in the adolescent age range (during periods of growth) but can occur at any age as well as pre- or perinatal. Testicular torsion is the most significant cause of testicular loss.

Pathophysiology

As the testicle twists around the spermatic cord, venous blood flow is cut off, leading to venous congestion and ischemia of the testicle. The testicle will become tender, swollen, and possibly erythematous. As the testicle further twists, the arterial blood supply is cut off which leads to further testicular ischemia and eventually necrosis. [5]

In most individuals, the testicle rotates between 90-180 degrees and compromised blood flow. Complete torsion is rare and quickly decreases the viability of the testes. Salvage is possible if the torsion is less than 8 hours but rare if more than 24 hours have elapsed.

History and Physical

Testicular torsion often presents as an abrupt onset of unilateral scrotal pain. The pain may be constant or intermittent, but not positional. The patient may have associated symptoms of nausea or vomiting. There may be associated lower abdominal and inguinal pain, or alternatively, these may be the presenting complaint rather than scrotal pain. 

The testicle may be in an abnormal or transverse lie and maybe in a high position. The testicle may be swollen, erythematous, and have an absence of the normal cremasteric reflex; however, it should be noted that the presence or absence of the cremasteric reflex is not as sensitive as once thought. Additionally, the cremasteric reflex is unreliable in young patients, especially those less than one year old. 

The Prehn sign is not reliable for predicting torsion (relief of pain with testicle elevation).

Torsion of the testicular appendages is more common and not dangerous. During early-onset, this may be differentiated from testicular torsion by maximal tenderness to palpation near the head of the epididymis or testis, an isolated tender nodule, and/or a blue dot appearance on the testis. The characteristic blue dot is due to the cyanotic torsed appendage.  The testicular appendage tends to calcify and degenerate over two weeks, and typically no surgical intervention is required. 

Other differential diagnoses to be considered are epididymitis, orchitis, inguinal hernia, symptomatic hydrocele, testicular necrosis of other etiology, and scrotal hematoma. 

Evaluation

The TWIST scoring system is often used to determine the presence of testicular torsion. It has been validated in several studies in ruling out torsion. The TWIST tool includes:

Hard testis – 2

Swelling – 2

Nausea/vomiting – 1

Absent cremasteric reflex – 1

High riding testis – 1

The higher the score, the greater the probability that the patient has torsion. Ultrasound is recommended for those with low scores. Those with high TWIST scores can be taken for surgery without ultrasound.

Ultrasound is the primary diagnostic modality beyond the physical exam. Ultrasound for testicular torsion is approximately 93% sensitive and 100% specific. Trained sonographers should perform this exam in a timely manner. The point-of-care ultrasound technique to evaluate the testicle involves the high-frequency transducer (5 to 10 MHz), ample ultrasound gel, and proper patient positioning. The process is described in brief below: 

1. Place the patient supine and frog-legged with a towel under the scrotum for support. Using ample gel and minimal pressure, evaluate the unaffected testicle first.  

2. Scan the testicle in its entirety in both the transverse and longitudinal planes. Scan with grayscale first while noting the presence of fluid collections and testicular texture. A normal testicular is around 4 x 3 x 2.5cm. In the longitudinal plan or long axis, the testicle appears as an oval structure with homogenous echotexture and smooth rounded borders. In the transverse plane or short axis, the testicle appears as a circular structure with homogenous echotexture and smooth rounded borders. Side-by-side comparison of the testicles is critical to evaluate for size, fluid collections, changes of echotexture, and discrepancies of color Doppler. If the testicle is torsed, there will often be a hydrocele present with a testicle with reduced color or power flow.

Color flow doppler must be applied to both the affected and unaffected testicle of the patient. Begin with the unaffected testicle to gain a sense of what normal vascular flow looks like in this particular patient. Power Doppler is useful in the evaluation of testicular vascular flow as well. Power Doppler has greater sensitivity for vascular flow but does not allow the examiner to discern between the arterial and venous flow.  

Doppler can be employed to evaluate for both venous and arterial flow by placing the Doppler gate on areas of vascular flow and evaluating for both venous and arterial Doppler waveforms. Arterial waveforms will have large spikes due to the peaks of arterial blood pressure whereas venous waveforms appear typically as plateaus of Doppler flow. Applying Doppler and checking for both venous and arterial flow can further demonstrate the severity of the torsion.  The same technique will be employed on the affected testicle. 

Assessment for pyuria with urine analysis is typically part of the acute scrotal pain workup. The presence of pyuria is consistent with epididymitis, orchitis, or urinary tract infection but does not rule out the possibility of testicular torsion.  [6][7]

Treatment / Management

Ultrasound is not a perfect test for testicular torsion, especially in the very young. For example, 40% of neonatal testicles may have no apparent color flow doppler. If the clinical concern is high, seek urologic surgery consultation immediately. Any delay in treatment could result in testicular necrosis and loss. The typical window of opportunity for surgical intervention and testicular salvage is 6 hours from the onset of pain. Therefore, early urologic surgery consultation upon presentation may be critical even in the absence of confirmatory testing. 

Manual detorsion should be attempted if urological intervention is not immediately available. The abnormal testicle should be rotated in a medial to lateral direction (open book) 180 degrees and then evaluated for pain relief. If the pain is increased, consider rotating the testicle in the opposite direction. Ultrasound also can be used serially to evaluate for return of blood flow at the bedside. If unsuccessful, further manual detorsion may be attempted as the testicle can twist 180 degrees.[5][8][9]

In neonates, bilateral scrotal exploration is done. Contralateral orchiopexy is always done to prevent future torsion. Patients who require an orchiectomy for a non-viable testis usually have a testicular prosthesis inserted. The prosthesis is usually inserted 4-6 months after the initial surgery to allow for the inflammation to subside

Differential Diagnosis

• Testis tumor

• Epididymitis

• Hydrocele

• Traumatic hematoma

• Orchitis

Prognosis

Over the years there has been a marked improvement in the salvage of the testes following torsion However, poor results still occur especially in African Americans, young patients, and those who lack health insurance. The best results are obtained if the surgery is done within 8 hours of symptoms. However, recurrence can also occur after orchiopexy.

Complications

Pearls and Other Issues

Ultrasound is a sensitive and specific test for the evaluation of testicular torsion. Early urology involvement is crucial to avoid testicular loss. The use of color flow is essential in the evaluation of testicular torsion.  

Enhancing Healthcare Team Outcomes

Testicular torsion is a surgical emergency that almost always presents to the emergency department. The disorder is usually managed by an interprofessional team.

The first person to encounter the patient is the triage nurse who must be familiar with the symptoms of the disorder. Time is of the essence and the nurse should be aware of torsion and quickly admit the patient and quickly notify the ED physician. The ED physician should consult with a radiologist for the appropriate test and at the same time consult with the urologist. The nurses should prepare the patient as if he will be going for surgery by keeping the child NPO and having all the blood work completed.

IF the testing confirms torsion, the urologist is usually required to perform the surgery. The nurse should educate the family and the patient about the potential complications, including loss of the testis and infertility. The nurse should ensure that the patient is administered no food or drink by mouth and have the patient prepared to go for urgent surgery. More importantly, the nurse should avoid giving any pain medications until the patient has been seen by the urologist- or the pain medication will mask the symptoms and delay the diagnosis. Only through a systemic approach to diagnosis and treatment, is the salvage of the testis a possibility.[10][11] Open communication between the team members is vital is the outcomes are to be improved. [Level 5]

Outcomes

The outcomes of testicular torsion depend on when the patient presents to the ED and how quickly the diagnosis is made and treatment is undertaken. Delays in diagnosis and treatment always lead to testicular atrophy. About 20-40% of cases of testicular torsion result in an orchiectomy. The risk of losing a testis is much higher among African Americans and younger males. For those who present within the first 6 hours of symptoms, the salvage rate is nearly 100% but this number quickly drops to less than 50% if the delay in seeking help is more than 12-24 hours. More importantly, when the testis is fixed by orchiopexy, there is also a potential for future torsion.[12][4] [Level 5]

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Figure

Side by side comparison of testicles with power doppler. Testicular necrosis in the setting of testicular torsion. Contributed by Michael Schick DO, MA

References

1.

Monteilh C, Calixte R, Burjonrappa S. Controversies in the management of neonatal testicular torsion: A meta-analysis. J Pediatr Surg. 2019 Apr;54(4):815-819. [PubMed: 30098810]

2.

Osumah TS, Jimbo M, Granberg CF, Gargollo PC. Frontiers in pediatric testicular torsion: An integrated review of prevailing trends and management outcomes. J Pediatr Urol. 2018 Oct;14(5):394-401. [PubMed: 30087037]

3.

Velasquez J, Boniface MP, Mohseni M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jan 1, 2023. Acute Scrotum Pain. [PubMed: 29262236]

4.

Naouar S, Braiek S, El Kamel R. Testicular torsion in undescended testis: A persistent challenge. Asian J Urol. 2017 Apr;4(2):111-115. [PMC free article: PMC5717970] [PubMed: 29264215]

5.

Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatr Emerg Care. 2019 Dec;35(12):821-825. [PubMed: 28953100]

6.

Mellick LB, Mowery ML, Al-Dhahir MA. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jun 27, 2022. Cremasteric Reflex. [PubMed: 30020720]

7.

Bandarkar AN, Blask AR. Testicular torsion with preserved flow: key sonographic features and value-added approach to diagnosis. Pediatr Radiol. 2018 May;48(5):735-744. [PMC free article: PMC5895684] [PubMed: 29468365]

8.

Friedman AA, Palmer LS, Maizels M, Bittman ME, Avarello JT. Pediatric acute scrotal pain: A guide to patient assessment and triage. J Pediatr Urol. 2016 Apr;12(2):72-5. [PubMed: 27036070]

9.

Fantasia J, Aidlen J, Lathrop W, Ellsworth P. Undescended Testes: A Clinical and Surgical Review. Urol Nurs. 2015 May-Jun;35(3):117-26. [PubMed: 26298946]

10.

Tydeman C, Davenport K, Glancy D. Suspected testicular torsion – urological or general surgical emergency? Ann R Coll Surg Engl. 2010 Nov;92(8):710-2. [PMC free article: PMC3229386] [PubMed: 21047450]

11.

Murár E, Omaník P, Funáková M, Béder I, Horn F. [Acute scrotum is a condition requiring surgical intervention]. Rozhl Chir. 2008 Oct;87(10):517-20. [PubMed: 19110944]

12.

Howe AS, Vasudevan V, Kongnyuy M, Rychik K, Thomas LA, Matuskova M, Friedman SC, Gitlin JS, Reda EF, Palmer LS. Degree of twisting and duration of symptoms are prognostic factors of testis salvage during episodes of testicular torsion. Transl Androl Urol. 2017 Dec;6(6):1159-1166. [PMC free article: PMC5760391] [PubMed: 29354505]

Disclosure: Michael Schick declares no relevant financial relationships with ineligible companies.

Disclosure: Britni Sternard declares no relevant financial relationships with ineligible companies.

Testicular torsion. Cause, diagnosis, treatment

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Testicular torsion (testicular torsion, spermatic cord torsion) is an abnormal torsion of the spermatic cord caused by turning the testicle or mesorchium (folds between the testicle and its epididymis), which leads to infringement or necrosis of testicular tissue.

Causes of testicular torsion can be scrotal trauma, sudden movements, abdominal tension, which lead to a reflex contraction of the muscle that lifts the testicle. The absence of a normal attachment of the testicle to the bottom of the wicket – an anomaly that occurs during the period of attachment of the epididymis to the testicle, leads to a violation of mutual fixation, which entails the separation of these two formations.

As a result, there is a rotation of the testicle around the vertical axis. If the turn of the testicle together with the spermatic cord exceeds 180 °, the blood circulation in the testicle is disturbed, numerous hemorrhages are formed, thrombosis of the veins of the spermatic cord occurs, serous-hemorrhagic transudate in the cavity of the testicle proper, swelling of the skin of the scrotum develops.

Clinical picture.

The onset of the disease is acute: there is pain in the testicle and the corresponding half of the scrotum with irradiation to the groin, sometimes nausea, vomiting, collaptoid state. Clinical signs depend on the duration of the disease, the age of the patient and the location of the testis.

A painful tumor-like mass appears at the inguinal ring or in the upper third of the scrotum; in the future, the twisted testicle becomes pulled up and when you try to raise it even higher, the pain intensifies, in the following days there is swelling and hyperemia of the scrotum, due to a violation of the lymphatic drainage, a secondary hydrocele is formed.

Diagnostics.

Based on the clinical manifestations of the disease and the data of auxiliary instrumental methods of examination.

Doppler ultrasound: the architectonics of the testicle and its epididymis is well visualized and blood flow disorders in the testicle are revealed (blood flow decreases and even completely stops during torsion).

Treatment.

External manual testicular detorsion In 2-3% of patients, the distortion can be eliminated in the first hours of the disease by performing external manual detorsion.

Surgical treatment of edematous scrotum syndrome. Urgent surgery is needed, because the testicle is very sensitive to ischemia and can quickly die (irreversible changes occur after 6 hours).

Urologist: Vistovsky O. P.

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Testicular torsion. What is testicular torsion?

IMPORTANT
The information in this section should not be used for self-diagnosis or self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

Testicular torsion is a torsion of the spermatic cord, leading to the infringement of its constituent elements and disruption of the blood supply to the testicle. Testicular torsion is accompanied by a sudden acute pain syndrome, nausea, vomiting, collapse; local symptoms – unilateral swelling, hyperemia or blanching of the scrotum. For diagnostic purposes, if testicular torsion is suspected, diaphanoscopy, ultrasound and ultrasound of the vessels of the scrotum organs, and puncture of the testicular membranes are performed. In the first hours, external manual untwisting of the testicle can be undertaken to eliminate testicular torsion; in other cases, surgery is indicated. When a testicle necrosis occurs, it is removed (orchiectomy).

• Causes of testicular torsion
  • Testicular torsion classification
• Testicular torsion symptoms
• Diagnosis of testicular torsion
• Testicular torsion treatment
  • Prognosis and prevention of testicular torsion
• Prices for treatment

General

Testicular torsion – rotation, twisting of the spermatic cord around a vertical axis, accompanied by ischemia, and in severe cases – testicular necrosis. The spermatic cord is an anatomical formation, which includes the vas deferens, testicular arteries and veins, lymphatic vessels and nerves, surrounded by membranes of the spermatic cord. When the testicle is twisted, a sudden sharp violation of the blood supply to the testicle develops, which in a matter of hours can lead to its irreversible damage and even death. These circumstances make it possible to attribute testicular torsion to the category of emergency conditions encountered in clinical urology and andrology. Testicular torsion occurs in 1 in 4,000 males or 1 in 500 urological patients. Most often, the pathology develops in adolescent children aged 10-16 years, but it can also occur in newborn children and adult men.

Testicular torsion

Causes of testicular torsion

A prerequisite for testicular torsion is its excessive mobility, due to the lack of normal attachment of the organ to the bottom of the scrotum. A number of anatomical and topographical features that occur in some men can contribute to increased testicular displacement: aplasia or hypoplasia of the testicular guiding ligament, congenital elongation of the spermatic cord, testicular inversion, inguinal-scrotal hernia, separation of the elements of the spermatic cord (neurovascular bundle and vas deferens), and etc. A testicle that has not descended into the scrotum (with cryptorchidism) can be subjected to torsion. In children, testicular torsion is often associated with prematurity, morphological and functional immaturity of the reproductive system, and disproportionate growth of the genital organs.

The immediate factors provoking testicular torsion are usually scrotum injuries, active movements, outdoor games, physical activity, increased intra-abdominal pressure, wearing tight underwear and clothing, sexual intercourse, as well as other moments that entail a cremasteric reflex – contraction of the muscle that lifts the testicle . Torsion of the spermatic cord is accompanied by the rotation of the testicle around its vertical axis. When the testicle is rotated more than 180 °, a sharp violation of blood circulation in the gonad develops, thrombosis of the veins of the spermatic cord occurs, serous-hemorrhagic transudate accumulates in the cavity of the testicle proper – a secondary hydrocele develops.

Classification of testicular torsion

More often, testicular torsion is unilateral; Bilateral pathology is diagnosed extremely rarely. According to the mechanism of development, extravaginal and intravaginal testicular torsion is distinguished. With extravaginal (supra-thecal) torsion of the testicle, the twisting of the spermatic cord occurs together with its membranes. This form of pathology is usually observed in children under 1 year of age and is associated with the morphological immaturity of the structures of the spermatic cord, hypertonicity of the cremaster muscle, a short and wide inguinal canal, friability of the fusion of the membranes, etc.

In the case of intravaginal (intrathecal) testicular torsion, the spermatic cord twists inside its own vaginal membrane. This variant of testicular torsion is typical for children older than 3 years and adults. The mechanism of intravaginal testicular torsion is as follows. With a reflex contraction of the cremaster muscle, the testicle is pulled up and begins to make a rotational movement. The longer the mesentery of the testicle, the higher its mobility, and the stronger the force of muscle contraction and the greater the mass of the testis, the more pronounced the degree of testicular torsion.

Symptoms of testicular torsion

The earliest signal indicating a completed testicular torsion is an acute, sharp and sudden pain in the scrotum, which radiates to the inguinal region and perineum. The pain syndrome is so pronounced that it is accompanied by reflex nausea, vomiting, severe arterial hypotension (collapse). An exception to the general rule are cases of testicular torsion in newborns, which are painless and are usually detected on the basis of an increase in one half of the scrotum.

Local changes in testicular torsion include flushing (cyanosis) or blanching of the skin of the scrotum, its increased sensitivity to touch. Due to the development of dropsy of the testicular membranes, the scrotum looks swollen and edematous. A twisted testicle is located much higher than its normal location and higher than the second testicle. Possible dyspeptic disorders, frequent and painful urination, acute urinary retention, subfebrile condition.

In some cases, torsion of the hydatid (suspension, appendix) of the testicle, a rudimentary formation located in the region of the upper pole of the testicle, may be observed. The symptoms of testicular hydatid torsion are generally similar to those of testicular torsion, with the exception of more limited edema and scrotal hyperemia. Hydatid necrosis can cause purulent fusion of the scrotum tissues and cause its amputation.

Testicular torsion can result in atrophy of the spermatogenic epithelium and male infertility. Irreversible changes in the tissues of the testis can develop as early as 6 hours after the torsion of the spermatic cord, so this condition requires immediate contact with a specialist – a urologist, andrologist or surgeon.

Testicular torsion diagnostics

On examination and palpation, swelling and hyperemia of the scrotum is determined, pulled up to the external inguinal ring and an inactive testicle on the side of torsion; the consistency of the testicle is tight-elastic, the spermatic cord is thickened. An attempt to raise the testicle even higher causes increased pain (Pren’s symptom). Additional examinations that can reliably determine testicular torsion include diaphanoscopy, ultrasound of the scrotum and ultrasound of the scrotal vessels. An echographic sign indicating the viability of the testicle is the unchanged echo density of the organ; testicles with reduced or heterogeneous echogenicity are usually not viable.

Diagnostic puncture of the scrotum allows you to determine the nature of the contents of the membranes (exudate, blood, pus). Differential diagnosis of testicular torsion is carried out with inflammatory diseases of the scrotum (orchitis and epididymitis), hydrocele, angioedema.

Testicular torsion treatment

Treatment for testicular torsion should be started as soon as the diagnosis is made. In the first hours after the development of the disease, a conservative solution to the problem is possible with the help of external manual detorsion (untwisting) of the testicle. Testicular detorsion is performed with the patient lying on his back; at the same time, the scrotal tissue is grasped with the hand along with the testicle and rotated 180 ° in the direction opposite to the median suture of the scrotum, with simultaneous slight downward traction of the testicle. This manipulation is performed several times. Indicators of successful elimination of testicular torsion are a significant reduction or disappearance of pain in the scrotum, the mobility of the testicle and the occupation of its usual place in the scrotum. If several attempts at external detorsion fail, conservative tactics should be abandoned and surgical treatment of testicular torsion should be performed.

The operation for torsion of the spermatic cord is performed through the inguinal (with extravaginal form) or scrotal (with intravaginal testicular torsion) access. During surgery, the most critical step is the correct assessment of the viability of the testicle after its intraoperative detorsion. If, after the restoration of blood circulation, the testicle acquires a normal color, the testicle is repositioned and fixed to the tissues of the scrotum. When diagnosing testicular necrosis, its removal is indicated – orchiectomy, followed by implantation of an artificial testicle to correct a cosmetic defect. If, during the revision of the scrotum, torsion of the testicular hydatid is detected, its leg is bandaged at the base, after which the hydatid is cut off and removed. In the postoperative period, novocaine blockades of the spermatic cord, physiotherapy, drug therapy are carried out, aimed at improving microcirculation in the damaged organ.

Prognosis and prevention of testicular torsion

Only in 2-3% of patients, testicular torsion can be eliminated conservatively, in other cases, surgical intervention is inevitable.