Testicular Torsion

Overview

Snapshot

• A 14-year-old boy is brought to the emergency room for an acute onset of testicular pain. The sharp pain started 2 hours ago on the right side of his scrotum. He also reports nausea and vomiting associated with the pain. Physical exam reveals the right scrotum to be erythematous and swollen. The cremasteric reflex is absent. He is immediately rushed into surgery for detorsion.

Introduction

• Clinical definition
  • twisting of spermatic cord that results in compromised blood flow and ischemia
    • this is considered a surgical emergency
• Epidemiology
  • demographics
    • neonatal
    • adolescent years
• Pathogenesis
• processus vaginalis (path as testes leaves abdomen with peritoneal lining) twists, causing decreased or absent blood flow to testis and epididymis

Presentation

• Symptoms 
  • primary symptoms
    • in adolescents
      • acute onset and severe pain in unilateral scrotum
      • nausea
      • vomiting
    • in neonates
      • blue and firm unilateral scrotal mass
• Physical exam
  • inspection
    • erythema and swelling
  • tenderness to palpation
• absent cremasteric reflex (L1-2 nerve root) 

Imaging

• Doppler ultrasound
  • indications
    • if testicular torsion is suspected but not confirmed with physical exam and history
  • findings
• decreased or absent blood flow

Differential

• Epididymitis
• positive cremasteric reflex

Treatment

• Operative
  • orchiopexy (bilateral)
    • indications
      • within 24 hours of disease onset
        • 4-8 hour window before there is permanent damage from ischemia
    • bilateral orchiopexy should be performed as contralateral testis is also at risk for future torsion
    • outcomes
      • 90-100% with viable testes if within 6 hours
      • 50% if within 12 hours
• < 10% if after 24 hours

Complications

• Testicular ischemia
• Infertility or subfertility