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Affects 1 in 4,000 young men. Torsion is most common in adolescent males. However, older men and infant boys can also be affected. Testicular torsion is an emergency that untreated leads to infarction of the testis

About

• Commonest in boys and young men seen in 1 in 4000 but all ages vulnerable
• A surgical emergency - delay can lead to infertility
• The testis will infarct and atrophy
• Admit under Paediatric Surgery or Urology

Risks

• There is an x10 fold increased incidence with cryptorchidism
• Weaker connective tissue in the scrotum. Called a bell clapper deformity.
• Occurs after an injury to the groin.
• Rapid growth during puberty may also cause the condition.

Aetiology

• Predisposed to tort due to high attachment of the tunica vaginalis.
• Testis rotates which twists the vessels in the spermatic cord
• There is loss of venous drainage and infarction results

Clinical

• Nausea, vomiting, Sudden, severe, one-sided testicular pain
• High riding tender testis, testicular pain, red and swelling.
• Haematospermia may occur

Investigations

• FBC, U&E. CRP.
• Urine tests, which look for infection
• Doppler ultrasound is justifiable if the clinical picture is doubtful and an experienced radiologist is available. The presence of arterial flow on colour Doppler in this scenario can rule out torsion with an accuracy of 97 per cent. USS will also help identify a testicular mass.

Differentials

• Trauma, hernia, hydrocele and testicular tumour .
• Vasculitis due to Henoch-Schönlein purpura may also present as an acute scrotum

Management

• Urgent admission, analgesia, Start IV fluids prior to surgery.Although occasionally reported, testicular survival after eight hours of torsion is extremely unlikely. If there is any doubt regarding its viability, orchidectomy should be performed. Anti-sperm antibodies may form if a non-viable testis or one of doubtful viability is left within the scrotum and consequently the fertility of the remaining testis may be compromised.
• Surgical exploration to relieve the torsion by manual detorsion of the spermatic cord as delay can lead to infarction of the testis and infertility. The vascular supply must be restored within 6 hours. The affected testicle will be untwisted and then sutures placed around both testicles to prevent future torsion. As the defect is usually bilateral the unaffected testis is normally treated to prevent future torsion.

References

• Testicular torsion