Testicular Torsion (Twisting of the Testicle)
Testicular Torsion (twisting of the testicle)
Testicular torsion is an emergency condition that occurs when the testicle (also known as the testis) rotates, twisting the spermatic cord because it is not attached properly.
As a result, blood flow is affected as the blood vessels within the spermatic cord is twisted at the same time. Since all blood for the testicle comes through the spermatic cord, the blood supply is cut off with this twist. The testicle will shrink (atrophy) if the blood supply is not restored within 6 hours. With no blood, the testicle will die (infarct).
Testicular torsion is a urological emergency, and you have to rush to the Emergency Department within 4-6 hours of the event if you wish to save the testicle and expect good results.
It can cause pain and swelling, and should be treated as an emergency.
Testicular torsion most commonly occurs in adolescent males and children, and even occur up to early adulthood.
Testicular swelling and pain in a male child and adolescent should be considered testicular torsion unless proven otherwise.
Symptoms
- Sudden, severe pain on one side of the scrotum
- Swelling of the testicle
- Change in scrotum color, especially redness or darkening at the later stages
- Slow-onset pain in the testicle, over many hours or days, can be a sign of torsion
Cause
Sometimes males may be born with no proper tissue holding the testes to the scrotum (called the “bell clapper” deformity). This predisposes the testes to twist inside the scrotum.
Torsion can happen on either side, but rarely on both sides simultaneously. Physical activity doesn’t cause torsion. It may happen during exercise, sitting, standing or even sleeping.
Diagnosis
This condition is diagnosed by history and clinical examination of a swollen painful testicle, which is elevated on one side of the scrotum in a young male.
At times, infection of the testicle can also present with swelling and pain on one side of the scrotum.
Ultrasound is sometimes done to confirm if an enlarged testicle is due to an infection (to check if there is an enlarged epididymis and adequate blood flow), but precious time should not be wasted doing an ultrasound if there is a strong suspicion of testicular torsion, or in a case of a young child when infection of the testicle is very uncommon to rare. This is because torsion of the testicle with resultant inflammation may provide false positive results in a Doppler ultrasound as a result of increased blood flow arising from inflammation.
There are certain situations when the testicle may twist, and then revert back to normal by untwisting. On examination, the testicle then will appear to be normal. Care should be taken that this subtle twisting may lead to re-twisting again in future. This is called intermittent testicular torsion. When the urologist suspects this, fixing of both the testicles will be done as a preventive strategy so that the testicle does not re-twist in the near-future and become an emergency. This is because most cases of testicular torsion present late to the Emergency Department and usually ends up requiring the removal of the dead (infarcted) testicle.
Surgical Exploration and Fixation of the Testicle
Treatment
Treatment of testicular torsion is immediate surgical exploration and to assess if there is twisting of the testicle. The spermatic cord needs to be untwisted (de-torsion) to restore the blood supply as soon as possible. Lasting damage starts after 6 hours of torsion. Nearly 75% patients need the testicle removed (orchidectomy) if surgery is delayed past 12 hours.
Longer duration of torsion increases the risk of tissue necrosis and death
- Torsion recognized within 6 hours has an 80-100% salvage rate to save the testicle
- Persistent symptoms > 24 hours has a nearly 0% salvage rate to save the testicle
After untwisting the testicle, the doctor will check the color of the testicle and whether adequate blood supply has been resumed. If adequate blood supply has resumed, the testicle must be fixed by sutures (called orchidopexy) so that it does not twist in future. The opposite unaffected testicle should also then be fixed as the “bell-clapper” deformity that predisposes to testicular torsion is present on the opposite side in 50% of cases.
In the event it is too late and the testicle has already died (infarct), and blood flow cannot salvage the testicle, then the testicle need to be removed and the opposite testicle need to be fixed.
If the testicle has already died (infarcted), it must be removed and cannot be left back. This is because a dead testicle can be a source of infection and abscess formation, and it has been suggested that it may subsequently affect the function of the opposite normal testicle in future as a result of presumed immune damage (known as sympathetic orchiopathy).
When to see the urologist
Any child or young adult with pain and swelling of the testicle need to be considered testicular torsion unless proven otherwise.
The urologist need to be consulted with 4-6 hours of the event if good results are to be achieved.
A delay longer than this will result in higher chances that the testicle may already be dead (infarcted). But even with such a delay there may still be a chance to salvage the testicle if the twisting of the testicle was incomplete and not too tight to result in a significant loss of blood supply.