Testicular Torsion and Torsion of the Testicular or Epididymal Appendage

(1)

Pediatric Surgery, AlSadik Hospital, Qatif, Saudi Arabia

26.1 Introduction

Acute scrotal pain requires immediate surgical attention to determine the underlying cause and to treat accordingly.
The diagnosis of acute scrotal pain may not be straightforward and in some patients, immediate surgical exploration may be necessary in order to treat torsion of the testes early to achieve good results.
Acute scrotal pain and swelling in children and young adults indicates torsion of the testis until proven otherwise.
In approximately two thirds of patients, history and physical examination are sufficient to make an accurate diagnosis.
Testicular torsion is a true surgical emergency and must be differentiated from other complaints of testicular pain because a delay in diagnosis and management can lead to loss of the testicle.
Testicular torsion may interrupt blood flow to the testis and epididymis.
The degree of testicular torsion is however variable varying from 180 to 720°.
Testicular torsion accounts for about 26 % of cases of acute scrotum.
It occurs when the spermatic cord twists leading to testicular ischemia and necrosis as a result of cutting off the testicle’s blood supply.
The most common underlying cause is a congenital malformation known as a “bell-clapper deformity”.
This congenital anomaly is results in the long axis of the testicle becoming oriented transversely rather than cephalocaudal.
In this malformation, the testis is inadequately affixed to the scrotum allowing it to move freely on its axis which can lead to twisting of the cord and its vessels.
In the “bell-clapper deformity”, the testis hangs within the scrotum and can swing like a bell clapper in a bell, allowing for easy torsion. Males born with the bell clapper deformity have no attachments around either testicle, so that torsion can potentially occur on either side (Fig. 26.1).

Fig. 26.1

Diagrammatic representation of the bell-clapper deformity. This allows the testicle to rotate freely on the spermatic cord within the tunica vaginalis and predisposes to intravaginal torsion of testis
Bilateral testicular torsion, however, is an exceedingly rare event.
Testicular torsion occurs more commonly in patients who have an inappropriately high attachment of the tunica vaginalis. This allows the testicle to rotate freely on the spermatic cord within the tunica vaginalis (intravaginal testicular torsion).
The bell clapper deformity is present in approximately 12 % of males; 40 % of them are affected in both testicles.
It has been estimated that irreversible ischemia and necrosis of the testis begins around six hours after the onset of torsion.
This calls for early diagnosis and emergency correction of torsion to minimize the risk of testicular infarction.
The diagnosis of testicular torsion is clinical and if doubt an emergency Doppler ultrasound can be done.
Testicular torsion commonly develops during puberty but can also be seen in newborns as a result of intrauterine torsion or soon after birth.
The exact incidence of testicular torsion is not known but it has been estimated to occur in about 1 in 4,000 to 1 in 25,000 males per year before 25 years of age.
Testicular torsion is most frequent among adolescents with about 65 % of cases presenting between 12 and 18 years of age.
It has been estimated that in 95 % of men with testicular torsion the testis can be saved if treated within six hours of the onset of pain.
Other causes of acute scrotal pain that should be ruled out include:
- Orchitis
- Epididymitis, epididymo-orchitis
- Torsion of the testicular or epididymal appendages
- Trauma-related causes of acute scrotum
- Acute hydrocele
- Testicular tumor
- Idiopathic scrotal edema

26.2 Etiology and Risk Factors

The exact etiology of testicular torsion is not known
The “bell-clapper deformity”
- This is the commonest cause of testicular torsion
- It accounts for 90 % of the cases
- It is a congenital malformation of the processus vaginalis
- In this condition, rather than the testes attaching posteriorly to the inner lining of the scrotum by the mesorchium, the mesorchium terminates early and the testis is free floating in the tunica vaginalis.
- This condition is bilateral and calls for fixation of the other testis when one testis is affected. This is to prevent subsequent torsion of the other side.
A large mesentery between the epididymis and the testis can also predispose itself to torsion, although this is rare.
Contraction of the spermatic muscles shortens the spermatic cord and may initiate testicular torsion.
Other etiologic factors involved in intravaginal testicular torsion include:
- Undescended testicle
- Sexual arousal or activity
- Physical exercise
- An active cremasteric reflex
- Cold weather.
A larger testicle either due to normal variation or a tumor increases the risk of torsion.

26.3 Diagnosis

The diagnosis of testicular torsion is clinical based on the history and presenting signs and symptoms.
With a convincing history and physical examination, no time should be wasted on investigations and immediate surgical exploration should be done.
Doppler ultrasound should be done only in low suspicion cases to rule out torsion and differentiate this from epididymo-orchitis. Doppler ultrasonography can be used to demonstrate arterial blood flow to the testis while providing information about other testicular pathology. It is about 90 % accurate in diagnosing testicular torsion.
- In testicular torsion, there is no blood flow or the blood flow is markedly decreased.
- In epididymo-orchitis, there is normal or slightly increased blood flow.
- The sensitivity of color Doppler in detecting acute testicular torsion in children is 90–100 %, with specificity being 100 %.
- Other studies have suggested that color Doppler ultrasonography was only 86 % sensitive, 100 % specific, and 97 % accurate in the diagnosis of testicular torsion (Figs. 26.2 and 26.3).
  
  Figs. 26.2 and 26.3
  
  A Doppler ultrasound showing bilateral torsion of testes
- Doppler ultrasonography has (Figs. 26.4 and 26.5):
  
  Figs. 26.4 and 26.5
  
  A Doppler ultrasound showing epididymitis. Note the enlarged left epididymis and the good blood flow to the testis
  
  94 % sensitivity.
  
  96 % specificity.
  
  95.5 % accuracy.
  
  89.4 % positive predictive value.
  
  98 % negative predictive value.
In doubtful cases, an isotope scan (technetium-99 m pertechnetate) can be done. Radionuclide scans have a sensitivity of 90–100 % accuracy in detecting testicular blood flow.
- This is the most accurate investigation but it is not readily available
- Add to this the time it requires to organize and do this investigation particularly in cases of torsion where urgency is required
- In testicular torsion, there is no uptake of the uptake is markedly reduced
- In epididymo-orchitis, there is normal uptake and uniformly symmetric activity.
- A urine analysis and culture can be done to roll out infection.
- The complete blood count can be normal. However, the WBC count is elevated in as many as 60 % of patients who have testicular torsion.
Surgical exploration should not be delayed for the sake of performing imaging studies.

26.4 Intermittent Testicular Torsion

This is a less serious variant of testicular torsion.
It is a chronic condition characterized by the symptoms of testicular torsion but followed by eventual spontaneous detortion and resolution of pain.
The attack may be associated with nausea or vomiting
These patients are however at significant risk of developing complete torsion
It is important recognize this condition and physicians treating these patients should be aware of this.
The treatment is elective bilateral orchiopexy.
This is curative and 97 % of patients who undergo bilateral orchidopexy experience complete relief from their symptoms.

26.5 Classification of Testicular Torsion

Testicular torsion is classified is classified into two types depending on onset:
- Acute testicular torsion
- Intermittent testicular torsion
Testicular torsion is also classified anatomically into two types:
- Intravaginal torsion
  
  This is the commonest type
  
  Commonly develops during puberty
  
  The torsion occurs within the tunica vaginalis
  
  Intravaginal torsion comprises approximately 16 % of patients with torsion presenting in emergency departments with acute scrotum.
  
  Thepeak incidence occurs in adolescents aged 13 years.
  
  The left testis is more frequently involved.
  
  Bilateral cases account for 2 % of all testicular torsions.
- Extravaginal torsion (Figs. 26.6, 26.7, 26.8, 26.9, and 26.10)
  
  Fig. 26.6
  
  A clinical photograph showing a newborn with intrauterine torsion of testis. Note that the patient is healthy and of good weight
  
  Figs. 26.7, 26.8, and 26.9
  
  Clinical and intraoperative photographs showing intrauterine torsion of testes. Note the discoloration of the affected scrotum which is slightly elevated. Note also the frankly necrotic testis
  
  Fig. 26.10
  
  Diagrammatic representation of the two types of testicular torsion, the intravaginal and extravaginal torsions
  
  This much less common
  
  Extravaginal torsion comprises approximately 5 % of all testicular torsions.
  
  This type occurs exclusively in newborns
  
  The condition is most often a prenatal (in utero testicular torsion) event.
  
  It is associated with high birth weight.
  
  Up to 20 % of cases are synchronous, and 3 % are asynchronous bilateral.
  
  This type of torsion occurs outside of the tunica vaginalis, when the testis and gubernaculum can rotate freely.
  
  The torsion usually occurs intrauterine and rarely soon after birth
  
  It is usually unilateral but can also occur bilaterally.
  
  The newborns with this type of torsion usually present immediately after birth with scrotal swelling, and dark discoloration of the scrotum
  
  Clinically, the affected testis is usually firm and painless
  
  The scrotal skin characteristically fixes to the necrotic gonad.
  
  The affected testis is usually necrotic
  
  The treatment is orchidectomy and contralateral orchidopexy to obviate the risk of torsion on the other side

26.6 Effects of Testicular Torsion

Torsion of the testes causes venous occlusion and engorgement as well as arterial obstruction and ischemia and subsequent infarction of the testis. The extent of this depends on two factors:
- The degree of torsion:
  Torsion of testis occurs as the testis and the cord rotate between 90° and 180°, compromising blood flow to and from the testis.
  
  Complete testicular torsion usually occurs when the testis twists 360° or more.
  
  Incomplete or partial torsion occurs with lesser degrees of rotation.
  
  In some cases, the degree of testicular torsion may extend to 720°.
- The duration of torsion:
  The duration of testicular torsion is the most important factor that prominently influences the salvage rates of the affected testis and late testicular atrophy.
  
  Testicular salvage is most likely if the duration of torsion is less than 6 h.
  
  If 24 h or more elapse, testicular necrosis develops in most patients.