Torsion of the Testicle

Torsion of the Testicle



Testicular torsion is a true urologic emergency, requiring a provider to arrive at a timely diagnosis with a fast transition to surgical intervention in order to prevent testicular injury or necrosis. It is a clinical problem in both pediatric and adult urology, with a recent population-based study giving a yearly incidence of 3.8 in 100,000 for males younger than 18 years old (1). This predicts that 1 in 1,500 males will undergo surgery for torsion by that age, compared to older estimates of 1 in 4,000 for men younger than 25 years old (2). Despite wide recognition of this condition, 30% to 41% all cases will have a nonviable testis at the time of surgery and undergo orchiectomy (1,3,4). Ramifications of delayed treatment include atrophy, possible testicular loss, decreased endocrine function, and reduced sperm count and future fertility. If torsion is suspected, emergent scrotal exploration should be undertaken given that even partial necrosis has been seen to occur as early as 4 hours (5,6). The injury to the testis occurs from ischemia as well as reperfusion from reactive oxygen species (7).

There is a bimodal incidence of torsion with peaks at 1 month of age and a second at 12 years, thought to reflect the clinical distinction between extravaginal torsion in the perinatal period and intravaginal torsion in older children. In this way, the anatomy of a testicular torsion is correlated with the expected age of the patient—the point of difference is whether the torsion occurs above or below the reflection of the tunica vaginalis (Fig. 62.1). Intravaginal torsion results from a twist in the spermatic cord within and not involving the tunica vaginalis. Also known as a “bell clapper deformity,”, it is hypothesized to be due to an abnormally high insertion of the tunical attachments to the testis and epididymis so that there is incomplete attachment (Fig. 62.2). Intravaginal torsion is seen in the older age group primarily, although can be seen rarely in the perinatal period. Surprisingly, autopsy studies report the incidence of a bell clapper deformity to be as high as 13% in normal subjects, thus unlikely to account solely for the cause of torsion (8). Individuals with undescended testes are also presumed to be at a higher risk although this is from
only a handful of accounts and has not changed the current recommendations that infants undergo orchidopexy at the age of 6 to 12 months. At this time, no other predisposing factors can be definitively linked with testicular torsion.

FIGURE 62.1 A: Extravaginal torsion. The tunica vaginalis is involved with the twist of the spermatic cord. B: Intravaginal torsion involves the spermatic cord below the reflection of the tunica vaginalis onto the spermatic cord. (Adapted with permission from Marshall, Fray F. Operative Urology. Philadelphia: WB Saunders, 1991:537. Copyright 1991 W.B. Saunders Co./Elsevier.)

Extravaginal torsion, however, is a twist of the testis, cord, and tunica vaginalis due to deficient attachment of the gubernaculum to the dartos, and thus, it is much more likely to occur in the perinatal period. Possible predisposing factors include a large birth weight and difficult delivery, but these remain only postulations (9,10). Extravaginal torsion encompasses perinatal cases, of which an estimated 72% occur in utero and present as a “vanishing” nonpalpable testis at birth (11). The remaining important minority of cases present variably depending on the timing of the event and may be insidious. Suggestive findings at birth include an indurated, erythematous scrotum, a dark discoloration with or without edema, and/or a coexisting hydrocele. Often, the infant will be asymptomatic.

FIGURE 62.2 The patient’s right testicle demonstrates a “bell clapper” deformity with anomalous attachment of the spermatic cord and testicle. The patient’s left spermatic cord and testicle does not exhibit the bell clapper deformity. (Courtesy of Elizabeth B. Yerkes, MD.)

Apr 24, 2020 | Posted by in UROLOGY | Comments Off on Torsion of the Testicle
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