Torsion of the Testis

Torsion of the testis may more accurately be called torsion of the spermatic cord. It causes occlusion of testicular blood vessels and unless prompt action is taken the viability of the testis is compromised.

It is fairly common and usually seen in adolescent boys. They are mostly over the age of 10 with a peak incidence around 14. The left side is more commonly affected than the right with 2% of cases being bilateral. There were 2,825 cases admitted to hospitals in England in the year 2002-2003. The mean age of patients was 15 years. 37% were aged 15 to 59. None was over 75. This represents roughly 1 case per 20,000 population (10,000 males) per year.

A high insertion of the tunica vaginalis produces a "bell clapper testis" with a horizontal lie rather high in the scrotum. This lie with the long axis in the horizontal rather than the vertical plain is usually bilateral.

Acute swelling of the scrotum in a boy 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.

History

• There is typically sudden, severe pain in one testicle.
• There may be lower abdominal pain and in any boy presenting with abdominal pain the testes should be checked.
• It often comes on during sport or physical activity.
• There is quite often a history of previous, brief episodes of similar pain. This is presumably torsion that corrected itself. There may be nausea and vomiting.
• Occasionally the symptoms are milder and less acute.
• Easing pain is not necessarily a good sign of spontaneous resolution. Pain also eases as necrosis sets in.

Examination

• There is usually reddening of scrotal skin.
• There is a swollen, tender testicle retracted upwards.
• Lifting the testicle up over the symphysis increases pain whereas in epididymitis this usually relieves pain.
• In the early stages, the epididymis may be felt in an abnormal anterior rather than typical posterior position but this depends upon the degree of torsion that may be from 180 to 720°. Later, gross swelling prevents this finding.
• The testes on both sides are characteristically in the "bell clapper position" with a horizontal long axis.

• Torsion of testicular or epididymal appendage
  • This usually occurs in boys aged between 7 and 12 years.
  • Systemic symptoms are rare.
  • There is usually localized tenderness but only in the upper pole of the testis.
  • Occasionally, the "blue dot sign" is present in light-skinned boys.
• Epididymitis, orchitis, epididymo-orchitis
  • These conditions most commonly occur from the reflux of infected urine or from sexually acquired disease caused by gonococci and Chlamydia.
  • Hence they tend to affect an older age group.
• Hydrocele
  • Swelling is usually painless.
  • The scrotum will transilluminate.
• Incarcerated hernia
  • This may be diagnosed by careful examination of the inguinal canal.
• Testicular tumour
  • Scrotal enlargement occurs more slowly
  • It is only rarely accompanied by pain. Typically the normal slightly delicate sensation of the testis is absent.
• Mumps
  • There is swelling of the parotid glands in mumps
  • Mumps orchitis is rare before puberty.

Doppler ultrasound will show absence of arterial flow. Scintillation scanning using ^99mTc-pertechnetate is also very valuable. A twisted testis is avascular. Tumours show increased vascularity and trauma reduced vascularity. Both techniques have a small number of false negatives.¹ Used together, the sensitivity and specificity should be very high.
A survey of urologists in the North-west of England found that 4 of 29 always like to use imaging. Most use it only if the clinical diagnosis is unclear. It is imperative to remember that this is a condition in which time is of the essence and waiting a couple of hours for a slot in the ultrasound department may compromise the viability of the testis.

• It may be possible to reduce the torsion manually. The testes usually rotate in different directions. The left testis rotates anticlockwise and the right testis clockwise in torsion. Hence they need to be rotated in the opposite direction. If this relieves the pain it is the correct direction. If it aggravates, it try the other direction.
• If this is done it should be verified by colour doppler. If the manoeuvre is successful, orchidopexy must still be performed. This should be done in the immediate future, preferably before the patient leaves hospital.
• If full manual reduction of torsion cannot be performed or if there is doubt about the diagnosis and reason to suspect torsion, the scrotum must be explored.
• The testis must be unwound at operation and inspected for viability. If it is not viable, it should be removed.
• If the testis is viable then orchidopexy should be performed to prevent recurrence.
• Whether the affected testis is removed or conserved, the contralateral one should undergo orchidopexy as the risk of recurrence on the other side is otherwise high.²

Sudden onset of pain in the scrotum in an adolescent boy during physical activity such as playing rugby, is so characteristic that it used to be said that masters at prep schools often became adept at the diagnosis and immediate treatment of torsion. Despite the obvious advantages of such prompt management, it is most unlikely that any teacher nowadays would dare to touch a boy so, in the present political climate. Even if instant reduction of torsion is completely successful, it is important that the boy should consult a doctor with a view to orchidopexy.

A survey from New York found that those under 18 were likely to present rather later than those who are older. They found that 90% of orchidectomies for a non-viable testis were in that group.³ Delay has a substantial adverse effect on survival of the testis and a paper from Dorset showed that late presentation is a substantial problem.⁴

• The extent and duration of torsion have a major influence on both the immediate salvage rate and late testicular atrophy.
• Testicular salvage most likely occurs if the duration of torsion is less than 6 to 8 hours.
• If it exists for 24 hours or more, testicular necrosis is usual.
• The absence of one testis has no significant effect on fertility, provided that the other functions normally. If both are affected by torsion the outlook may be very bleak.
• The absence of a testis may still have a significant psychological effect and so it is usual to implant a prosthesis if orchidectomy is required. This is usually delayed for 6 months to let inflammation subside and it is usually inserted via an inguinal incision.

In men who have had a unilateral torsion, fertility is often impaired. This may be due to subclinical torsion on both sides. Another possibility is that a pathological condition predisposes to both abnormal spermatogenesis and torsion of the spermatic cord. The "bell-clapper" testis tends to be high and so temperature may be higher than in glands that hang lower. There may also be an autoimmune component as a result of injury to one testis.

Recurrent, intermittent pain, with a "bell-clapper" testis, requires orchidopexy.⁵