Testicular Torsion scrotal emergency.pdf

Departmental CME presentation, general surgery dept, Hospital Kemaman, Terengganu, Malaysia

1. Testicular
Torsion
By;
Dr Muhammad Affiq
Supervisor;
Mr Muhammad Taufiq Khalila
Jabatan Pembedahan Am
Hospital Kemaman

2. Outline
Overview
Etiology
Scrotal Anatomy
Bell clapper anomaly
Pathophysiology
Neonatology
Case
Clinical presentation
Examination
TWIST Scoring
Investigation
Imaging (if questionable
diagnosis)
Management
Complications
Take home message
Referrence

3. Overview
Testicular torsion; twisting of
the blood supply and
spermatic cord to ipsilateral
testis. May lead to testicular
ischemia
Source; https://www.ncbi.nlm.nih.gov/books/NBK448199/

4. Overview
•Testicular torsion is a surgical emergency affecting 3.8 per
100,000 males younger than 18 years annually.
10% to 15% of acute scrotal disease in children, and results in an orchiectomy rate of 42% in boys
•Prompt recognition and treatment are necessary for testicular
salvage, and torsion must be excluded in all patients who present
with acute scrotum.
•Testicular torsion is a surgical emergency
Source; Testicular Torsion: Diagnosis, Evaluation, and Management, Uni. of Iowa

5. Etiology
Normal testis is anchored and cannot rotate.
For torsion to occur, one of abnormalities must be present;
➢Invension of the testis (upside down)
➢High investment of tunica vaginalis (testis hanging like clapper of bell)
➢Separation of epididymis from the body of the testis
So, whenever abdominal muscle contract, the cremaster contract as
well, spiral attachment of the cremaster + above abnormalities favours
the rotation. → precipitating factors; straining, lifting heavy weight ,
coital. But can be happen even during sleep
Source; Bailey and Love, 26
th
edition, 2013, p. 1380

6. Bell clapper deformity (most common)
The tunica vaginalis is usually adhered to the
posterolateral aspect of the testicle and within
it, the spermatic cord is not mobile. If the
attachment of the tunica vaginalis is high, then
this allows for the spermatic cord to twist inside,
leading to intravaginal torsion.
Itis bilateral in at least 2/5th of cases. (some
study 80%)
Risk Factors
•Bimodal age of distribution:at birth
and 12-18 years
•14% of cases occur in adults; older
patients have worse outcomes
•Prior episode of torsion
•Family history
•Trauma (minor case)
•Occur in the presence of testicular
malignancy in adults.
Source; Testicular Torsion - Micheal A. Schick (https://www.ncbi.nlm.nih.gov/books/NBK448199/)
Testicular Torsion EmDoc (https://www.emdocs.net/emdocs-podcast-episode-83-testicular-torsion/)
Etiology

7. Scrotal anatomy

8. Normal vs. Bell clapper anomaly

9. Pathophysiology
•Twisting of the testicle along the spermatic cord→↓venous
outflow→vascular congestion→swollen/painful testicle
•↑pressure and/or further twisting→↓arterial flow→ischemia
•Severity depends on duration & degree of cord rotation.
•Severe ischemia and necrosis start in 4-6 hours
Source; Testicular Torsion EmDoc (https://www.emdocs.net/emdocs-podcast-episode-83-testicular-torsion/)

10. Pathophysiology (cont.)
•Two forms:
•Intravaginal
•Adolescents/young adults
•Abnormal attachment of the tunica vaginalis
•Bell clapper deformity allows spermatic cord to twist
•Extravaginal
•Neonates
•Tunica vaginalis is not adhered to the gubernaculum
•Tunica vaginalis and spermatic cord twist together.

11. Neonatology

12. Case
17 years old boy, suddenly waking up today at 2.30am for acute
severe left scrotal pain, radiate to lower abdomen, associated with
vomiting. Patient otherwise denied of trauma/UTI sx.
Came to ED hospital dungun, pain not resolve despite of IM
morphine given.
On examination, left testis swollen, tender, cremasteric reflex
present.
What’s your provisional diagnosis and differentials?

13. •Provisional dx; Testicular torsion
•Differentials:
•Epididymitis, orchitis, and UTIs
•Torsion of the appendix testis or appendix epididymis→Blue dot sign
•Sexually transmitted infections
•Oncologic diagnoses
•Diffusely hard testicle→lymphoma and leukemia
•Idiopathic edema, hernia, hydroceles, varicocele
•Fluctuating pain/swelling, positional swelling
•Trauma→Ecchymoses, visible injury
•Small tense strangulated inguinal hernia
Blue dot sign

14. Clinical presentation
➔
➔
➔
➔
➔

15. Examination
•
•
•
•
•⅓
•
•
•

16. TWIST scoring for torsion
•Testicular Workup for Ischemia and Suspected Torsion (TWIST) score
is a 7-point tool to clinical evaluation acute scrotal pain.
Source; Diagnosing with a TWIST: Systematic Review and Meta-Analysis of a Testicular Torsion Risk Score- PubMed NIH

17. TWIST scoring (cont.)
•Barbosa (2022) showed;
Low-risk patients (0-2 score) rule out of torsion, and favorable
specificity
Intermediate-risk (3-4score) need for further workup with ultrasound.
High-risk patients (5-7 score) facilitating urgent surgical exploration.
Source; Diagnosing with a TWIST: Systematic Review and Meta-Analysis of a Testicular Torsion Risk Score- PubMed NIH

18. Testicular Torsion: Diagnosis, Evaluation, and Management – American Family Physician

19. Investigation
•UFEME – to exclude UTI cause
•FBC – to see infective markers
•RP – patient may have AKI in ischemia, metabolic acidosis and
hyperlatatemia
•VBG Lactate – tissue ischemia may lead to raise of lactate and
metabolic acidosis
•Coagulation profile – expect for early surgical intervention by
clinically diagnose.
•GSH – preparing for operative management
•AXR

20. Imaging (in questionable diagnosis)
-USG Doppler; the first line imaging modality.(https://www.youtube.com/watch?v=IT4qnNQ6IKw)
•Enlarged, hyperemic testicle with↑echogenicity, irregular contour & reactive hydrocele (note: latter might not appear for several
hours).
•Assess for no flow or decreased flow velocity in intratesticular arteries. (Doppler)
Degrees of torsion:
•Complete –testicle twists ≥360
o
, US usually shows absence of intratesticular flow.
•Incomplete – testicle twists <360
o
. Flow is decreased but present.
•Intermittent – testicle torses and detorses.
•Special signs on USG:
•Whirlpool sign – twisted spermatic cord with spiral pattern.
•Pseudomass –congested epididymis/vas deferens/vascular bundle below twisted spermatic cord.
•Horizontally lying testicle.
•Sensitivity 86-98%; specificity 90-98%.
•Even with a normal ultrasound, if the history/exam are concerning
-Radionuclide imaging (Scintigraphy) injection of an isotope intravenously followed by blood flow images of the scrotum.
Testicular isotope scanning can differentiate epididymitis, which results in “hot spots” caused by increased perfusion near the
affected testicle, from testicular torsion, which results in “cold spots” caused by decreased blood flow to the affected testicle.
Source; Testicular Torsion EmDoc (https://www.emdocs.net/emdocs-podcast-episode-83-testicular-torsion/)

21. Management
•NBM patient with IVD maintenance
•Early clinical decision for early surgical intervention;
Scrotal exploration, detorsion of the affected testis, bilateral
orchidopexy KIV orchidectomy.
- to explained the patient for orchidectomy if testis cant be salvage (possible high medicolegal
issue)
- Orchidectomy risk ranging from 39% to 71% in most cases
-4-8 hours windows; 90-100% percentage of testicular salvageable
if 12 hours; 50% salvageable, if 24 hours, less than 10% salvageable.
Source;
Acute scrotum- Paediatric Urology, European Association of Urology
Testicular Torsion: Diagnosis, Evaluation, and Management – American Family
Physician

22. •Manual detorsion –to increase percentage of testicular
salvage
initially be done by outward rotation of the testis - like opening a book,
see if pain improving, unwind if pain worsening
Detorsion is NOT for replacing surgical intervention
Despite successful detorsion, need for immediate orchidopexy, NOT
elective.
Can use USG bedside assessment while detorsion
•External cooling while waiting surgical exploration
Source; Scrotal cooling as a protective method in tissue preservation after testicular torsion - Central
European Journal of Urology

23. •Antibiotics; IV ciprofloxacin 500mg BD – cover genito uro related infection
•*If Torsion Appendix of testis(hydatid of Morgagni)– can be treat non operative
with non inflammatory analgesia, if exploration done, not necessarily for contralateral exploration.
Follow up in 6weeks, clinically and USG.
Source;
Acute scrotum- Paediatric Urology, European Association of Urology
Testicular Torsion: Diagnosis, Evaluation, and Management – American Family
Physician

24. SCROTAL EXPLORATION OPERATION
(overview)
•Patient under spinal in lithotomy position, area cleaned and draped
•Tranverseincision made for bilateral scrotum, crossing the scrotal raphe.
•Open by layer (skin, dartos facia and muscle, external spermatic fascia,
cremasteric fascia and muscle, internal spermatic fascia, tunica vaginalis
(parietal)
•Untwist the torsion (assess the degrees)
•Assess for the colourof testis, pulsation of testicular artery
•Wrap testis with warm gauze while exploring another side
•Reasses the testis, prick the testis to see the bleeding, sign of perfusion
•Testis anchored at lateral, posterior and inferior pole to Dartos muscle
(orchidopexy) using absorbable suture. Bilateral testis must be done.
•Lastly closed by layers

27. •https://www.youtube.com/watch?v=wgTQpSNydx0

28. Complications;
SUBFERTILITY;
•is found in 36-39% of patients after torsion.
(caused by by post-ischaemia-reperfusion injury that is caused after the detorsion when
oxygen-derived free radicals are rapidly circulated within the testicular parenchyma)
•Early surgical intervention (4-8 hours) with detorsion was found to
preserve fertility.
•A recent study showed a normal pregnancy rate after unilateral
testicular torsion, with no difference between the patients undergoing
orchidopexy and those after orchidectomy.
Source; https://uroweb.org/guidelines/paediatric-urology/chapter/the-guideline

29. •LOSS OF TESTIS (atrophy)
•INFECTION (GANGRENOUS TESTIS)
•COSMETIC DEFORMITY
•LOSS OR DIMINISHED EXOCRINE AND ENDOCRINE FUNCTION
IN MEN.

30. Post operative outcome
A study;
Degree of twisting and duration of symptoms are
prognostic factors of testis salvage during episodes of
testicular torsion
•25.7% atrophy rate after orchiopexy.
•Less than 6 h (from presented symptoms) was a significant predictor of
testicular salvage
•If surgical exploration is delayed, testicular atrophy will occur by 6 to 8 h,
with necrosis ensuing within 8 to 10 h of initial presentation.
Salvage rates of over 90% are seen when surgical exploration is
performed within 6 h of the onset of symptoms, decreasing to 50% when
symptoms last beyond 12 h. The chance of testicular salvage is less than
10%, when symptoms have been present for over 24 h
Source; Degree of twisting and duration of symptoms are prognostic factors of testis salvage during episodes of testicular
torsion - Department of Urology at Winthrop University Hospital in Mineola, NY, USA

31. Take Home Messages
•Acute scrotal severe pain is a red flag (similar urgency as acute
limb ischemia), testicular torsion is an urological emergency need
urgent surgical intervention.
•Most of testicular torsion can be diagnose clinically
•Surgical intervention window period must be within 4-8hours
since onset.
•Testicular torsion high possibly to be medicolegal case if delayed
in management- patient may loss of one of his organ.

32. Referrances;
1.Testicular Torsion: Diagnosis, Evaluation, and Management – American Family Physician
(https://www.aafp.org/pubs/afp/issues/2013/1215/p835.html)
2.Testicular Torsion - Micheal A. Schick (https://www.ncbi.nlm.nih.gov/books/NBK448199/)
3.Testicular Torsion EmDoc (https://www.emdocs.net/emdocs-podcast-episode-83-testicular-torsion/)
4.Understanding testicular torsio- Zero to hero (https://www.youtube.com/watch?app=desktop&v=emozZmyBrXo)
5.Diagnosing with a TWIST: Systematic Review and Meta-Analysis of a Testicular Torsion Risk Score- PubMed NIH
(https://pubmed.ncbi.nlm.nih.gov/35238603/#:~:text=Purpose%3A%20The%20Testicular%20Workup%20for,nausea%2Fvomi
ting%20(1).)
6.Acute scrotum- Paediatric Urology, European Association of Urology (https://uroweb.org/guidelines/paediatric-
urology/chapter/the-guideline)
7.Scrotal cooling as a protective method in tissue preservation after testicular torsion
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8771140/#:~:text=Physicians%20of%20all%20other%20professions,on%20t
he%20course%20of%20treatment )
8.Bailey and Love, 26
th
edition, 2013, - Torsion of testis
9.Degree of twisting and duration of symptoms are prognostic factors of testis salvage during episodes of testicular torsion
- Department of Urology at Winthrop University Hospital in Mineola, NY, USA, 2017
10.Pastest MRCS Part A; Essential Revision notes
11.Basic science for the MRCS, – Andrew T. Raftery