Testicular torsion/ Torsion of testes

Torsion of testes/ Testicular torsion is an urological emergency.

1. Testicular Torsion
Sushil Gyawali
MS resident
Urology and Kidney Transplant Surgery

2. Case Scenarios
•1) A 15 year old boy , wakes up from sleep with sudden onset
severe pain and mild swelling and redness in his left scrotum.
He vomits for 2 times and is restless. The pain increases on
touching his scrotum. His parents takes him to nearby
hospital.

3. Case 2
2) A 23 year male, has gradual swelling in his right
testicle with moderate pain over 2 days and gives
history of dysuria and fever (101⁰F) 1 day back. The
pain increases on standing , however sometimes
decreases on elevating the right testicle.

4. Introduction
•Torsion of the spermatic cord structures and
subsequent loss of the blood supply to the
ipsilateral testicle.
•Urological emergency
•Accounts for 7%–30% of cases of acute scrotum.
Sheth KR et al . J Urol 2016

5. Epidemiology
•Primarily adolescents/Puberty and neonates
•Below 25 years (12-18 yrs)
•Occasionally in 40-50yrs
•Left testis is more frequently involved.
•Bilateral cases : 2%
•Extravaginal torsion: 5% of total cases

6. Risk factors
•Underlying bell clapper deformity
•Undescended testicle
•Long spermatic chord
•Trauma and
•Prior intermittent torsion
Keays, M., & Rosenberg, H. (2019). Canadian Medical Association Journal,

7. Pathophysiology
•Normally the tunica vaginalis does not completely
surround the testis and epididymis & is attached
securely to the posterior lateral aspect of the
testicle, and, within it, the spermatic cord is not
very mobile.
•If the attachment of the tunica vaginalis to the
testicle is inappropriately high, completely
surrounds the testis, epididymis, and part of the
spermatic cord, predisposing to intravaginal
torsion (bell clapper deformity): adolescents
•17% of males and is bilateral in 40%.

8. Extravaginal torsion
•In neonates; the tunica vaginalis is not
yet secured to the gubernaculum and,
the spermatic cord + tunica vaginalis,
undergo torsion as a unit.
•Painless scrotal swelling, discoloration,
and a firm mass in the scrotum;
•Testes are usually necrotic from birth
and must be removed surgically
•Pre and postnatal
Extra Vs Intravaginal torsion

9. Torsion and malignancy
•Testicular torsion is associated with testicular malignancy, especially
in adults
•A study found a 64% association of testicular torsion with testicular
malignancy.
•This is thought to be secondary to a relative increase in the
broadness of the affected testicle compared with its blood supply
Barthold JS. Campbell-Walsh Urology .10e

10. Torsion
•Torsion occurs between 90°and 180°,compromising blood flow
•Complete torsion : twists 360°or more; may extend to 720°.
•Viability of the testicle
depends on :
Degree of torsion &
Duration of torsion
Twisting
Venous occlusion/
engorgement
arterial ischemia
infarction/necrosis

11. Presentation
•Sudden, severe unilateral scrotal pain
•Nausea and vomiting; 1/3rd (mostly children)
•Scrotal swelling and redness
•Pain not relieved by elevation of the scrotum
•Spontaneously or activity/trauma induced
•Pain may lessen as the necrosis becomes more
complet
•In neonates: painless, hard, nontender testis
that is fixed to the overlying discolored scrotal
skin.

12. Examination
•Neonate: firm, hard, scrotal mass, which
does not transilluminate in an otherwise
asymptomatic newborn male.
•The scrotal skin characteristically fixes to
the necrotic gonad.
•In an older patient: a swollen, tender,
high-riding testis with abnormal
transverse lie and loss of the cremasteric
reflex.

13. Other Signs
•Fever +/-
•Distress
•Cremasteric reflex : almost always absent or diminished and its
presence r/o other causes of acute scrotal pain
•Prehn sign: (relief of pain with elevation of the testicle), unreliable for
diagnosis.

14. Work Up
•Clinical diagnosis
•TWIST (Testicular Workup for Ischemia and Suspected Torsion)
scoring system)
A clinical decision tool; determining the risk, thus decreasing the
indication for ultrasound.
Sheth KR et al : Journal of Urology (2016)

15. TWIST scoring
i.Testis swelling (2)
ii.Hard testis (2)
iii.Absent cremasteric reflex (1)
iv.Nausea/vomiting (1)
v.High-riding testis (1)
A score of 0: 100% negative predictive value
A score of 6 or 7 is highly predictive of torsion

16. TWIST interpretation
1) score 0-2: low risk
•100% negative predictive value for torsion
•generally no ultrasound or urological consultation required
2) score 3-4: intermediate risk
•ultrasound warranted
3) score 5 or above: high risk
•100% positive predictive value for torsion
•ultrasound not required, urgent urological consultation and surgery
required to salvage testicle

17. Investigations
•Urinalysis/urine c/s : r/o UTI
•TC: increased in 60%
•USG : Color Doppler (diagnostic modality of choice)
-nt / ↓ blood flow in the affected testicle( incomplete)
↓ flow velocity in the intratesticular arteries
↑ resistive indices (RI >0.75)
Hypervascularity with a low resistance flow pattern (after partial
torsion-detorsion)
Altered echotexture

18. Other USG findings
•Reactive hydrocele
•Reactive thickening of the
scrotal skin with hyperaemia
•Epididymo-orchitis: closely mimic the appearances of torsion as well
as spontaneously detorted testis

19. USG: whirlpool sign
•Whirlpool sign—a spiral-like
pattern ,twisting of the spermatic cord;
In high-resolution USG and/or
color Doppler USG
•Is definitive sign for testicular torsion in pediatric and adult patients,
but has a limited role in neonates.
McDowall J et al. A systematic review and meta-analysis. Emerg Radiol. 2018

20. Other Imaging
•Radionuclide scanning (scintigraphy) of the scrotum is the most
accurate imaging technique, but it is not routinely available (Tc-99m
pertechnetate )
•Role of MRI in the diagnosis of torsion is limited, although MRI is
likely to be highly sensitive.

21. Differential Diagnosis
•Epididymo-orchitis
•Traumatic swelling
•Torsion of testicular appendix
•Strangulated Hernia
•Hydrocele
•Varicocele
•Testiticular tumor

22. Treatment
•Immediate surgical exploration
•within 6 hours of symptom onset.
•manual detorsion: medial to lateral (opening a book)
•If treatment delayed: decreased fertility or may require orchiectomy.
•Intermittent torsion: elective b/l orchiopexy
Ramchandra et al. West Journal of Emg Med. 2015

23. Salvage rate?
•The time between onset of pain and performance of detorsion:
•< 6 hours –90-100% salvage rate
•6-12 hours –20-50%
•12-24 hours: <20%
•>24 hours –0-10%
Ringdahl et al. Am Fam Physician 2006

24. Surgical detorsion
•Bilateral scrotal orchiopexy (if viable) is often recommended to treat
the torsed testis and prevent torsion of the other testis.
•Neonatal torsion is controversial, but is most often treated with
elective exploration and contralateral orchiopexy.
Postnatal-immediate exploration
Sharp VJ et al. Am Fam Physician. 2013

25. Surgery
•Midline raphe incision or bilateral transverse
scrotal incisions
•Enter the ipsilateral scrotal compartment,
incise the tunica vaginalis, and then
deliver the testicle for examination.
•The spermatic cord is then untwisted.
•Evaluate the testis for viability.
•If viability is in question, place the testicle in
warm sponges and reevaluate after several
minutes.

26. Signs of viability :
•a return of color, return of Doppler flow, and arterial bleeding after
incision of the tunica albuginea.

27. •To prevent subsequent torsion, fix viable gonads to
the scrotal wall with 3-4.0 nonabsorbable sutures.
•A dartos pouch can be made, into which the
testicle is placed.
•Contralateral orchiopexy is always performed when
testicular torsion is confirmed intraoperatively, in
order to prevent future torsion of that testicle.
•If the testis is necrotic, perform an orchiectomy
3 point fixation

28. Supportive
•analgesics
•antiemetics
•IV fluids

29. Complication of torsion
•permanent damage
•subfertility
•infection
•testicular atrophy
•orchidectomy
•poor cosmesis

30. THANK YOU

31. •Around the 23rd week of gestation, the testis
undergoes transabdominal migration to a location
near the internal inguinal ring. The testis does not
migrate transinguinally to its final position until after
the 28th week of gestation, and this is usually
complete between the 30th and 32nd week of
gestation.
•A case report describes a necrotic testicle in a
newborn that resulted from torsion at an estimated
20th week of gestation.

32. •torsion commonly have a bilateral “bell clapper”
deformity in which the testicle does not attach at its
lower pole to the tunica vaginalis.
•As a result, the testis is excessively mobile and
tends to position horizontally rather than vertically
within the scrotum.
•These factors, along with the increase in testicular
weight that occurs with puberty, predispose to
torsion,