Testicular torsion

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management

Definition

Testicular torsion is a urological emergency caused by twisting of the spermatic cord, leading to reduced blood flow to the testicle and potential testicular ischaemia.

Aetiology

Testicular torsion occurs due to anatomical defects or external factors.

Common Causes:

  • Bell-clapper deformity: congenital abnormality where the testis is inadequately attached to the scrotum, allowing excessive movement.
  • Cremasteric muscle contraction: exaggerated response due to cold exposure or trauma.
  • Rapid growth: more common in adolescents due to hormonal changes.

Pathophysiology

  • Twisting of the spermatic cord leads to occlusion of venous drainage.
  • Arterial blood flow is compromised, causing ischaemia.
  • Prolonged torsion leads to testicular necrosis, requiring orchiectomy.

Risk Factors

  • Adolescence (peak incidence 12–18 years).
  • Previous episodes of intermittent torsion.
  • Family history of testicular torsion.
  • Cold weather (induces cremasteric contraction).
  • Testicular trauma.

Signs and Symptoms

  • Acute onset severe testicular pain: sudden, unilateral pain.
  • Nausea and vomiting: common in torsion.
  • High-riding testicle: testis is retracted upwards in the scrotum.
  • Absent cremasteric reflex: stroking the inner thigh does not cause testicular elevation.
  • Scrotal swelling and erythema: may develop as torsion progresses.
  • Pain not relieved by elevation: prehn’s sign negative (helps differentiate from epididymitis).

Investigations

  • Clinical diagnosis: testicular torsion is primarily a clinical diagnosis and should not be delayed for investigations.
  • Scrotal ultrasound with Doppler: may show absent blood flow, but should only be used in equivocal cases.
  • Urinalysis: performed to exclude infection (normal in torsion, pyuria in epididymitis).
  • Blood tests: FBC and CRP may be done if infection is suspected.

Management

1. Emergency Surgical Exploration:

  • Urgent surgical exploration: should be performed within 6 hours of symptom onset to prevent testicular necrosis.
  • Orchiopexy (testicular fixation): if viable, the affected testis is untwisted and sutured to the scrotal wall to prevent recurrence.
  • Contralateral orchiopexy: performed on the unaffected testis due to high recurrence risk.
  • Orchiectomy (removal of testicle): if the testis is non-viable.

2. Pre-Hospital and Non-Surgical Management:

  • Attempt manual detorsion if immediate surgery is not available.
  • Manual detorsion involves rotating the testis outwards (like opening a book).
  • Surgical fixation is still required after successful manual detorsion.

3. Post-Operative Care:

  • Monitor for wound infection.
  • Advise scrotal support and avoid heavy lifting for 4 weeks.
  • Psychological support if orchiectomy is performed.

4. Patient Education and Prevention:

  • Educate on recognising early symptoms to prevent delay in treatment.
  • Encourage early presentation to A&E for sudden testicular pain.
  • Regular follow-up if underlying anatomical abnormality is detected.
RenalmypanotesTesticular torsion