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Testicular Torsion

Aka: Testicular Torsion
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  1. Epidemiology
    1. Incidence: 1:4000 males under age 25 years
    2. Young to middle aged men
    3. Bimodal distribution
      1. Newborns
      2. Teens and older
  2. Pathophysiology
    1. "Bell Clapper" deformity allows spermatic cord to twist
      1. Responsible for torsion in 90% of cases
      2. Tunica vaginalis completely surrounds Testis
      3. Provides inadequate posterior fixation of Testis
      4. Asymptomatic men have this on autopsy in 12% cases
      5. Usually results in intravaginal torsion
    2. Extravaginal torsion in neonates
      1. Unilateral defect of incomplete attachment
        1. Gubernaculum and testicular tunics
        2. Dartos fascia
  3. Risk Factors
    1. Trauma (only responsible for 4-8% of cases)
    2. Most torsions have onset while sleeping
    3. Vigorous Exercise
    4. Prior episode of similar pain spontaneously resolved
    5. Testicular hypertrophy during Puberty
    6. Testicular mass
    7. Cryptorchidism (status-post repair)
    8. Long intrascrotal length of vas deferens
  4. Symptoms
    1. Sudden severe unilateral Scrotal Pain
      1. If trauma present, pain lasts >1 hour
      2. Keep high level of suspicion
      3. Testicular Torsion cause of pain in 16-42% of boys
    2. Scrotal edema and erythema
    3. Lower Abdominal Pain
    4. Nausea or Vomiting
    5. Careful gait
  5. Signs
    1. Tender, firm affected Testicle
    2. Testicle may appear to be retracted upward
    3. Testicle swollen and erythematous
    4. Testicle may have horizontal lie
    5. Cremasteric Reflex absent
      1. Most sensitive finding in Testicular Torsion
      2. Presence of reflex suggests epidydimitis
    6. Prehn's Sign Negative
      1. Elevation of Scrotum does not relieve pain, and may instead worsen pain
  6. Differential Diagnosis
    1. Torsion of Testicular Appendage
    2. Epididymitis
    3. Incarcerated Hernia
    4. Varicocele
    5. Scrotal edema
  7. Lab
    1. Urinalysis normal in 90% patients
    2. Contrast with epidydimitis in which pyuria present
  8. Precautions
    1. Consider occult Testicular Torsion if Undescended Testicle
  9. Imaging
    1. Doppler Ultrasound
      1. Absent or decreased blood flow in Testicular Torsion
      2. Affected Testicle may appear enlarged
      3. Contrast with increased blood flow in Epididymitis
      4. Efficacy
        1. Test Sensitivity: 88%
        2. Test Specificity: 90%
    2. Radionuclide scanning
      1. Decreased perfusion in Testicular Torsion
      2. Contrast with increased perfusion in Epididymitis
      3. Test Sensitivity: 100%
  10. Evaluation
    1. Pain <6 hours and findings suggest torsion
      1. Immediate surgery
    2. Pain >6 hours or diagnosis uncertain
      1. Doppler Ultrasound of Scrotum
      2. Surgery for findings consistent with torsion
  11. Management
    1. Maintain high index of suspicion
    2. Immediate surgical consultation
      1. Surgical exploration is critical
      2. Definitive detorsion is goal
      3. Prophylactic orchiopexy of contralateral side
        1. Prevents recurrence of torsion on opposite side
    3. Attempt manual detorsion by rotating Testicle pedicle (do not delay surgery)
      1. Important
        1. Manual detorsion temporarily corrects problem
          1. Consider if >6 hours before specialist can correct
          2. Lifting Testicle may also temporize by alleviating pain and allowing reperfusion
        2. Manual detorsion does not obviate surgery
          1. Surgery required for definitive resolution
          2. Non-viable Testicle must be removed
          3. Prophylactic orchiopexy of contralateral side
      2. Position patient in supine position
      3. Consider pre-anesthetic
        1. Intravenous Sedation or
        2. Local 2% Lidocaine injected into vas deferens
      4. Rotate Testicle away from midline
        1. Grasp Testicle between thumb and index finger
        2. Rotate affected Testicle as if opening a book
          1. Rotate right Testicle clockwise or
          2. Rotate left Testicle counter-clockwise
        3. Rotate at least 180 degrees
          1. More than one turn may be required
          2. Continue until pain relief and stop if pain worsens
        4. Efficacy
          1. Successful in 26-80% of torsion cases
      5. References
        1. Cornel (1999) BJU Int 83:672-4
  12. Prognosis
    1. Testes salvage is time dependent on Restored Blood Flow
      1. Restored in 6 hours: 80-100% of Testes salvaged
      2. Restored in 12 hours: 50% iof Testes salvaged
      3. Restored >24 hours: 10-20% of Testes salvaged
    2. References
      1. Barada (1989) J Urol 142:746-8
  13. References
    1. Lewis (1995) J Pediatr Surg 30:277-82
    2. Hawtrey (1998) Urol Clin North Am 25:715-23
    3. Ringdahl (2006) Am Fam Physician 74:1739-46

Spermatic Cord Torsion (C0037856)

Definition (MSH) The twisting of the SPERMATIC CORD due to an anatomical abnormality that left the TESTIS mobile and dangling in the SCROTUM. The initial effect of testicular torsion is obstruction of venous return. Depending on the duration and degree of cord rotation, testicular symptoms range from EDEMA to interrupted arterial flow and testicular pain. If blood flow to testis is absent for 4 to 6 h, SPERMATOGENESIS may be permanently lost.
Concepts Disease or Syndrome (T047)
MSH D013086
ICD9 608.2, 608.20
ICD10 N44, N44.0, N44.00, N44.02
SnomedCT 198046000, 155937003, 198048004, 198045001, 81996005, 49198006
English Spermatic Cord Torsion, Spermatic Cord Torsions, Testicular Torsion, Testicular Torsions, Torsion, Testicular, Torsions, Spermatic Cord, Torsions, Testicular, SPERMATIC CORD, TORSION, SPERMATIC CORD TORSION, Spermatic cord torsion, TORSION TESTIS, Torsion, Spermatic Cord, Torsion of Testis, Torsion of testis NOS, Torsion of testis unspecified, TESTICULAR TORSION, TORSION OF TESTICULAR CORD, spermatic cord torsion, spermatic cord torsion (diagnosis), testicular torsion, testicle cord torsion, testicle torsion, torsion of testis (diagnosis), torsion of testis, Testis torsion, TESTICLE TORSION, Torsion of testis NOS (disorder), Torsion of testis unspecified (disorder), Torsion of testis, unspecified, Torsion of spermatic cord NOS, Spermatic Cord Torsion [Disease/Finding], testis torsion, testicles torsion, Torsion;testis, cord spermatic torsion, testies torsion, torsion of the testis, torsion testis, torsion of testicle, Torsion of testis, Torsion of spermatic cord, Torsion of testicle, Testicular torsion, Torsion of spermatic cord (disorder), Torsion of testis (disorder), spermatic cord; torsion, testicle; torsion, torsion; spermatic cord, torsion; testis, torsion testes
Italian Torsione del testicolo, Torsione del funicolo spermatico, Torsione testicolare, Torsione del cordone spermatico
Dutch torsio testis, torsie van zaadleider, testis torsie, testis; torsie, torsie; testis, torsie; zaadstreng, zaadstreng; torsie, testistorsie, Testiculaire torsie, Torsio testis
French Torsion d'un testicule, Torsion du testicule, Torsion du cordon spermatique, Torsion testiculaire
German Torsion des Hodens, Torsion des Samenstrangs, Torsion des Funiculus spermaticus, Hodentorsion, Samenstrangtorsion, Torsion, Hoden-
Portuguese Torção do testículo, Torção do cordão espermático, Torção testicular, Torção do Cordão Espermático, Torção Testicular
Spanish Torsión del cordón espermático, Torsión de testículo, Torsion of testis, Torsion of spermatic cord, torsión de testículo, SAI (trastorno), torsión de testículo, SAI, torsión de testículo, no especificada (trastorno), torsión de testículo, no especificada, torsión del cordón espermático (trastorno), torsión del cordón espermático, torsión del testículo (trastorno), torsión del testículo, torsión testicular, Torsión testicular, Torsión del Cordón Espermático, Torsión Testicular, Torsion Testicular, Torsion del Cordon Espermatico
Japanese 精巣捻転, 精索捻転, ｾｲｻｸﾈﾝﾃﾝ, ｾｲｿｳﾈﾝﾃﾝ, 精索捻転症, 睾丸捻転症, 精巣捻転症, 睾丸捻転病
Swedish Testikeltorsion
Czech funiculus spermaticus - torze, Testikulární torze, Torze varlete, Torze chámovodu
Finnish Siemennuoran kiertymä
Russian SEMENNOGO KANATIKA PEREKRUT, ZAVOROT IAICHKA, ЗАВОРОТ ЯИЧКА, СЕМЕННОГО КАНАТИКА ПЕРЕКРУТ
Korean 고환의 염전
Polish Skręcenie powrózka nasiennego
Hungarian A ductus spermatikus torsioja, heretorsio, Heretorsio, Testicularis torsio
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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