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Testicular Torsion

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  1. Epidemiology
    1. Incidence: 1:4000 males under age 25 years
    2. Young to middle aged men
  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. Vigorous Exercise
    3. Prior episode of similar pain spontaneously resolved
    4. Testicular hypertrophy during Puberty
    5. Testicular mass
    6. Cryptorchidism (status-post repair)
    7. 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. Signs
    1. Tender, firm affected Testicle
    2. Testicle may appear to be retracted upward
    3. Testicle swollen and edematous
    4. Cremasteric Reflex absent
      1. Most sensitive finding in testicular torsion
      2. Presence of reflex suggests epidydimitis
    5. Prehn's Sign Negative
      1. Elevation of scrotum does not relieve 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. Management (High index of suspicion!)
    1. Immediate Urology referral
      1. Rapid detorsion and scrotal exploration
      2. Fixation of uninvolved side
      3. Bilateral orchiopexy
    2. Where urologist is not immediately available
      1. Lifting the scrotom alone may allow detorsion
      2. Attempt manual detorsion by rotating Testicle pedicle
  9. Radiology
    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. 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
    2. Attempt manual detorsion (do not delay surgery)
      1. Important
        1. Manual detorsion temporarily corrects problem
        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 180 decreases 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. Efficacy
          1. Successful in 26-80% of torsion cases
      5. References
        1. Cornel (1999) BJU Int 83:672
  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
  13. References
    1. Lewis (1995) J Pediatr Surg 30:277
    2. Hawtrey (1998) Urol Clin North Am 25:715
    3. Ringdahl (2006) Am Fam Physician 74:1739

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.
ConceptsDisease or Syndrome (T047)
ICD9608.2, 608.20, 608.22
MSHD013086
EnglishSPERMATIC CORD TORSION, Spermatic Cord Torsions, Testicular Torsion, Testicular Torsions, Torsion of spermatic cord, Torsion of testicle, TORSION OF TESTICULAR CORD, Torsion of Testis, Torsion of testis unspecified, TORSION TESTIS
Spanishtorsion del cordon espermatico, torsion del testiculo, torsion testicular
Parent ConceptsSpermatic Cord Torsion (C0037856), Other male genital organ diseases NOS (C0156311), Genital Diseases, Male (C0017412), Testicular Non-Neoplastic Disorder (C1336723), Testicular Diseases (C0039584), Disease of scrotum (C0268919), Disorder of spermatic cord (C0403795), Duplicate concept (C1274013)
SourcesCOSTAR, DXP, ICD9CM, LCH, MSH, MTHICD9, NCI, NDFRT, OMIM, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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