Testicular torsion

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Testicular torsion
Classification and external resources
Illu testis surface.jpg
1. Epididymis 2. Head of epididymis 3. Lobules of epididymis 4. Body of epididymis 5. Tail of epididymis 6. Duct of epididymis 7. Deferent duct (ductus deferens or vas deferens)
ICD-10N44
ICD-9608.2
OMIM187400
DiseasesDB12984
MedlinePlus000517
eMedicinemed/2780
MeSHD013086
 
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Testicular torsion
Classification and external resources
Illu testis surface.jpg
1. Epididymis 2. Head of epididymis 3. Lobules of epididymis 4. Body of epididymis 5. Tail of epididymis 6. Duct of epididymis 7. Deferent duct (ductus deferens or vas deferens)
ICD-10N44
ICD-9608.2
OMIM187400
DiseasesDB12984
MedlinePlus000517
eMedicinemed/2780
MeSHD013086

Testicular torsion occurs when the spermatic cord (from which the testicle is suspended) twists, cutting off the testicle's blood supply, a condition called ischemia. The principal symptom is rapid onset of testicular pain. The most common underlying cause is a congenital malformation known as a "bell-clapper deformity" wherein the testis is inadequately affixed to the scrotum allowing it to move freely on its axis and susceptible to induced twisting of the cord and its vessels. The diagnosis can be made clinically but an urgent ultrasound is helpful in evaluation. Irreversible ischemia begins around six hours after onset and emergency diagnosis and treatment is required within this time in order to minimize necrosis and to improve the chance of salvaging the testicle.

Risk factors[edit]

Congenital[edit]

Conditions that allow the testicle to rotate predispose to torsion.[1] A congenital malformation of the processus vaginalis known as the "bell-clapper deformity" accounts for 90% of all cases.[2] In this condition, rather than the testes attaching posteriorly to the inner lining of the scrotum by the mesorchium, the mesorchium terminates early and the testis is free floating in the tunica vaginalis.

Temperature[edit]

Torsions are sometimes called "winter syndrome" because they are more frequent in cold conditions, specifically decreasing atmospheric temperature and humidity.[3]

Diagnosis[edit]

Immediate testing for torsion is indicated when the onset of testicular pain is sudden and/or severe. In general a doppler ultrasound should be obtained in low suspicion cases to rule out torsion while in those cases with a convincing history and physical exam immediate surgical detorsion (derotation) is reasonable.[1]

Clinical exam[edit]

Prehn's sign, a classic physical exam finding, has not been reliable in distinguishing torsion from other causes of testicular pain such as epididymitis.[4] In cases of true torsion the cremasteric reflex is typically absent (the twisted cords of the testicle make reflexive responses all but impossible). On physical examination, the testis will be swollen, tender, and high-riding, with an abnormal transverse lie.[5] The individual will not usually have a fever, though nausea is common.

Imaging[edit]

A doppler ultrasound scan, also called a high-frequency transducer sonography and including pulsed color Doppler imaging, of the scrotum is nearly 100% accurate at detecting torsion.[1] It is identified by the absence of blood flow in the twisted testicle, which distinguishes the condition from epididymitis.[6]

Radionuclide scanning of the scrotum is the most accurate, diagnostic, imaging technique, but it is not routinely available, particularly with the urgency that might be required.[7] The agent of choice for this purpose is technetium-99m pertechnetate.[8] Initially it provides a radionuclide angiogram, followed by a static image after the radionuclide has perfused the tissue. In the healthy patient, initial images show symmetric flow to the testes, and delayed images show uniformly symmetric activity.[8]

Pathophysiology[edit]

Torsion is due to a mechanical twisting process. It is also believed that torsion occurring during fetal development can lead to so-called neonatal torsion or vanishing testis, and is one of the causes of an infant being born with monorchism (one testicle)[9] .

Treatment[edit]

With prompt diagnosis and treatment the testicle can usually be preserved.[1] Typically, when a torsion takes place, the surface of the testicle has rotated towards the midline of the body. Non-surgical correction can sometimes be accomplished by manually rotating the testicle in the opposite direction (i.e., outward, towards the thigh); if this is initially unsuccessful, a forced manual rotation in the other direction may correct the problem.[10]:p.149 The success rate of manual detorsion is not known with confidence.

Testicular torsion is a surgical emergency that requires immediate intervention to restore the flow of blood.[1] If treated either manually or surgically within six hours, there is a high chance (approx. 90%) of preserving the testicle. At 12 hours the rate decreases to 50%; at 24 hours it drops to 10%, and after 24 hours the rate of preservation approaches 0.[1]

Epidemiology[edit]

Torsion is most frequent among adolescents with about 65% of cases presenting between 12 – 18 years of age.[11] It occurs in about 1 in 160 males before 25 years of age;[1][2] but it can occur at any age, including infancy.[10]:p.149

Intermittent testicular torsion[edit]

A variant is a less serious but chronic condition called intermittent testicular torsion (ITT), characterized by the symptoms of torsion but followed by eventual spontaneous detortion and resolution of pain. Nausea or vomiting may also occur.[10]:p.150 Though less pressing, such individuals are at significant risk of complete torsion and possible subsequent orchiectomy and the recommended treatment is elective bilateral orchiopexy. Ninety-seven percent of patients who undergo such surgery experience complete relief from their symptoms. [12]:p.316

Extravaginal testicular torsion[edit]

A torsion which occurs outside of the tunica vaginalis, when the testis and gubernaculum can rotate freely, is termed an extravaginal testicular torsion. This type occurs exclusively in newborns. Neonates experiencing such a torsion present with scrotal swelling, discoloration, and a firm, painless mass in the scrotum. Such testes are usually necrotic from birth and must be removed surgically.[12]:p.315

Torsion of the testicular appendix[edit]

This type of torsion is the most common cause of acute scrotal pain in boys ages 7–14. Its appearance is similar to that of testicular torsion but the onset of pain is more gradual. Palpation reveals a small firm nodule on the upper portion of the testis which displays a characteristic "blue dot sign." This is the appendix of the testis which has become discolored and is noticeably blue through the skin. Unlike other torsions, however, the cremasteric reflex is still active. Typical treatment involves the use of over-the-counter analgesics and the condition resolves within 2–3 days.[12]:p.316

References[edit]

  1. ^ a b c d e f g Wampler SM, Llanes M (September 2010). "Common scrotal and testicular problems". Prim. Care 37 (3): 613–26, x. doi:10.1016/j.pop.2010.04.009. PMID 20705202. 
  2. ^ a b Ringdahl E, Teague L (November 2006). "Testicular torsion". Am Fam Physician 74 (10): 1739–43. PMID 17137004. 
  3. ^ "Climatic Conditions and the Risk of Testicular Torsion in Adolescent Males". Jurology.com. Retrieved 2011-09-28. 
  4. ^ Lavallee ME, Cash J (April 2005). "Testicular torsion: evaluation and management". Curr Sports Med Rep 4 (2): 102–4. PMID 15763047. 
  5. ^ Liu DR. Chapter 127. Urologic and Gynecologic Problems and Procedures in Children. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011.
  6. ^ Arce J, Cortés M, Vargas J (2002). "Sonographic diagnosis of acute spermatic cord torsion. Rotation of the cord: a key to the diagnosis". Pediatr Radiol 32 (7): 485–91. doi:10.1007/s00247-002-0701-z. PMID 12107581. 
  7. ^ Sexually Transmitted Diseases Treatment Guidelines, 2010 from Centers for Disease Control and Prevention, Recommendations and Reports. December 17, 2010 / Vol. 59 / No. RR-12
  8. ^ a b Medscape > Testicular Torsion Imaging by David Paushter. Updated: May 25, 2011
  9. ^ Callewaert PRH, Kerrebroeck PV (2010 June ). "New insights into perinatal testicular torsion ". Eur J Pediatr 169 (6): 705–12. doi:10.1007/s00431-009-1096-8. PMC 2859224. PMID 19856186. 
  10. ^ a b c Uribe, Juan F. (1 January 2008). Potts, Jeannette M., ed. Genitourinary Pain and Inflammation: Diagnosis and Management. Totowa, New Jersey: Humana. pp. 149–. ISBN 978-1-60327-126-4. Retrieved 8 July 2013. 
  11. ^ Edelsberg JS, Surh YS (August 1988). "The acute scrotum". Emerg. Med. Clin. North Am. 6 (3): 521–46. PMID 3292226. 
  12. ^ a b c Kavoussi, Parviz K.; Costabile, Raymond A. (2011). "Disorders of scrotal contents: orchitis, epididimytis, testicular tortion, tortion of the appendages, and Fournier's gangrene". In Chapple, Christopher R.; Steers, William D. Practical urology: essential principles and practice. London: Springer-Verlag. ISBN 978-1-84882-033-3. 

External links[edit]