What is Testicular Torsion?
Visits to the emergency department for problems with the scrotum are fairly frequent, making up at least 0.5% of all visits. One common issue is testicular torsion, where the testicle gets twisted in the scrotum. This is a serious situation that needs immediate medical attention, as prompt examination can help in taking quick action to prevent losing the affected testicle. Ultrasound is the best method to check what is going on inside the scrotum.
It’s important to diagnose testicular torsion early as the health of the testicle can start to worsen significantly 6 hours after symptoms begin. Testicular torsion is most commonly seen in young people, but it can happen in older individuals as well, although it’s rare. Surgery is the only way to treat this condition.
What Causes Testicular Torsion?
Testicular torsion mostly occurs in younger people, typically under 25 years old, and it’s normally caused by a birth defect of the testicular region. How it comes on can vary – it could happen spontaneously, happen due to effort like sports, or, though less common, be related to an injury. This condition is responsible for a significant number of emergency room visits due to pain in the scrotum.
Testicular torsion is the twisting of the part that carries the blood supply and the cord that carries sperm. The internal covering layer of the testes, known as the tunica vaginalis, is usually firmly attached to the back side of the testicle. The spermatic cord, which carries sperm, is not supposed to move around within it. However, if the attachment point of the tunica vaginalis is high, it allows the spermatic cord to twist inside, leading to what is known as intravaginal torsion. This flaw is sometimes referred to as the bell clapper deformity, and it’s found on both sides in at least 40% of cases.
Newborns, on the other hand, are more likely to develop a different type of twist, known as extravaginal torsion. This happens because the tunica vaginalis isn’t yet attached to the gubernaculum, an anchoring cord in the scrotum, making both the tunica vaginalis and the spermatic cord prone to twisting. This issue can come about weeks or even months prior to birth and it is managed differently. However, it’s important to note that newborns can also have intravaginal torsion.
Lastly, it’s worth mentioning that in adults, testicular torsion can happen in instances where there is a testicular cancer.
Risk Factors and Frequency for Testicular Torsion
Testicular torsion, a major cause of testicular loss, mostly happens during adolescence, which is a period of growth. However, it’s important to note that it can occur at any age, including before or after birth.
Signs and Symptoms of Testicular Torsion
Testicular torsion typically begins suddenly with pain on one side of the scrotum. This pain can be continuous or it might come and go, but it doesn’t change with different body positions. Sometimes, the person might also feel nauseous or might vomit. The pain might also be felt in the lower abdomen or groin, and in some cases, these might be the first symptoms instead of the scrotal pain.
The affected testicle might be lying in an unusual position or higher than normal. It might also be swollen, red, and the usual reflex response known as the cremasteric reflex might be absent. However, it’s worth mentioning that this reflex isn’t always a reliable sign of testicular torsion, especially in young children under a year old.
Another sign, known as the Prehn sign (where lifting the testicle relieves the pain), isn’t a reliable predictor of testicular torsion either.
Testicular appendage torsion (twisting of an appendage related to the testicle) is more common but it’s not harmful. This can be distinguished from testicular torsion in the early stages by severe tenderness near the head of the epididymis or testicle, a painfully tender lump, and/or a blue spot on the testicle, which is due to the twisted appendage turning blue. This twisted appendage tends to harden and break down over two weeks, and usually doesn’t require surgery.
- Sudden pain in one side of the scrotum
- Pain might be continuous or come and go
- Possible nausea and vomiting
- Pain might also occur in the lower abdomen or groin
- The affected testicle might be in an unusual position or higher than normal
- The testicle might be swollen and red
- Absence of the cremasteric reflex
- Severe tenderness near the head of the epididymis or testicle in case of testicular appendage torsion
- A painfully tender lump in case of testicular appendage torsion
- A blue spot on the testicle in case of testicular appendage torsion
Other conditions with similar symptoms, such as epididymitis, orchitis, inguinal hernia, symptomatic hydrocele, testicular necrosis from other causes, and scrotal hematoma should also be considered.
Testing for Testicular Torsion
The TWIST scoring system is a tool doctors use to check for testicular torsion, a condition where the testicle becomes twisted. The system gives points based on different signs and symptoms:
– Hard testicle – 2 points
– Swelling – 2 points
– Nausea or vomiting – 1 point
– Absent cremasteric reflex (the normal contraction of the testicle when touched) – 1 point
– High riding testis (one testicle is higher than the other) – 1 point
The higher the score, the more likely it is that you have testicular torsion. Doctors often suggest an ultrasound for people with lower scores. For those with high scores, surgery might be suggested straight away, without needing an ultrasound for confirmation.
An ultrasound, a test that uses sound waves to create images of the inside of your body, is usually the main way to confirm whether or not you have testicular torsion, after the doctor has examined you physically. It is usually very accurate – about 93% sensitive and 100% specific.
During an ultrasound, you’ll lie on your back with your legs spread and a towel supporting your scrotum. The doctor will put a special gel on a handheld device (transducer), and move it gently over the area. They will check both testicles, looking for changes in size, fluid collections and color differences. If torsion is present, there is often fluid (a hydrocele) around the testicle and it may have less color flow, indicating reduced blood supply.
The ultrasound also uses “color Doppler” and “power Doppler” technology to evaluate blood flow in the testicles. These technologies can show both arterial and venous flow, which gives the doctor a more complete picture of the blood supply to the testicles.
Additionally, doctors may take a urine sample to check for pyuria – an excessive amount of white blood cells in the urine, which can be a sign of infection. This is normally part of the evaluation for severe testicle pain. Pyuria is usually seen in epididymitis, orchitis, or urinary tract infections, but its absence doesn’t rule out the possibility of testicular torsion.
Treatment Options for Testicular Torsion
An ultrasound is not always able to accurately determine if an infant has a twisted testicle, a condition known as testicular torsion. For instance, 40% of newborn babies may not show any apparent blood flow through the affected testicle using an ultrasound method called color flow Doppler. If the possibility of testicular torsion is high based on symptoms, seeking immediate help from a urologist, a doctor who specializes in diseases of the urinary tract and the male reproductive system, is crucial. Delaying treatment could lead to the death of the affected testicle due to lack of blood flow, a condition known as testicular necrosis, which can result in the eventual loss of the testicle.
The window for successfully treating testicular torsion by surgery and saving the testicle is usually 6 hours from when the pain first begins. Therefore, it’s critical to consult a urologist as soon as possible, even if an ultrasound or other tests haven’t confirmed the condition.
If a urologist is not immediately available, it might be necessary to try and manually untwist the testicle. This involves gently turning the affected testicle from the middle to the side, a movement known as the “open book” technique. Once turned, an evaluation for pain relief is done. If the pain increases, consider rotating the testicle in the opposite direction. An ultrasound can be used frequently to check for the return of blood flow. If initial efforts aren’t successful, further attempts at manual untwisting could be tried, as the testicle might have twisted more than 180 degrees.
For newborn babies, both testicles are usually examined through a surgical procedure. A preventative procedure called orchiopexy is always performed on the other testicle to prevent future twists. If a testicle is determined to be non-viable, meaning it can’t be saved, it would have to be surgically removed through a procedure known as orchiectomy. After this, a testicle-shaped prosthetic can be inserted, typically 4-6 months after the initial surgery, once the inflammation has gone down.
What else can Testicular Torsion be?
Other possible conditions that could be mistaken for a testicular issue include:
- Tumor in the testes
- Epididymitis (inflammation of the tube at the back of the testicle)
- Hydrocele (swelling in the scrotum)
- Traumatic hematoma (blood clot caused by injury)
- Orchitis (inflammation of the testicles)
What to expect with Testicular Torsion
Over time, the success rate of saving the testicles after a condition called torsion, where the spermatic cord supplying the testes gets twisted, has significantly improved. However, results can still be poor, predominantly in African Americans, young patients, and those without health insurance. The best outcomes are seen when surgery is performed within 8 hours of the onset of symptoms. Nevertheless, there’s a possibility that the condition could happen again even after a surgical procedure called orchiopexy, which secures the testicles in place to prevent torsion.
Possible Complications When Diagnosed with Testicular Torsion
Potential Side Effects:
- Loss of a testicle
- Infection
- Infertility
- Change in physical appearance
- Decreased body regulation functions in men
