CHAPTER 32 Testicular Torsion
Step 1: Surgical Anatomy
♦ Acute scrotal pain, particularly with erythema and edema, is the usual presentation of testicular torsion. The differential diagnoses of the acute scrotum are numerous (see Table 32-1), but testicular torsion, which results from a twisting of the spermatic cord, is the most serious and is a true surgical emergency.
♦ In the non-neonate, the physical examination findings are typically characterized by a unilaterally tender scrotum with varying degrees of erythema and edema. The testicle tends to ride higher in the scrotum and have a characteristic transverse orientation (Fig. 32-1).
♦ An anatomic anomaly of incomplete testicular fixation or “bell-clapper” deformity is necessary for testicular torsion to occur in the non-neonate (Fig. 32-2). This type of torsion is termed intravaginal, with the twist occurring within the tunica vaginalis because of the lack of normal attachments of the tunica vaginalis along the posterior aspect of the cord, epididymis, and testicle (Fig. 32-3).
Step 2: Preoperative Considerations
♦ In the neonate, the classic examination shows a dark, firm hemiscrotum with or without obvious tenderness and erythema, depending on when the torsion occurs perinatally (Fig. 32-5). In the older child, the hemiscrotum is usually significantly tender and erythematous as described above. The classic history is the sudden onset of unilateral testicular pain that is unrelenting and often associated with nausea and vomiting.
♦ A “golden” period of 4 to 8 hours from the time of torsion is considered the acceptable time frame to operate in order to have the best chance for testicular salvage. In the neonate, that period may be long past the time the patient delivers, and the chance of testicular salvage is typically not good.
♦ In the older child, time is of the essence, and every effort should be made to get to the operating room as soon as possible if the patient has a history and examination consistent with torsion.
♦ Other diagnostic studies most often are indicated in the patient with a nonclassic history or examination. Radioisotope scanning has been used historically to determine testicular flow, but it has mostly been replaced with high-resolution ultrasound with color-flow Doppler.
♦ The absence of vascular flow suggests testicular torsion (Fig. 32-6). Longstanding torsion may be associated with testicular necrosis, which appears heterogeneous on ultrasound (Fig. 32-7). It must be emphasized that these adjunctive studies should not delay surgical intervention in a patient who clinically is thought to have testicular torsion so as not to decrease the chance for testicular salvage. These studies are best used to help confirm a diagnosis other than testicular torsion.
♦ In the older child, little preoperative preparation is necessary or indicated unless there are significant health issues that would increase anesthetic risk. Some clinicians recommend an attempt at manual detorsion while on the way to the operating room. This should not delay or replace operative intervention even if it is considered successful. Because the attempt at detorsion might have been incomplete, surgical exploration is still required for complete evaluation and treatment.
♦ In the neonate who is born with a dark, firm hemiscrotum and is nontender, the torsion has probably occurred remotely enough that testicular salvage is unlikely and urgent exploration might not be warranted, particularly in a child with any other conditions that would affect his anesthetic risk. Contralateral asynchronous torsion, even within the first hours and days of life, has been reported. For this reason, early exploration and contralateral testicular fixation may be warranted in the healthy neonate. A newborn with findings suggestive of acute torsion around the time of delivery or after should certainly have urgent surgical intervention.
Step 3: Operative Steps
♦ The approach to testicular torsion can be tailored to the age of the patient. In general, a first-generation cephalosporin is given before the procedure.
Neonatal Torsion
♦ Neonatal torsion is often approached using an inguinal incision that allows access to the entire cord to address any other pathology such as a patent processus vaginalis (Fig. 32-8).
♦ When torsion is encountered, the spermatic cord is detorsed and the testis is wrapped in a warm, moist gauze. The contralateral testis is delivered and fixation performed.
♦ The ipsilateral testis is then reassessed to determine viability. The testicular capsule can be nicked with a scalpel to evaluate for active bleeding. Fluorescein may also be administered intravenously and the testis inspected with a Wood’s lamp. These assessments are unreliable, and we do not generally perform them.
♦ If findings are equivocal, orchiopexy is generally performed. If the testis appears nonviable, the cord is controlled proximally with non-absorbable suture ligation and the testis is excised.
♦ If the testis is viable, a dartos pouch can be fashioned through a transverse scrotal incision and the orchiopexy performed as in the setting of cryptorchidism, where the testis is brought from the inguinal to scrotal incision after a tunnel is created bluntly.
♦ Some clinicians prefer to tighten the subcutaneous tissues surrounding the cord with absorbable suture as the testis is brought through the scrotal incision. Others fix the tunica albuginea of the testis to the adjacent dartos tissue or dermis with absorbable suture to prevent future torsion. The overlying skin is closed with running absorbable suture.
♦ The contralateral testis is approached through a transverse scrotal incision. It is often helpful to develop the dartos pouch before delivering the testis (Fig. 32-9). The testis is fixed to the adjacent tissue in similar fashion (Fig. 32-10).
Non-neonatal Torsion
♦ In non-neonatal torsion, the most common approach is through a midline scrotal incision (Fig. 32-11). Once at the dartos level, the incision is deviated and advanced over the involved testis and the testis delivered. If the testis is viable, it is fixed to the surrounding dartos tissue in three positions with nonabsorbable suture (Fig. 32-12).
♦ The contralateral testis is approached through the septum and fixed in identical fashion. The dartos tissue is closed using running absorbable suture, including the lateral dartos tissue in addition to the median septum. The overlying skin is closed in running subcuticular fashion using absorbable suture.
♦ In either age group, contralateral fixation is extremely important. The preexisting anatomic defect, whether a bell-clapper deformity in adolescents or poor investment of the parietal tunica vaginalis to the adjacent dartos tissue, is a bilateral problem, and failing to fix the contralateral testis leaves it at risk for future torsion.
Step 4: Postoperative Care
♦ The procedure is generally done on an outpatient basis; postsurgical incisional pain pales in comparison to the torsion itself. Postoperative antibiotics are not usually given.
♦ The patient is seen back for re-evaluation 2 to 3 weeks after surgery and again approximately 6 months later to evaluate for delayed atrophy. In theory, testis atrophy raises the potential for anti-sperm antibodies and is an important counseling point. At present, however, the available literature does not recommend re-exploration for excision.
♦ As in any other boy, we recommend an athletic support brief for all sports and a protective cup for contact sports. This is even more important in a boy with only one testis. Although unlikely, recurrent torsion after fixation has been reported, and families should be counseled to be sensitive to the signs and symptoms that should prompt urgent surgical evaluation.
Baker LA, Sigman D, Mathews RI, et al. An analysis of clinical outcomes using color Doppler testicular ultrasound for testicular torsion. Pediatrics. 2000;105(3 Pt 1):604-607.
Gatti JM, Murphy JP. Current management of the acute scrotum. Semin Pediatr Surg. 2007;16(1):58-63.
Hutson J. Undescended testis, torsion and varicocele. In: Grosfeld JL, Coran G, et al, editors. Pediatric surgery. Philadelphia: Mosby Elsevier; 2006:1193-1214.
Kiesling VJJr, Schroeder DE, Pauljev P, et al. Spermatic cord block and manual reduction: primary treatment for spermatic cord torsion. J Urol. 1984;132(5):921-923.
Mor Y, Pinthus JH, Nadu A, et al. Testicular fixation following torsion of the spermatic cord—does it guarantee prevention of recurrent torsion events? J Urol. 2006;175(1):171-173. discussion 173-174
Murphy J. The acute scrotum. In: Ziegler NM, Weber TR, et al, editors. Operative pediatric surgery. New York: McGraw-Hill; 2003:563-567.
