John M. Gatti and Janine Pettiford

Testicular Torsion

Torsion of the testis results from twisting of the spermatic cord which compromises the testicular vasculature and results in infarction. Even if the testis is not removed, the consequent ischemic damage can affect testicular morphology and fertility. There appears to be a 4-8-hour window before significant damage occurs once torsion develops.⁴ Table 52-1 shows that the probability of testicular salvage declines significantly beyond six hours. Emergency exploration is indicated even beyond this window because testicular viability is difficult to predict.⁵

Two types of torsion occur: intravaginal and extravaginal. Intravaginal torsion is more common in children and adolescents (compared to neonates), and occurs when the spermatic cord twists within the tunica vaginalis (Fig. 52-1). Intravaginal torsion develops because of abnormal fixation of the testis and epididymis within the tunica vaginalis. Normally, the tunica will invest the epididymis and posterior surface of the testis, fixing it to the scrotum with a vertical lie. Abnormal fixation occurs when the tunica vaginalis attaches more proximally on the spermatic cord, creating a long mesorchium around which the testis can twist. The testis will then lie horizontally and the pendulous testis is predisposed to twisting with leg movement or cremasteric contraction. This anatomic variant is classically described as the ‘bell-clapper’ deformity and has an incidence as high as 12% in cadaveric studies. Often, it is found in the contralateral scrotum as well.⁶

Extravaginal torsion occurs perinatally when the spermatic cord twists proximal to the tunica vaginalis (Fig. 52-2). During testicular descent into the scrotum, the tunica vaginalis is not firmly fixed to the scrotum, allowing the tunica and testis to spin on the vascular pedicle.

Testicular torsion typically occurs before age 3 years or after puberty. It is less common in prepubertal boys and after age 25 years. Patients present with the sudden onset of severe, unilateral pain in the testis, lower thigh, or lower abdomen, often associated with nausea and vomiting. Episodes of intermittent testicular pain may precede the acute presentation, suggesting prior incomplete torsion with spontaneous detorsion. Physical examination may reveal an enlarged testis that is retracted up toward the inguinal region with a transverse orientation and an anteriorly located epididymis. However, it is usually difficult to obtain a good exam because of the scrotal pain and tenderness. In contrast, focal tenderness at the superior pole of the testis or along the epididymis is often found with a torsed appendix testis or epididymitis (Fig. 52-3). Depending on the duration of torsion, the hemiscrotum can show varying degrees of swelling and erythema, which may obliterate landmarks and make the examination more difficult. The cremasteric reflex is often absent with testicular torsion, but a positive reflex does not reliably exclude it.^7–9

The diagnosis of testicular torsion is usually clinically apparent and managed by immediate scrotal exploration. When torsion is difficult to diagnosis, other studies may be beneficial. A urinalysis revealing pyuria and bacteriuria is more indicative of infectious epididymitis/orchitis, but can also be found with torsion. High-resolution ultrasonography (US) with color flow Doppler and radionuclide imaging allows determination of testicular blood flow. Ultrasound is more commonly used because it allows determination of the blood flow, is less time consuming, is more readily available, and does not expose the patient to ionizing radiation.10,11 In experienced hands, color flow Doppler ultrasound imaging has a sensitivity of 89.9%, a specificity of 98.8%, and a false-positive rate of 1%.¹² Also, Doppler ultrasound may detect coiling of the spermatic cord, indicating torsion, even with normal blood flow within the testis.¹³ Ultrasound should only be used when the diagnosis is equivocal because imaging studies will only delay scrotal exploration.

If testicular torsion is suspected but a delay to the operating room is unavoidable, manual detorsion can be attempted. Detorsion is performed with a medial to lateral, ‘open book’ rotation because this will be the correct direction in two-thirds of patients.¹⁴ If successful, the testis will drop lower in the scrotum and the patient will report sudden pain relief. If the initial attempt is not successful, an attempt in the reverse direction may be warranted.¹⁵ Although these maneuvers may decrease the degree of ischemia, prompt exploration and fixation remain mandatory because the detorsion may not be complete and torsion can reoccur.

Exploration is typically performed using a median raphe scrotal incision. The symptomatic hemiscrotum is entered and the testis delivered, detorsed, and placed in warm, moist sponges while the contralateral hemiscrotum is explored. The unaffected testis should be fixed to the scrotal wall with nonabsorbable suture in at least three points. Excluding the tunica vaginalis allows better fixation of the testis to the scrotum.16,17