Testicular torsion

Testicular torsion happens when the testes rotate freely on the spermatic cords, twisting the cords. If the rotation twists several times, impediment of blood flow results and immediate damage to the testes will occur. Testicular torsion is a urological emergency affecting about 12 percent of fetuses during gestation and newborns, approximately 17 percent of adolescents, and can affect 64 percent of adult males with testicular cancer.

Definition & Facts

An inherited trait or rapid growth during puberty may allow for free rotation of the testicle on the spermatic cord. When the spermatic cord twists, an ischemia or reduced blood supply occurs. The condition commonly presents directly after birth or in adolescence. One in 4,000 males will be affected before the age of 25.

Usually only one testicle is affected by torsion. Enlargement of the testicle due to adolescent growth or a tumor increases the risk of testicular torsion. Surgery to attach the spermatic cord is indicated to keep the problem from recurring.

A testicle may twist and then unwind on its own. This is called intermittent torsion and detorsion. Nevertheless, any severe testicular pain needs emergency attention even if it goes away without intervention.

Symptoms & Complaints

A mild inflammation around the entire area is common, with redness and swelling of the testicle (orchitis). The position of the testicle may appear higher than usual. Urination can be painful, and blood may be present in semen. Lumps may be visible in the scrotal sac. 

Causes

Climate plays a part in testicular torsion. Cold air causes the scrotum to contract. If torsion has occurred while the testicle is loose, the sudden contraction upon cold air causes the testicle to become trapped in a contracted position, resulting in torsion. 

A common deformity in the way the testicle is attached to surrounding tissue contributes to torsion of the spermatic cord. 90 percent of those presenting with the condition have a malformation of the processus vaginalis. The testes do not attach to the inner lining of the scrotum normally, but instead, terminate early and leave the testicle to float freely in the scrotum, increasing the risk of twisting. There is no procedure as yet to check for this deformity.

Age is a factor in the event, as males from the ages of 10-25 are most affected. If a previous torsion which disappeared without treatment is indicated, the individual is likely to experience the condition again unless surgery is performed and the underlying condition corrected. Sometimes an injury to the groin precedes testicular torsion. 

Diagnosis & Tests

Questions to verify symptoms are the first approach to diagnosis of testicular torsion. A physical examination of the testicles, scrotum, abdomen and groin are important to verify the condition. The doctor will test reflexes by pinching the inside of the thigh. This will normally cause the testes to contract, but this will not be present with testicular torsion. Medical tests are often necessary to confirm the diagnosis. These will include:

• Clinical urine tests to check for infection.
• An ultrasound of the scrotum to check for proper blood flow.

Treatment & Therapy

Manual detorsion is sometimes performed successfully for testicular torsion. The testicle is simply uncoiled manually within the scrotal sac. Doppler sonagram will confirm success.

If a person has been suffering pain for several hours and testicular torsion is suspected from observation, immediate surgical intervention will be indicated. A commonly performed surgical treatment is called orchiopexy. The spermatic cord is unwound and the cord is fixed to the scrotal wall with non-absorbable sutures. Both testicles are secured, even though only one may be affected, so that future torsion events will not occur.

The testicle is considered viable or living if its color returns and Doppler imaging reveals healthy blood flow. However, even when the testicle appears viable after surgery, as many as 50 percent of patients develop testicular atrophy in the following months. Usually these patients experience more pain than usual post-surgery as well. An orchiopexy that does not use a suture to pierce the tunica albugenia or layer of connective tissue covering the testicles, has been found to produce a more favorable outcome.

Another study indicates that the use of nicotinamide may reduce injury from ischemia in both early and post-surgical recovery. Antioxidant treatment has also been shown to be efficacious, consisting of melatonin and corticosteroids. A specified amount per day may be recommended immediately after surgery.

If ischemia, or impairment of blood flow exists for too long, the testicle is irreparably damaged. Then an orchiectomy is performed, in which the damaged or necrotic testicle is removed. Fertility and normal male sexual function can still occur with one testicle. In other words, having one testicle removed does not render a male infertile. No apparent changes are noted physically after such a procedure. Patients are counseled as to potential injury to the remaining testicle through contact sports. 

A testicular prosthesis may be placed after orchiectomy. This can be done approximately six months after surgery, to make sure all inflammatory issues are resolved.

Prevention & Prophylaxis

There is no prevention of testicular torsion. It can be caused by inherited conditions, prenatal conditions or testicular malignancy. It is a very rare condition, but it is essential to know the symptoms because immediate treatment is required to prevent death of the testicle and consequent removal. 

Prophylaxis will include surgery, antibiotics if infection is present and medications to ensure adequate blood supply (reperfusion) of the testicle once intervention is complete. Orchiopexy, or proper attachment of the spermatic cord, should prevent further episodes of testicular torsion.