Testicular torsion is a urological emergency requiring urgent treatment. It refers to the rotation of the spermatic cord along its longitudinal axis, leading to impaired blood supply and resulting in acute ischemia and necrosis of the testis. The annual incidence is approximately 1 in 4,000 among males under the age of 25. It is generally believed that testicular torsion lasting more than six hours may cause irreversible damage to the testis to varying degrees.
Etiology and Classification
Intravaginal testicular torsion is primarily associated with factors such as an excessively long mesorchium, which increases testicular mobility; horizontal testicular orientation; or developmental abnormalities of the testis, epididymis, or tunica vaginalis. Testicular torsion is classified into intravaginal and extravaginal types. The intravaginal type is more common and primarily occurs in adolescents, while the extravaginal type almost exclusively occurs in newborns.
Clinical Manifestations
The main symptom is sudden onset of unilateral scrotal pain, which typically occurs during sleep or after vigorous physical activity. It may initially manifest as dull pain that rapidly progresses to severe pain. The pain can radiate to the ipsilateral inguinal region and lower abdomen and may be accompanied by nausea and vomiting. Although no clear triggering factors are present, many patients report a recent history of trauma or strenuous physical activity. For torsion involving an undescended testis in the abdominal cavity, the pain localizes to the lower abdomen.
Diagnosis and Differential Diagnosis
Testicular torsion should be considered in young patients and children presenting with acute scrotal pain. Physical examination often reveals a testis that is elevated and horizontally positioned, with an enlarged and poorly defined epididymal contour, shortened spermatic cord, and absent cremasteric reflex. The Prehn sign (exacerbation of testicular pain with elevation of the scrotum) may be positive. Doppler ultrasonography, which has high sensitivity, is the preferred diagnostic method. It may reveal an enlarged testis on the affected side with absent or significantly reduced blood flow compared to the contralateral side. Contrast-enhanced ultrasonography can improve diagnostic accuracy. It is important to note that in the early stages of torsion, venous outflow may be obstructed while arterial blood flow remains present.
When the clinical history and physical findings strongly suggest testicular torsion, but the diagnosis cannot be conclusively established by ultrasound, immediate surgical exploration is advised to minimize the risk of a missed diagnosis.
Differential diagnosis includes conditions such as acute epididymo-orchitis, torsion of testicular appendages, strangulated inguinal hernia, and testicular tumors.
Treatment
The treatment principle for testicular torsion focuses on promptly restoring blood flow to the affected testis. Early and accurate diagnosis, followed by timely and effective intervention, is crucial in salvaging the testis. Once torsion is suspected, immediate manual detorsion or emergency surgical exploration becomes essential.
Manual detorsion is suitable for patients in the early stage of torsion with mild scrotal edema and exudation. If manual detorsion is unsuccessful, early surgical exploration is recommended. Surgical exploration within six hours of symptom onset is associated with a higher likelihood of testicular salvage. The probability of preserving the testis decreases significantly if scrotal symptoms persist for more than 12 hours.
Intraoperative decisions are based on findings: the options include detorsion and preservation of the testis, bilateral testicular fixation, or excision of the affected testis with fixation of the contralateral testis. Testicular atrophy may still occur postoperatively in cases where the testis is preserved.