Testicular Torsion - An Overview

What Is Testicular Torsion?

Testicular torsion is a severe and painful condition that affects the testicles. It occurs when the spermatic cord twists, cutting off blood flow to the affected testicle. Without immediate treatment, this can lead to the death of the testicle. The spermatic cord provides blood to the testicles in men and individuals assigned male at birth (AMAB). Located in the scrotum beneath the penis, the testicles are reproductive organs responsible for producing hormones and sperm.

How Severe Is Testicular Torsion?

Testicular torsion is a critical medical emergency. If the individual experiences sudden, intense pain in one of the testicles, contact a healthcare provider or visit an emergency room (ER) immediately. The likelihood of saving the affected testicle decreases when the treatment is delayed:

• Nearly everyone retains their testicle if treated within four to six hours.

• About 50 % of people retain their testicles if treated after 12 hours.

• Only around 10 % of people retain their testicles if treated after 24 hours.

What Are the Symptoms of Testicular Torsion?

The symptoms include:

• Spontaneous and severe pain in the scrotum (sack present below the penis that holds the testis).

• Abdominal pain.

• Nausea and vomiting.

• Abnormal positioning of the testis.

• Swelling of the scrotum.

• Polyuria (frequent urination).

• Fever.

• Younger people often have severe pain in the scrotum that occurs early in the morning or the middle of the night.

When to See a Doctor?

If the person experiences sudden or severe pain in the testicles, seek medical care immediately. Timely treatment may help save the testis from permanent damage. Immediate medical care should be taken for intermittent torsion and detorsion. Intermittent torsion and detorsion are cases in which the testicle twists and untwists itself. The person may experience sudden pain, which goes away without treatment. However, surgical intervention is required to prevent it from twisting again.

What Causes Testicular Torsion?

Most cases of testicular torsion occur in individuals with a "bell clapper" deformity. Typically, testicles are anchored to the scrotum, preventing them from twisting. However, with a bell clapper deformity, the testicles hang loosely in the scrotum and swing freely, much like a clapper in a bell, which can cause them to twist. Testicular torsion can also result from an injury to the testicle or scrotum. Physical activities like lunging, jumping, or twisting do not cause testicular torsion. Although torsion may occur during exercise, the activity itself is not the cause.

What Are the Risk Factors for Testicular Torsion?

The risk factors include:

• Age: It is more common in age groups between twelve to eighteen.

• Family History: This disease can be inherited.

• History of Testicular Torsion: Intermittent torsion and detorsion are conditions in which the testicle twists and untwists. The person with these conditions may experience sudden pain, which goes away without treatment. However, surgical intervention is required to prevent it from twisting again.

What Are the Complications of Testicular Torsion?

The complications involve:

• Prolonged loss of blood flow to the testicles causes permanent damage to the testicles and may have to be surgically removed.

• Infertility (Inability to produce offspring).

• Cosmetic deformity.

• Loss or reduced exocrine and endocrine function in men.

What Is the Diagnosis of Testicular Torsion?

Diagnosis involves the physical examination of the scrotum, testicles, abdomen, and groin. They may check for testicular reflexes by pinching the inner thighs, which causes flinching of the testis. The reflex is absent in testicular torsion.

Other diagnostic tests involve:

• Urine Test: Urine is checked for infection.

• Scrotal Ultrasound: It helps detect decreased blood flow in the testicle, a sign of testicular torsion. It is the common diagnostic procedure used in testicular torsion and has sensitivity and specificity rates of 93 % and 100 %, respectively.

• Surgery: It can be used to check for a differential diagnosis or detect any associated condition.

• Twist Scoring System: This test is used to evaluate the extent of testicular torsion. The twisting tool includes:

• Hard testis -2.

• Swelling -2.

• Nausea or vomiting -1.

• Cremastric reflex absent -1.

• High riding testes -1.

The individual with a higher score has a high probability of having testicular torsion. An ultrasound is performed to further evaluate the low scores, and individuals with the highest score can be directly advised for surgery.

Differential Diagnosis:

• Traumatic hematoma (Blood collection due to injury causing tissue damage).

• Hydrocele (Fluid-filled sac around testicle causing swelling).

• Epididymitis (Inflammation of epididymis, often due to infection).

• Testis tumor (Abnormal growth in testicle, potentially cancerous).

• Orchitis (Inflammation of testicles, often caused by infection).

Testicular Torsion in Infants and Newborns:

Testicular torsion is rare in newborns and infants. The symptoms involve hard, swollen, or darker color testes. Ultrasound is ineffective in diagnosing testicular torsion, so the doctor may opt for surgery.

What Is the Treatment for Testicular Torsion?

• Surgical Modalities: 40 % of the neonatal testicles have no color flow Doppler; hence, ultrasound may not always be suggested. If the test scores are high, urologic surgery should be performed immediately, as the window of opportunity is six hours from the onset of pain. Beyond this, there may be necrosis and permanent loss of the testicle.

• Manual Detorsion: This procedure is attempted if surgery is not an option. It is done by rotating the testis from the medial to the lateral direction in a 180-degree direction and then checking for pain. The testes are rotated in the opposite direction if the pain levels increase.

• Treatment Modalities in Neonates: The scrotum is examined, and the common procedure performed is contralateral orchiopexy (fixing the testes to the inner scrotal wall). This procedure helps prevent future twisting. In addition, a testicular prosthesis is inserted after an orchiectomy (surgical removal of one or both testicles). It is inserted four to six months after the surgery.

How Quickly Will the Person Feel Better After Testicular Torsion Surgery?

The first few days after testicular torsion surgery are typically the most painful, with swelling or bruising in the scrotum or groin lasting about a week. After a week, pain should decrease, and individuals can usually resume normal activities, including work or school. Avoid heavy lifting and strenuous activities, including sports, for at least three to four weeks. Consult the healthcare provider before resuming any such activities. Remember, everyone's body is different, so recovery times can vary. Follow the healthcare provider’s instructions for managing pain and discomfort during the recovery from testicular torsion surgery.

How Is Testicular Torsion Prevented?

Some males inherit a trait where their testicles can rotate within the scrotum. For those with this trait, the only way to prevent testicular torsion is through surgery that secures both testicles to the inside of the scrotum.

Conclusion

Testicular torsion happens when the testis gets twisted around the spermatic cord, causing obstruction of blood flow and leading to pain and swelling. The symptoms include spontaneous and severe pain in the scrotum, abdominal pain, nausea and vomiting, and abnormal positioning of the testis. In addition, testicular torsion occurs when the tissues around the testis are loosely attached, which causes rotation of the testis. Diagnostic tests involve urine tests, scrotal examination, and ultrasound. Treatment modalities involve manual detorsion, surgical detorsion, and surgical removal of the testis.