Torsion of the testis - Disorders of the male genital system

Disorders of the male genital system

Torsion of the testis

Definition

Twisting of testis on its pedicle is a surgical emergency.

Age

Most occur in young children and peripubertally, less common over 25 years.

Sex

Male

Aetiology

Torsion occurs if the testis is insufficiently fixed by its lower pole to the tunica vaginalis by the gubernaculum testis, so allowing it to twist.

Pathophysiology

Twisting of the testis on the spermatic cord leads to venous/haemorrhagic infarction.

Clinical features

Characteristically the patient presents with an acutely tender swollen testis of sudden onset, there may be a history of minor trauma or recent vigorous exercise. Nausea and vomiting are common associated symptoms. There may be history of previous self-resolving episodes of pain, particularly at night in young boys (can be associated with nocturnal sexual arousal that occurs during REM sleep). Examination classically reveals a red hemiscrotum, with an asymmetrically high, swollen testis (pulled up by the shortened, twisted spermatic cord). However, it may be difficult to examine due to pain. The cremasteric response is absent in torsion (stroking or pinching the inside of the thigh should cause the ipsilateral testis to rise), but this response is not reliable below the age of 30 months or over 12 years.

The main differential is epididymoorchitis in which the tenderness may be localised to the epididymis and pain may be relieved by support of the scrotum, but it can be difficult to distinguish particularly as the testis can also swell in this condition.

Complications

If surgery is delayed beyond 12–18 hours the blood supply is compromised and infarction occurs requiring surgical orchidectomy.

Investigations

Diagnosis is clinical and surgery should not be delayed. However, in dubious cases, colour Doppler USS may be performed to look for blood flow, if absent torsion is very likely.

Management

The scrotum is explored, the twist is reversed and if the testis is viable both testes are fixed in position as the condition is a bilateral defect. If surgical fixation is performed promptly fertility is unimpaired.