Pediatrics

Testicular torsion

OVERVIEW: What every practitioner needs to know

Testicular torsion is a medical emergency and requires immediate surgical management.

Are you sure your patient has testicular torsion? What are the typical findings for this disease?

Pre and postpubertal boys

Most commonly presents in adolescent boys, but can be seen at any age.

Acute onset of scrotal pain in the absence of significant trauma.

Scrotum will appear red and swollen and tender to touch.

Absence of the cremasteric reflex on the affected side has been associated with presence of torsion.

Testis will appear "high riding" compared with the contralateral side.

Nausea and vomiting frequently noted.

Newborn

Presents as a painless hard intrascrotal mass in the newborn, with some scrotal enlargement.

Incidence and Epidemiology

Testicular torsion can occur at any age, but is most frequently noted in pubertal boys.

Second most common presentation is in the newborn: 70% noted to be prenatal; 30% noted to be postnatal

Adolescent torsion - Intravaginal torsion - testicle undergoes torsion within the tunica vaginalis.

The "bell-clapper" deformity (Figure 1) - lack of fixation of the testis to the scrotal wall because of abnormality of the tunica. Usually noted to be bilateral and can be seen in 12%.

Figure 1.

Horizontal lie of the testis at the time of exploration

Thin mesenteric attachment to the testis - also frequently noted.

Newborn torsion - Extravaginal torsion - testicle and tunical layers undergo torsion within the scrotum.

Lack of fixation of the tunica/gubernaculum to the scrotal wall

Presentation

Adolescent torsion - Acute scrotal pain is a medical emergency. Testicular salvage rates correlate strongly with the duration of the ischemia. Misdiagnosis is associated with medicolegal liability, so clinicians so should have a high index of suspicion. If the diagnosis is suspected on physical examination, immediate surgical intervention is recommended (Figure 2).

Figure 2.

Preoperative appearance of adolescent with testis torsion -testis was nonviable at exploration.

Newborn torsion - due to the timing of the torsion, few, if any, of these testes are viable. Infants are usually asymptomatic. The torsion is identified when the mother or nursing staff are doing routine diaper care in the nursery (Figure 3). Intra-abdominal or missed torsion in a newborn may present as lack of testis descent in infancy.

Figure 3.

Newborn testis torsion.

What other disease/condition shares some of these symptoms?

Pre and post pubertal boys

Epididymo-orchitis: most common cause of scrotal pain in adolescent males. Inflammation of the epididymis and testes can be secondary to retrograde spread of bacterial infection from the urinary tract.

Torsion of the appendix testis can lead to scrotal pain and the acute onset of a hydrocele in the pubertal male. Typical "blue dot" sign in the scrotum noted due to the focal nature of the torsed appendix.

Inguinal hernias may present with scrotal pain and swelling. Typically, reduction of the hernia sac can lead to reduction in pain; however, strangulation of the hernia is a surgical emergency.

Varicoceles in the adolescent male can present with scrotal swelling; however, pain is usually chronic, if present.

Traumatic injury of the testis may be missed or concealed by the patient and can present with new onset of scrotal enlargement due to an enlarging hematoma.

Newborn

Infants with testis loss secondary to intra or postpartum torsion can present as cryptorchidism. Typically the testis is nonpalpable or only a small remnant nubbin remains. At the time of laparoscopic or open evaluation, blind ending vessels or an atrophic testis may be identified.

What caused this disease to develop at this time?

Increase in testes size associated with the development of puberty appears to be a predisposing factor for the development of torsion in the adolescent. In the older adult male, the spread of lymphoma to the testes with the associated testicular enlargement can lead to the development of torsion.

Testicular torsion in the newborn is felt to be due to lack of appropriate fixation of the tunical layers to the scrotum. Since testicular descent and fixation in the scrotum occurs late in fetal life (38 to 40 weeks), torsion typically occurs just prior to, at, or shortly after delivery.

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

Since most boys presenting with torsion are healthy, no laboratory studies are typically required for confirmation of diagnosis. A urinalysis and culture may be indicated if the diagnosis of epididymitis is being entertained.

Would imaging studies be helpful? If so, which ones?

Diagnosis of torsion can be made with the use of Doppler ultrasonography. In the prepubertal male, this can be quite difficult due to the poor definition of intratesticular flow on ultrasound. In the adolescent male, this is more definitive. When performed by a trained pediatric radiologist, torsion can be identified with great reliability. Ultrasound evaluation can reliably identify the intrascrotal pathology, be it trauma, varicocele, epididymitis, hernia, or hydrocele.

Newborn torsion can be diagnosed by lack of flow on ultrasonography.

In the past, testicular scanning was the most definitive modality for determination of torsion. However, difficultly with obtaining this study in an emergency situation and the length of time taken for the performance of the study has reduced the utility of the study.

If you are able to confirm that the patient has testicular torsion, what treatment should be initiated?

Suspicion of the diagnosis of torsion in the adolescent male requires immediate surgical exploration to prevent testis loss. When surgical management is delayed beyond 10 hours, there is minimal potential for testicular rescue.

At the time of surgical exploration, if the testis is noted to be nonsalvageable, orchiectomy should be performed. If the testis can be salvaged, orchiopexy using a three-point fixation technique or placement in a subdartos pouch is the management of choice (Figure 4). In either instance, the contralateral testis should also be fixed using techniques that will permanently prevent torsion.

Figure 4.

Intraoperative detorsion led to eventual preservation of the testis, seen here.

The management of newborn torsion remains controversial. Since newborn torsion is due to lack of fixation of the tunical layers into the scrotum, and since the process of fixation is noted to occur rapidly after birth, many authors have recommended close follow-up only. Additionally, the potential risk of general anesthesia in the newborn and the lack of viability of the torsed testis has led some clinicians to pursue a nonoperative management strategy.

Since timing of fixation of the tunical layers may be delayed in some children (as late as age 10 in some studies) other surgeons have recommended immediate surgical exploration and fixation of the contralateral testis, as case reports have documented the occurrence of contralateral metachronous torsion, a devastating situation.

The risk of anesthesia in the newborn, while present, can be minimized with a 24-hour period of postoperative observation. Additionally, concerns have been raised about the capacity for close follow-up and ability to intervene in a timely fashion if contralateral torsion does occur.

What are the adverse effects associated with each treatment option?

N/A

What are the possible outcomes of testicular torsion?

Despite early surgical management, the potential for fertility may be compromised. Many boys have had prior episodes of torsion that may have spontaneously reduced. With acute unilateral torsion, there appears to be bilateral impact on testicular blood flow that can potentially lead to long-term injury of both testes.

Hormonal balance typically remains preserved.

What causes this disease and how frequent is it?

A trend (although not statistically significant) to increased occurrence of torsion in colder months has been noted. The greatest incidence has tended to be in the fall and winter. It has been postulated that the heightened cremasteric reflex associated with cold weather can lead to torsion.

Familial torsion has been reported in 4 to 5 families in the world literature. Typically, this has involved a father and two sons in the same family. No evidence of a strict genetic basis has been identified for torsion

How do these pathogens/genes/exposures cause the disease?

In the mouse model, loss of the testicular hormone Insl3, which is critical for development of the gubernaculum, has been implicated in increasing the risk of torsion. Poor formation of the gubernaculum has been postulated to lead to abnormal fixation of the testes and potential for rotation of the testes.

Other clinical manifestations that might help with diagnosis and management

N/A

What complications might you expect from the disease or treatment of the disease?

N/A

Are additional laboratory studies available; even some that are not widely available?

Many families request semen analysis following torsion; however, this is a difficult test to obtain in the adolescent male. Since treatment for poor seminal parameters would not be instituted immediately, it is preferable to allow the adolescent male to delay testing until adulthood and perhaps until attempts at conception have failed.

How can testicular torsion be prevented?

Due to the congenital nature of predisposing factors, prevention is not possible.

What is the evidence?

The role of ultrasonography for evaluation of testis torsion in children

Nasrallah, PF, Manzone, D, King, LR. "Falsely negative Doppler examinations in testicular torsion". J Urol. vol. 118. 1977. pp. 194-5.

Baker, LA, Sigman, D, Mathews, RI. "An analysis of clinical outcomes using color Doppler testicular ultrasound for testicular torsion". Pediatrics. vol. 105. 2000. pp. 604-7.

Two papers exploring the controversy in the management of neonatal torsion

Kaye, JD, Levitt, SB, Friedman, SC. "Neonatal torsion: a 14-year experience and proposed algorithm for management". J Urol. vol. 179. 2008. pp. 2377-83.

Das, S, Singer, A. "Controversies of perinatal torsion of the spermatic cord: a review, survey and recommendations". J Urol. vol. 143. 1990. pp. 231-3.

Excellent reviews on the evaluation and management of boys with acute scrotum

Kadish, HA, Bolte, RG. "A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages". Pediatrics. vol. 102. 1998. pp. 73-6.

Sessions, AE, Rabinowitz, R, Hulbert, WC. "Testicular torsion: direction, degree, duration and disinformation". J Urol. vol. 169. 2003. pp. 663-5.

Surgical management of testicular torsion and factors that affect outcomes

Redman, JF, Barthold, JS. "A technique for atraumatic scrotal pouch orchiopexy in the management of testicular torsion". J Urol. vol. 154. 1995. pp. 1511-2.

Rampaul, MS, Hosking, SW. "Testicular torsion: most delay occurs outside hospital". Ann R Coll Surg Engl. vol. 80. 1998. pp. 169-72.

Cimador, M, DiPace, MR, Castagnetti, M, DeGrazia, E. "Predictors of testicular viability in testicular torsion". J Pediatr Urol. vol. 3. 2007. pp. 387-90.

Mansbach, JM, Forbes, P, Peters, C. "Testicular torsion and risk factors for orchiectomy". Arch Pediatr Adolesc Med. vol. 159. 2005. pp. 1167-71.

A good review of the entity of intermittent torsion

Eaton, SH, Cendron, MA, Estrada, CR. "Intermittent testicular torsion: diagnostic features and management outcomes". J Urol. vol. 174. 2005. pp. 1532-5.

A must-read on the medicolegal aspects of testicular torsion

Matteson, JR, Stock, JA, Hanna, MK. "Medicolegal aspects of testicular torsion". Urology. vol. 57. 2001. pp. 783-7.

Ongoing controversies regarding etiology, diagnosis, treatment

The major controversy that continues is the need for and timing of intervention in newborns presenting with testicular torsion. As noted above, there is considerable debate of the benefit of surgical management and the potential for metachronous contralateral torsion. Parents should be extensively counseled regarding these controversies and should be able to participate in the decision-making process. Complete documentation of this conversation is crucial.

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