Testicular Torsion

• The acute scrotum is a common urologic complaint, and the differential diagnosis rests between testicular torsion and other causes of pain.
• While epididymitis, orchitis, torsion of the appendix testis, hydrocoele and hernias all represent entities seen by emergency physicians, and are real emergencies to the patients that present with them, testicular torsion represents the true urologic emergency.

Epidemiology/Pathophysiology

• Testicular torsion occurs at a baseline frequency with two additional significant peaks occurring at infancy and puberty.
• The baseline frequency is due to the presence of a so-called "bell clapper’s" deformity in a subset of the population.
• This lack of physical tethering system for the testicle places these individuals at a unique risk for the disease and is responsible for the reports of torsion in all age groups.
• In one series as many as 40% of individuals with torsion were found to have such an abnormality.
• The two peaks are seen at times during maturation when the testicle grows relatively faster than its tethering gubernaculums.
• The result is a testes that can rotate about its axis, pinching off the blood supply.
• When torsion occurs, the venous blood supply is obstructed resulting in edema and hemorrhage. These in turn lead to occlusion of the arterial blood supply to the gonad.
• Although reported in all age groups from neonates to the elderly, the peak incidence is in individuals between the ages of 12 and 18 yr, with an incidence of 1 in 4000 in those below the age of 25 yr of age.

Diagnosis

• The initial evaluation of a patient with acute scrotal pain or swelling should focus on ruling out the presence of testicular torsion.
• A history of an acute onset of pain, and the absence of dysuria, suggest torsion over such entities as epididymitis or orchitis.
• The pain of torsion is usually described as thunderclap in onset and is not associated with a discrete mass such as might be seen in an inguinal hernia.
• The testicle is tender over its entirety unlike torsion of the appendix testis, and the pain is continuous and unremitting.
• The absence of a high-riding testicle or the presence of a cremasteric reflex should not be used as evidence that torsion does not exist.
• Of interest to the emergency physician is the phenomenon of torsion/detorsion of the testicle, nephrolithiasis. The classic presentation is of a young man who presents with a history of significant scrotal pain that has resolved by the time he arrives in the emergency department. He denies any dysuria or urethral discharge; however he states that he has two such episodes in the past two days.
• The emergency department workup is normal.
• The concept of an intermittently torsing testicle should be entertained in this setting and appropriate referral to Urology should be given as well as discharge instructions for immediate return in the face of any returning pain.
• From a laboratory standpoint, the only mandatory test would be a dip urinalysis looking for hematuria/pyuria. The presence of either of these might suggest an infectious etiology of the patient’s pain. Urologic consultation should be obtained early as surgical exploration is definitive therapy.
• Imaging of the testicle and its blood supply may be accomplished using color flow doppler or radionuclide imaging.
• Although the former is considered the standard of care by many, studies have shown it has important limitations especially in the pediatric population.
• In one study, up to 40% of normal testes in a pediatric population scanned showed no blood flow. Overall the specificity is reported to be between 83-100% and the sensitivity 89-100% for decreased or absent testicular blood flow when compared to the contralateral testicle. Radionuclide imaging has been reported to have a sensitivity of 87-100% and a specificity of 93-100%. Despite these impressive numbers, radionuclide imaging is considered an alternative in those cases where doppler is not practical or the results are inconclusive.
• In one study, the color flow doppler had a sensitivity of only 57% for torsion. Therefore, it should be stressed once again that the diagnosis of this disease should not rely on any single test.
• The long term ramifications are of enough significance that clinical judgment and surgical intervention may be all that is necessary to make and confirm the diagnosis.

Treatment

• Emergency department therapy for patients with a suspected torsion focuses on analgesia and preparation for surgical exploration.
• In the mid-1990s there was a group of authors that suggested conservative management protocol of the patient with the acute scrotum. Overwhelmingly the follow-up literature was not supportive for such a treatment strategy.
• Orchipexy by the urologist should be done emergently and should involve both testicles. In some rare cases there have been reports of torsion after orchipexy, a phenomenon which appears to be related to the use of absorbable sutures.
• As an aside, in the event that no urologist is available to perform the surgery, and given the time sensitive nature of the disease (4-6 h of ischemia time), a general surgeon may be consulted to perform the procedure.

Prognosis

• Overall, testicular torsion carries a relatively poor prognosis with regards to the involved side.
• The literature reports a salvage rate of 55% to as low as 18% with time to surgery being the single most important prognostic factor. Within 10 h, >80% of testes are lost and by 24 h the number reaches almost 100%. Reasons for delay include hesitation in seeking medical advice as well as misdiagnosis.
• Ipsilateral torsion not only places the affected testicle at risk but also the contra lateral testicles. It has been demonstrated that torsion of one testicle leads to decreased blood flow to the contra lateral side, with relative hypoxia and apoptosis. The subsequent decrease in germ cells has been implicated in decreased fertility of these patients.
• One suggested solution is to increase blood flow via capsaicin which has been shown to decrease the apoptosis which occurs after testicular torsion in rats.
• Glucocorticoids and nitric oxide have also been suggested as anti-apoptotic agents and have also been shown to be effective in rats, but no studies of these agents have yet been carried out in human subjects.