Testicular torsion occurs when the spermatic cord twists, reducing blood flow to the testicle. There are two main types - intravaginal torsion which is more common and often seen at puberty due to a "bell-clapper" deformity, and extravaginal torsion which occurs in newborns without this deformity. Risk factors include a history of cryptorchidism or an abnormally long spermatic cord. Physical exam may reveal an elevated, tender testicle with absent cremasteric reflex. Ultrasound can show reduced blood flow, but surgery should not be delayed for imaging. Manual detorsion can be attempted in some cases but all patients require surgical exploration to detorse

1. Testicular Torsion
DR. MANISMK

2. WHAT IT
MEANS ??

3. Twisting of the
spermatic cord
leading to
decreased blood
flow to the testicle
resulting in
ischemia, infarction
and tissue necrosis.
NO FLOW

5. TWO TYPES OF
TESTICULAR TORSION

6. Intravaginal torsion
Intravaginal torsion Is the more common
type, occurring most frequently at puberty.
It results from anomalous suspension of the
testis by a long stalk of spermatic cord,
resulting in complete investment of the
testis and epididymis by the tunica
vaginalis. •
 This anomaly has been likened to a bell-
clapper

7. “Bell-clapper” deformity, a congenital condition in which the testis hangs
within the scrotum (red arrows) and can swing like a bell clapper in a bell,
allowing for easy torsion. Males born with the bell clapper deformity have no
attachments around either testicle, so that torsion can potentially occur on
either side. The bell clapper deformity is present in approximately 12% of
males; 40% of them are affected in both testicles.

8. Extravaginal torsion
 Most often occurs in newborns without
the “bell clapper” deformity.
 It is thought to result from a poor or
absent attachment of the testis to the
scrotal wall, allowing rotation of the
testis, epididymis, and tunica vaginalis
as a unit and causing torsion of the cord
at the level of the external ring

9. Etiology
 The etiologic factors involved in intravaginal testicular torsion include
congenital anomaly, bell clapper deformity, undescended testicle,
sexual arousal or activity, exercise, active cremasteric reflex, and cold
weather
 Contraction of the spermatic muscles shortens the spermatic cord and
may initiate testicular torsion.
Torsion may occur in either
 clockwise or
 counterclockwise direction

10. Epidemiology:
 Most common cause of acute scrotal pain in prepubertal
boys
 Torsion present in 3.2% of all children presenting to the ED
with scrotal pain
 Risk factors:
History of cryptorchidism,
horizontal testicular lie,
 increased spermatic cord length

12. Pathophysiology:
 Torsion occurs as the testicle rotates between 90° and 180°,
compromising blood flow to and from the testicle. •
 Complete torsion usually occurs when the testicle twists 360°
or more; incomplete or partial torsion occurs with lesser
degrees of rotation. The degree of
torsion may extend to 720°
 Testicular salvage is
Most likely if the duration
of torsion Is less than
6-8 hours. If 24 hours or
more elapse, testicular
necrosis develops
in most patients.

13. DR. MANISMK

14. DR. MANISMK

16. Differential Diagnosis
 Hydrocele
 Epididymitis
 Trauma
 Inguinal hernia
 Testicular tumor
Hydrocele
Epididymitis
HERNIA
Scrotal abscess

17. Pay attention to history, clinical
picture and pain expression of
patient

18. History
 Sudden onset of scrotal pain (less
frequently, abdominal or inguinal pain)
 Nausea and vomiting
 History of blunt trauma (~ 10% of
patients)
 History of similar pain in the past
 Duration of symptoms should NOT guide
management
 Historically, believed that symptoms > 24
hours inconsistent with salvageable tissue
 However, testicle may torse + detorse
making it difficult to know how long
ischemia present

19. Physical Examination
Unilateral tender, firm testicle
Scrotal erythema, edema and swelling
Affected testicle typically higher than the unaffected one.
- Loss of cremasteric reflex
30% of males with normal testicles will have an absent
cremasteric reflex

20.  stimulation of the skin on the front and inner thigh (over Scarpa's triangle)
retracts the testis on the same side. Stimulus usually causes cremasteric
muscle contraction.
 Normal: Cremasteric reflex present (testicle rises). Seen in Epididymitis;
 Abnormal: Cremasteric reflex absent (no testicle rise). Suggests Testicular
Torsion

21. Diagnosis
The diagnosis of testicular torsion should be
pursued in any patient with acute scrotal pain.
Physical exam, history and imaging all have
significant limitations.
In patients with a high suspicion for torsion,
emergent surgical consultation should not be delayed
by diagnostic
imaging as “time is testicle”
Scrotal Ultrasound

22. Right Testicle with Decreased Flow on Color Doppler -

23. Left Testicle Hypoechoic and Swollen -

24. Management:
 ALL patients with suspicion for testicular torsion should have
immediate consultation with a urologist for potential operative
exploration and repair.
 Establish IV access and provide analgesia
 Manual detorsion
 Can be attempted if urology consultation is not immediately available
 May be successful in
 25-80% of testicular
 torsion cases (Rosen’s 2014)
 Procedure
 Place patient supine
 Provider stands at the patients feet
 Apply “open book” rotation: rotate affected testicle away from midline
 Rotation required may be anywhere from 180o – 720o
DR. MANISMK

25.  Regardless of the success of manual detorsion, all patients
will require surgical evaluation
Intraoperative finding of a testicular torsion

26.  Surgical exploration via scrotal approach with detorsion,
evaluation of testicular viability, orchidopexy of viable testicle,
orchiectomy of nonviable testicle

27. THANK YOU !!!