A presentation that will help clinicians attain the basic diagnostic skills required to effectively manage patients.

1. SURGERY
TESTICULAE TORSION
DR. CHONGO SHAPI (BSc. HB, MBChB)

2. TESTICULAR TORSION
Testicular torsion refers to twisting of the spermatic cord
structures, either in the inguinal canal or just below the
inguinal canal.
It is a surgical emergency because it causes strangulation
of gonadal blood supply with subsequent testicular
necrosis and atrophy.
Acute scrotal swelling in children and adolescent
indicates torsion of the testis until proven otherwise.
Types
1.Extravaginal torsion: This type manifests in the
neonatal period and most commonly develops prenatally
in the spermatic cord, proximal to the attachments of the
tunica vaginalis.
2.Intravaginal torsion: This type occurs within the
tunica vaginalis, usually in older children.
Etiology:
Extravaginal torsion: The testes may freely rotate prior to
the development of testicular fixation via the tunica
vaginalis within the scrotum.
Intravaginal torsion: Normal testicular suspension ensures
firm fixation of the epididymal-testicular complex
posteriorly and effectively prevents twisting of the
spermatic cord. Torsion is usually spontaneous and
idiopathic but some predisposing factors include:
1. Bell-clapper deformity lack of fixation posteriorly to
the tunica by the testis, resulting in the testis being freely
suspended within the tunica vaginalis.
2.A large mesentery between the epididymis and the testis
3. History of trauma in 20% of patients
4. 1/3 have had prior episodic testicular pain which may
denote previous torsion that rotated
5. Contraction of cremasteric muscle or dartos muscles
shortens the spermatic cord and may initiate testicular
torsion may play a role and is stimulated by trauma,
exercise, cold, sexual stimulate.
6. Cryptochirdism.
7. Testicular atrophy-post infectious or traumatic.
Age
Tends to occur in young men-it is uncommon in men over
25 years of age and rare in men over 30 years of age. It
peaks at 14-18 years.
Pathophysiology
Torsion of the spermatic cord interrupts blood flow to the
testis and epididymis. The thick walled arteries initially
remain patent as venous congestion occur leading which
lead ischemia and infarction of the testis.
The degree of torsion may vary from 180-720°.Increasing
testicular and epididymal congestion promotes
progression of torsion.
The extent and duration of torsion prominently influence
both the immediate salvage rate and late testicular
atrophy.
Testicular salvage most likely occurs if the duration of
torsion is less than 4-6 hours. If 24 hours or more elapse,
testicular necrosis develops in most patients.
-Urinalysis or microscopic examination of urethral mucus
Clinical presentation
Prenatal torsion manifests as a firm, hard, scrotal mass,
which does not transilluminate in an otherwise
asymptomatic newborn male. The scrotal skin
characteristically fixes to the necrotic gonad
Presentation in older patients
1The sudden onset of severe testicular pain followed by
inguinal and/or scrotal swelling
2.Nausea and vomiting may occur
3.Fever may occur
4.Testis may be high in scrotum with a transverse lie
5. Scrotum is enlarged, red, erythematous and echymosis
may be evident
6. Absence of cremasteric reflex
Differential Diagnosis of scrotal swelling and pain.
1.Trauma: History of injury and examination may reveal
a hematoma. Urinalysis may show hematuria
2. Viral Orchitis: Mumps virus and the enteroviruses
may cause acute unilateral or bilateral orchitis. In orchitis
due to mumps virus, there is usually associated parotitis.
3. Urolithiasis: Rarely, patients with urolithiasis present
with pain localized mainly in the scrotum; however, in
most cases, back or flank pain has preceded the scrotal
pain, or there is a history of nephrolithiasis. Ureteric colic
radiates to the testis.
.In such cases, the testicle and epididymis are normal to
palpation. Hematuria is an important diagnostic clue. The
diagnosis may be confirmed by excretory urography.
4. Incarcerated Hernia: Inguinal hernias incarcerated in
the scrotum may cause scrotal pain that may be confused
with testicular pain.
Bowel sounds are heard in the scrotum early in
incarceration; if the hernia strangulates bowel sounds are
no longer audible. Intestinal hernia is almost always
associated with clinical findings of intestinal obstruction
.Nausea, abdomian pain and vomiting . Ultrasonography
is diagnostic.
5. Epididymitis, orchitis, epididymo-orchitis
-These conditions most commonly occur from the reflux
of infected urine or from sexually acquired disease
caused by gonococci and Chlamydia
-Tends to occur in sexually active men over 20 of age.
-There may be a history of urinary tract infection or
urethritis and urethral discharge.
-Pain begins gradually and is less severe than in testicular
torsion
- Often associated with systemic signs and symptoms
associated with urinary tract infection
-Patients occasionally develop these conditions following
excessive straining or lifting and the reflux of urine-
chemical epididymitis
-Prehn's sign may be helpful in differentiating between
torsion and epididymitis: If pain is reduced when the
scrotum is lifted over the symphysis pubica, the pain is
due to epididymitis; if pain increases, the cause is
probably torsion.
-Physical examination reveals a tender epididymis, often
unilateral and often with erythema and edema of the
scrotal skin. Early on, the testicle may be normal or

3. will show leukocytes in most cases of epididymitis,
indicating preceding urinary tract infection or urethritis.
-A complete urological evaluation (ie, renal sonography,
urodynamic study) is necessary in prepubertal boys with
acute epididymitis.
Organisms in younger men-STD like-Chlamydia and
gonorrhea
Older men-Gram –ve organisms.
Treatment consists of bed rest, scrotal elevation, NSAIDS
for pain relief and antibiotics(broad spectrum- augmented
penicilins or2nd
cepahalosporins)
6.Torsion of testicular or epididymal appendage
This condition usually occurs in children aged 7-12 years.
Systemic symptoms are rare. Usually, localized
tenderness occurs but only in the upper pole of the testis.
Occasionally, the blue dot sign is present in light-skinned
boys
7.Hydrocele
Usually associated with patent processus vaginalis
Painless swelling is usually present.
Scrotal contents can be visualized with transillumination.
8.Testis tumor
Scrotal enlargement occurs, only rarely accompanied by
pain. Presentation is rarely acute.
Others
9.Acute varicocele-feel like a bag of worms
10.Henoch-Schonlein purpura
11.Scrotal abscess
12.Leukemic infiltrate
INVESTIGATIONS
To rule out differential diagnosis and confirm testicular
torsion.
Lab Studies:
1.FHG,Urinalysis and culture
If no clinical evidence of testicular torsion, a urinalysis
and culture may help exclude urinary tract infection and
epididymitis.
If testicular torsion is clinically suggested, perform
immediate surgical exploration, regardless of laboratory
studies because a negative finding upon exploration of the
scrotum is more acceptable than the loss of a salvageable
testis.
Imaging
Should not delay emergent surgical treatment of patients
with high probability of testicular torsion (ie, patients
under 18 years of age with acute unilateral testicular pain
and no signs or recent history of urinary tract infection).
a) Spermatic cord block-Anesthetizing the scrotal
contents will facilitate accurate examination. Inject
lidocaine without epinephrine (2%), 5-10 mL, around the
spermatic cord at the external inguinal ring.
b) Scrotal colour Doppler sonogram is usually
diagnostic by verifying arterial flow.
c) Radionuclide scan-In epididymitis, scanning of the
scrotum after intravenous injection of technetium Tc 99m
sodium pertechnate reveals increased scrotal uptake on
the affected side, whereas torsion shows decreased
uptake.Rign or hallo sign in torsion ,only outer part is
perfused inner part ischemic.
minimally tender. Later edema and erythema worsens and
becomes very tender.
d) U/S-can differentiate between swelling of the testis
and swelling of the epididymis and show if there is an
incarcerated hernia. Ultrasonography can also detect the
presence of varicocele and testicular cysts and masses
Aspiration of abscesses may also be done.
MANAGEMENT.
Emergency exploratory surgery is indicated if torsion is
clinically suspected.
Even if its not torsion some relief usually come from
decompression of swelling.
Salvage of testis only possible 4-6 hours after onset of
torsion.
-operation through the midline scrotal raphe.
-Enter the ipsilateral scrotal compartment; then, deliver
and untwist the testis.
-Evaluate the testis for viability. Signs of a viable testis
after detorsion include
✓ Return of color to pink
✓ Return of Doppler flow
✓ Arterial bleeding after incision of tunica
albuginea.
-If the testis is not viable, remove all the necrotic testis to
avoid prolonged, debilitating pain and tenderness.
Retention of a necrotic testis may exacerbate the potential
for subfertility, presumably because of development of an
autoimmune phenomenon which also affect the
contralateral testis.
-To prevent subsequent torsion, fix the contralateral testis
to the scrotal wall with 3-4 non absorbable sutures.
(Orchidopexy). This is also important because bilateral
involvement --ie, the "bell clapper" deformity (lack of
fixation of the cord structures by the testicular
mediastinum) --and the high incidence of recurrent
torsion and infertility in bilateral cases.
Complications
1. Delay of more than 4-6 hours between onset of
symptoms and the time of surgical (or manual) detorsion
reduces the salvage rate to 55-85%.
2. Retention of an injured testis can induce pathologic
changes to the contralateral testis.
3.Recurence if orchidopexy not done
4.Infertity