Testicular torsion is a surgical emergency where the testis twists around its axis, cutting off blood flow. It has two peaks in incidence in infants and young adults. Clinically it presents as acute scrotum with pain, swelling and an high riding horizontal testis. Diagnosis is usually clinical but Doppler ultrasound may help in doubtful cases. Management involves manual detorsion under sedation followed by surgical exploration and fixation if needed to prevent recurrence. Orchidectomy is performed if the testis is nonviable but younger children may have the testis preserved even if viability is doubtful to maintain hormonal function.

1. TESTICULAR TORSION

3. History
• 1st reported by Louis Delasiauve, a French Psychiatrist
• Had assisted the case 9 years earlier as an undergraduate
• The black gangrenous mass was first thought of as a kidney

4. Types of torsion

5. • Intravaginal
• Extravaginal – seen more often in neonates and rare in other age
groups

6. Intravaginal torsion Extravaginal torsion

7. Relevant anatomy
• Long narrow meso orchium leads to testis being suspended
horizontally – bell clapper deformity
• Congenital

8. Age distribution
• Bimodal distribution
• Infants and young adults

9. Age distribution
• Bimodal distribution
• Infants and young adults
Clinical features
• Acute scrotum
• Can also have previous similar
spontaneously resolving
episodes

10. Signs
• High riding testis
• Horizontal lie
• Edema
• Absent cremasteric reflex – not consistent in teenagers

11. DIAGNOSIS
• Clinical. It is a surgical emergency
• Colour doppler in case of doubt

12. Colour doppler

13. Management
• Manual detorsion + emergency scrotal exploration

14. Manual detorsion
• Done under IV sedation
• +/- cord block – because it masks the primary endpoint of successful
detorsion
• Done when the theatre is getting ready
• 2/3rd of patients will have lateral to medial torsion. And 1/3rd will have
medial to lateral torsion
• Attempt detorsion of 1800 in medial to lateral direction(open book). If pain
is decreasing but is still present, detort till the pain completely subsides or
till flow in colour doppler returns
• If pain is not decreasing or the detorsion is difficult(when done in wrong
direction), detort in lateral to medial direction
• Also detort in a caudocranial direction to release cremasteric muscle

16. Surgical exploration
• Median raphe incision
• Alternatively, two transverse anterolateral scrotal incision
• Affected side approached first
• TV opened
• Torsion and the degree of torsion noted
• Detorsion completed
• If viability precarious, wrap in warm saline for 15 minutes and begin
exploring the other side.
• Alternatively, a deep stab can be made in the testis to look for bleeding

17. Non viable testis
• Proceed with orchidectomy
• In children younger than 10 years, better to leave the testis if the
viability is doubtful, because spermatogenesis would not have started
and so, blood-testis barrier would not have formed.
• In children older than 10 years, BTB would have been disrupted by
the ischemia and autoimmune attack risk is high. So, orchidectomy
completed
• This rationale is to preserve whatever hormonal function is left over
in the ischemic testis

18. Viable testis
• Orchidopexy
• Three point fixation or subdartos pouch

19. Three point fixation
• TV sac everted to prevent hydrocele formation
• Non absorbable sutures taken in inferior, medial and lateral aspects of
tunica albuginea and fixed to dartos
• Alternatively, all three sutures can be fixed to medial septum

21. Subdartos pouch orchidopexy

23. References
• Robert and Hedges Clinical procedures in Emergency Medicine
• Emergency Urology – David Thurtle
• Urological emergencies – a practical guide, Hunter and McAnin
• Hinman atlas of urologic surgery, 4th edition
• Coran Pediatric surgery
• Lambert C.J., Dartos pouch technique orchiopexy. Military medicine,
132(9), 690-693, 1967