TORSIO TESTIS presentasion fixxed NEW

1. TORSIO TESTIS
dr. Ismar Ibrahim, Sp.B, Sp.BA
PPDS Ilmu Bedah FK Unri

2. HISTORY
1840
First published
report of
testicular torsion
Delasiauve
1897
First described
newborn torsion
Taylor
1922
Recognized
torsion of a
testicular
appendage
Colt

3. INTRODUCTION
01
03
02
04
Anterior aspect by
tunica vaginalis
The back by epididymis
Posterior surface the
epididymis
Normal testis fixed
within tunica & cannot
twist
The Testis Is Covered
By

4. INTRODUCTION

5. Early diagnosis & treatment
are saving testis & fertility
Diagnosis of testicular
torsion is clinical, diagnostic
testing should not delay
treatment
torsion cases resulted in
orchiectomy
After 6-12 hours
Salvage rate 80 – 100%
Testicular torsion result of
twisting of spermatic cord
 loss of blood supply
ipsilateral testis
Salvage rate decreases
near 0%
Within 6 hours
32% pediatric
INTRODUCTION

6. • Most commonly occurs in adolescents,
peak 12-18 years
• 16% presenting  acute scrotum
• Left testis more frequently involved.
• Bilateral torsion account for 2% of all
torsions
• Related bell-clapper anomaly (high insertion
tunica vaginalis on the spermatic cord)
CLASSIFICATION
Intravaginal Torsion

7. CLASSIFICATION
Intravaginal Torsion

8. Abnormal testicular suspension and
firm fixation (epididymis-testis
complex)
• Lack fixation
• Long axis testicle oriented transversal rather
than cephalocaudal
• Abnormal mesentery between the testis and
its blood supply  spermatic cord liable to
rotate within it
High abnormal attachment tunica
vaginalis to testicle (Bell clapper
deformity)
Bell clapper deformity occurs
17% of males & bilateral in 40%
Long mesentery-
like leash of vessels
(mesorchium)
CLASSIFICATION
Intravaginal Torsion Etiology

9. • 5% of all torsions
• 20% of bilateral synchronously
• 3% of bilateral asynchronously
• 70% occur prenatally and 30% occur
postnatally
• Most commonly seen in neonates
• Neonates  testes frequently have not fully
descended into scrotum
CLASSIFICATION
Extravaginal Torsion

10. CLASSIFICATION
Extravaginal Torsion

11. Tunica vaginalis not secured to
gubernaculum
Mobility testicle predisposes 
extravaginal torsion
The spermatic cord & tunica vaginalis,
undergoes torsion as a unit
CLASSIFICATION
Extravaginal Torsion Etiology

13. Torsion of the testes
causes venous occlusion
Arterial ischemia and
subsequent infarction of the
testis
The extend of depends
on two factors:
• The degree of torsion
• The duration of torsion
EFFECT OF TORSION OF TESTIS

14. Incomplete torsion 
90°-180°,
compromising blood
flow
Complete torsion
twists 360° or more..
720°
INCOMPLETE COMPLETE
THE DEGREE OF TORSION

15. THE DURATION OF TORSION
• Too simplistic regard atrophy as an ‘all or none’ phenomenon
• Atrophy can occur even less than 6 hours
Venus has a beautiful
name, but it’s terribly
CONSIDERATION
DECISION
The duration influences rates of
salvage testicular
Testicular salvage if the
duration of less than 6 hours.
24 hours or more testicular
necrosis.

16. • Appearances early torsion (3-h
history).
• The right testis is tender,
mildly swollen
• Lies in an elevated position
within the scrotum.
• This testis was judged to be
viable in view short history
• Operative findings indicating
good return of perfusion
following detorsion.

17. • Deceptively painless presentation testicular torsion in an
infant
• 3-day history minimal symptoms.
• Discoloration of scrotum
• Surgical exploration revealed necrotic testis

18. PRECIPITATING FACTOR
Coitus
Lifting a heavy
weight
Spontaneously
during sleep
Straining at stool

19. CLINICAL FEATURES
GENERAL
Most commonly sudden
agonizing pain in groin and
lower abdomen
Severe pain in
scrotum, radiates to
the inguinal region
Left testis is twice as
commonly involved as the
right
5
Associated symptoms
nausea and/or vomiting
3
Symptoms vary with
degree of torsion
History recurrent pain
[transient and resolves
spontaneous]
1 4
2
6

20. FACTOR PREDICTIVE
01
03
02
04
Acute onset of pain Duration of pain less
than 6 hours
Fever, nausea and
vomiting
History of trauma or
activities
05 06
Absence of cremasteric
reflex
Abnormal transverse
direction of testis

21. CLINICAL FEATURES
INTRAVAGINAL
Pain may lessen as the
necrosis becomes more
complete
Pale & diaphoretic,
usually is not febrile
Occur spontaneously, with
sport or activity, and trauma
(4-8% cases)
5
GIT (nausea and vomiting)
3
Sudden onset of severe
unilateral scrotal pain
Inguinal and/or scrotal
swelling erythema
1 4
2
6

22. CLINICAL FEATURES
INTRAVAGINAL

23. CLINICAL FEATURES
EXTRAVAGINAL
6 weeks of life
4
Scrotal skin fixes to
necrotic gonad
Occurs asymptomatic
newborn male
Scrotal mass, firm, hard,
non tender, does not
transilluminate
1 3
2

24. CLINICAL FEATURES
EXTRAVAGINAL

25. PHYSICAL EXAMINATION
• Enlargement and tender of the entire
(scrotum, testis)
• Edema involving the scrotal erythema
• High-riding testis
• Abnormal transverse lie of testis
• Palpation of the epididymis anteriorly
• Cremasteric reflex is almost absent or
diminished
• Prehn sign  (classically predictor of
torsion, but this is unreliable)

26. Lightly stroking the inner
thigh on the side of the
suspected torsion
The resultant reflex occurs
 stimulation sensory
fibers femoral branch of
the genitofemoral nerve
This afferent input ascends
to the brain, where there
are superimposed cortical
pathways
The signal to cross over
and connect with motor
centers that result in the
efferent
Stimulation genital branch
of the genitofemoral nerve,
which innervates the
cremaster muscle
Cremasteric reflex 
absent in acute torsion, the
presence of the reflex does
not exclude torsion
The reflex is more reliable
when absent on the side of
pain but present on the
normal side
It is less reliable when
absent on both sides
CREMASTERIC REFLEX

27. INVESTIGATIONS
Color Doppler and
power Doppler USG
arterial blood flow
Testicular torsion is a
clinical diagnosis
• Strongly suggest
testicular torsion,
emergency surgery
• Low suspicion
testicular torsion
exists
Plain Doppler USG
less accurate than
color Doppler
None of USG, radionuclide scan, color doppler
are absolutely accurate

28. INVESTIGATIONS
Doppler USG

29. 94%
95.5%
89.4%
Sensitivity
Accuracy
Positive Predictive Value
INVESTIGATIONS
Doppler USG
96%
96%
Specificity
98%
Negative Predictive Value

30. 01 02
03
Diagnosis is equivocal,
radionuclide scan of the
testis
Urinalysis & culture UTI
and epididymitis
Sensitivity of 90–100%
WBC count is elevated
in 60% of patients
INVESTIGATIONS

31. With Analgesia
Manually detorse
testicle in emergency
department (< 4 h)
• Successful (confirmed color
doppler ultrasound)
• Successful in 30–70% of
patients
Rotate testis in medial
to-lateral direction 
“open book” rotation
Patient should undergo
definitive surgical fixation
(orchidopexy) of both testes
Manual Detortion
TREATMENT
MANUAL DETORTION

32. 1
Scrotal exploration
the testis is detorted
Every attempt should be
made to preserve the
testis
Warm sponges applied
to increase vascularity
of the testis
Testis that appears necrotic
may improve & survive once
vascularity restored
2
3
4
TREATMENT
SURGICAL DETORTION

33. TREATMENT
SURGICAL DETORTION
• Orchiectomy not recommended even
for a testis that appears necrotic, both
testes should be fixed
• Decision to conserve or remove the
testis 
Duration of the history,
The appearance (color) of testis
Arterial bleeding on incising the
tunica albuginea
• Fixation of contralateral testis is
mandatory

34. Some advocate elective exploration and
contra orchidopexy
Testis necrotic  orchiectomy and
contralateral  orchidopexy
(non-absorbable sutures)
Retention necrotic testis potential for
subfertility, autoimmune phenomenon
TREATMENT
Treatment neonatal torsion still controversial

35. • The outcome depends duration and degree of testicular
torsion.
• Viability of the testis is only possible if there is no delay
between the onset of symptoms and the time of surgical or
manual detorsion.
PROGNOSIS

36. ALGORITMA PERINATAL
TESTICULAR TORTIO

37.  Atlas of Pediatric Surgical Techniques 2010 by Saunders, Inc., an imprint
of Elsevier Inc
 Essentials of Paediatric Urology Second Edition 2008 Informa UK Ltd
 Guide to Pediatric Urology and Surgery in Clinical Practic Springer Nature
Switzerland AG 2020
 Emergency Pediatric Surgery Surgical Clinics of North America February
2017 • Volume 97 • Number 1
REFERENCE

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