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Testicular Torsion Ultrasound
- 1. HAFIZAR
- 2. TESTICULAR TORSION An urologic emergency caused by twisting of the spermatic cord and blood supply that leads to ischemic injury to the testicle and consequently a loss of germ cells Definition ● Occurs most frequently in neonatal period and around puberty ● 11-21% of perinatal testicular torsion are bilateral testicular torsion ● Perinatal testicular torsions most commonly occur in prenatal period, and generally having extravaginal type ● Testicular torsions that occur during puberty are commonly intravaginal Epi- demiology
- 3. Testicular Torsion Testicle is covered by tunica vaginalis potential space around testis Tunica vaginalis attaches to posterior surface of testicle & allows very little mobility of testicle within scrotum Two types extravaginal and intravaginal torsion Anatomy Cohen S, Gans W, Slaughenhoupt B. AUA medical student curriculum: acute scrotum. 2016.
- 4. Derchi LE, Simonato A. Scrotal Masses. In: Urogenital imaging: a problem-oriented approach. Wiltshire: Wiley-Blackwell; 2009: p.343 Radamayr C, et al. EAU guidelines on paediatric urology. 2021 Knoop KJ. The atlas of emergency medicine. 5th ed. McGraw Hill. 2021.. Extravaginal Intravaginal Most cases of perinatal torsion Most cases of puberty torsion Due to incomplete attachment of gubernaculum and testicular tunica to scrotal wall Common among older children. The testicular mesentery is narrow in the tunica vaginalis, surrounding the testis and epididymis completely. Testis, epididymis and tunica vaginalis is free to twist proximal to the tunica attachment. Most are gangrenous at exploration. Salvage rate is poor Twisting of testing occurs within the tunica vaginalis about its vascular pedicle. It gives an appearance termed as the bell-clapper deformity
- 5. Testicular Torsion • Occurs in neonates (or in utero). Due to incomplete attachment of gubernaculum and testicular tunics to scrotal wall • Testis, epididymis and tunica vaginalis is free to twist proximal to the tunica attachment • Most are gangrenous at exploration. Salvage rate is poor Extravaginal Torsion Cohen S, Gans W, Slaughenhoupt B. AUA medical student curriculum: acute scrotum. 2016.
- 6. Testicular Torsion • In the neonate, the parietal layer of the tunica vaginalis may not fused firmly with the other layers of the scrotum • It is possible for the tunica vaginalis and the contained testis to twist within the scrotum • The twist occurs outside of the two layers of the tunica vaginalis • In boys and men, the parietal layer of the tunica vaginalis has fused with the other layers of the scrotum • Thus, extravaginal torsion cannot occur. Extravaginal Torsion Pathophysiology Cohen S, Gans W, Slaughenhoupt B. AUA medical student curriculum: acute scrotum. 2016.
- 7. Testicular Torsion • Common among older children • Twisting of testing occurs within the tunica vaginalis about its vascular pedicle • It gives an appearance termed as the bell-clapper deformity Intravaginal Torsion Cohen S, Gans W, Slaughenhoupt B. AUA medical student curriculum: acute scrotum. 2016.
- 8. Testicular Torsion • In most boys and men the testis is covered on its front and sides by the visceral layer of the tunica vaginalis • The posterior surface, however, is not so covered. It is fused to the layers of posterior scrotum and cannot twist around • In some, the entire surface of the testis and some length of the spermatic cord is covered with the visceral layer of the tunica vaginalis • That way, the testis hangs like the clapper of a bell within the scrotum and free to rotate within Intravaginal Torsion Pathophysiology Cohen S, Gans W, Slaughenhoupt B. AUA medical student curriculum: acute scrotum. 2016.
- 9. Testicular Torsion Pathophysiology Testicle twists spontaneously on spermatic cord Venous occlusion & engorgement Arterial ischemia & infarction Testicular torsion Cohen S, Gans W, Slaughenhoupt B. AUA medical student curriculum: acute scrotum. 2016.
- 10. Testicular Torsion Notes Most common cause of testis loss in the US Incidence in males < 25 y.o. ± 1 : 4000 Left testicle > right testicle Among neonatal cases: 70% prenatally & 30% postnatally 100% testis salvage rate in patients who undergo detorsion within 6 hours of the start of pain Detorsion > 12 hours 20% viability rate; delayed > 24 hours no viability Cohen S, Gans W, Slaughenhoupt B. AUA medical student curriculum: acute scrotum. 2016.
- 11. Testicular Torsion Sign & Symptoms Rapid onset of severe testicular pain & swelling May be preceded by trauma, physical activity, or no activity Most occurs in children or adolescents but should be considered in evaluating scrotal pain of any age Should be differential diagnosis of any sudden acute scrotal pain or swelling Cohen S, Gans W, Slaughenhoupt B. AUA medical student curriculum: acute scrotum. 2016.
- 12. Testicular Torsion Progressivity Early phase • May be able to palpate the torsed cord & testis Later phase • Progressive edema & inflammation After 12- 24 hours • Entire hemiscrotum appears as a confluent mass without identifiable landmarks may be indistinguishable from epididymoorchitis appearance Cohen S, Gans W, Slaughenhoupt B. AUA medical student curriculum: acute scrotum. 2016.
- 13. Testicular Torsion Clinical Findings Patients are usually afebrile Free of irritative voiding symptoms (e.g. dysuria) Normal urinalysis & normal WBC Later torsion ↑WBC in response to inflammation Absent of cremasteric reflex No effects from scrotal elevation No sign of infections Radmayr C, Bogaert G, Dogan HS, Kocvara R, Nijman JM, et al. EAU guidelines on paediatric urology. 2018.
- 14. An abnormal (horizontal) position of the testis is more frequent in testicular torsion than epididymitis Pain may lessen as the necrosis becomes more complete Testicular Torsion Epididymitis Cremasteric reflex X (100% sensitivity, 66% specificity) ✓ Elevation of the scrotum (Phren sign) - ↓↓ Pain Fever X ✓ Occurs more often (11- 19%) Testicular Torsion Epididymitis Normal Testis Radamayr C, et al. EAU guidelines on paediatric urology. 2021 Knoop KJ. The atlas of emergency medicine. 5th ed. McGraw Hill. 2021.
- 15. Low risk score 0-2 (less likely testicular torsion) Intermediate risk score 3-4 (equivocal, USG warranted) High risk 5 and above (immediate surgical exploration)
- 16. Testicular Torsion Ultrasound Findings (1) Most useful adjunct to patient’s history & physical examination Use Doppler flow to assess arterial flow arterial flow absent or decreased relative to contralateral testes (torsion is highly likely) Exclude significant testicular trauma, hernia extending to scrotum, distinguish epididymis (↑ flow to epididymis & adnexal structures; preserved testicular perfusion) Testicular perfusion is the key to ultrasound diagnosis Only if scrotal USG is readily available Cohen S, Gans W, Slaughenhoupt B. AUA medical student curriculum: acute scrotum. 2016.
- 17. Testicular Torsion Ultrasound Findings (2) Testicular torsion of right testis
- 18. Aim : to find out presence of blood flow in the testis into the center of testis Note the absence of flow to the testicle What to find? • Reduced blood flow in the affected testicle (incomplete) • Reduced flow velocity in the intratesticular arteries • Increased resistive indices (RI > 0.75( • Hypervascularity with a low resistance flow pattern (after partial torsion – detorsion) • Altered echotexture
- 19. Testicular Torsion Management (1) Manual detorsion is done without anaesthesia outwards rotation of the testis. Stop when pain increases or any obvious resistance (success immediate relief of symptoms & clinical findings) True vascular emergency urgent surgical exploration & detorsion is mandated Correction within 4-6 hours of onset excellent testicular preservation > 12 hours significant risk of subsequent testis atrophy with detorsion Testis salvage is often still appropriate if improvement of testicular appearance occurs with observation following detorsion Radmayr C, Bogaert G, Dogan HS, Kocvara R, Nijman JM, et al. EAU guidelines on paediatric urology. 2018.
- 20. Manual detorsion of the testis is done without anaesthesia Should be attempted in all patients if possible it is associated with improved surgical salvage rates Success is defined as the immediate relief of all symptoms and normal findings at physical examination Doppler US may be used for guidance Bilateral orchiopexy is still required after successful detorsion. Testicular Detorsion Radamayr C, et al. EAU guidelines on paediatric urology. 2021 Knoop KJ. The atlas of emergency medicine. 5th ed. McGraw Hill. 2021.
- 21. Testicular Torsion Management (2) Radmayr C, Bogaert G, Dogan HS, Kocvara R, Nijman JM, et al. EAU guidelines on paediatric urology. 2018. Bilateral orchiopexy is still required after detorsion. Not be done as elective but immediate procedure after successful detorsion. 2 important determinants: onset of symptoms & detorsion and degree of cord twisting Early surgical intervention (<13 hours) preserving fertility • Torsion >360o 4 hours severe testicular atrophy • Incomplete torsion (180-360o) 12 hours no atrophy observed • Torsion >360o >24 hours absent or severely atrophied testis
- 22. Testicular Torsion Management (3) Cohen S, Gans W, Slaughenhoupt B. AUA medical student curriculum: acute scrotum. 2016. Orchiectomy can relieve pain in affected patients After sharply entering the scrotum, the tunica vaginalis opened, the testis detorsed and wrapped in a warm, moist gauze The contralateral side then undergoes orchidopexy to prevent torsion on that side The affected testis is reinspected for signs of improved perfusion (“pinking up”) Orchiectomy as an alternative procedure
- 23. A return of color A return of Doppler flow Arterial bleeding after incision of tunica albuginea • Orchidopexy is performed by tacking tunica albuginea to Dartos in three places: • lateral, • medial, and • Inferior, or • three tacking sutures are placed medially by affixing testis to septum Radamayr C, et al. EAU guidelines on paediatric urology. 2021 Knoop KJ. The atlas of emergency medicine. 5th ed. McGraw Hill. 2021. Hinman
- 24. Testicular Torsion Management (4) Cohen S, Gans W, Slaughenhoupt B. AUA medical student curriculum: acute scrotum. 2016. Exploration of torsed testis Note Dark, cyanotic color of testis following 30 minutes of detorsion suggesting nonviability
- 25. Testicular Torsion Management (3) Testicle can be completely salvaged with up to 6 h of torsion. But unlikely salvaged beyond 12 h.
- 26. The time between onset of pain and performance of detorsion < 6 hours : 90 – 100% salvage rate 6 – 12 hours : 20 – 50% salvage rate 12– 24 hours : < 20% > 24 hours : 0 – 10% Ringdahl et al. Am Fam Physician. 2006
- 27. FOLLOW UP - Fertility - Insignificant difference in normal pregnancy rates between patients with unilateral testicular torsion undergoing orchidopexy and orchidectomy. - Subfertility - Subfertility is found in 36-39% patients after testicular torsion - 5-50% patients were found to have normal semen analysis in a long term follow up - Hormonal consequence → Hormone androgen level - FSH, LH and testosterone level are found to be higher in patients with a history of testicular torsion in comparison with normal population - Testicular endocrine function was found to be within normal range after testicular torsion Visser, A. J., & Heyns, C. F. (2003). Testicular function after torsion of the spermatic cord. Gielchinsky, I., Suraqui, E., Hidas, G., Zuaiter, M., Landau, E. H., Simon, A., Rosenberg, S. (2016). Pregnancy rates after testicular torsion. The Journal of urology, 196(3), 852-855.
Editor's Notes
- May be difficult to confirm with ultrasound, but if the rotation has disrupted the normal blood supply, ultrasound will demonstrate decreased echogenicity, compared with the normal testis, in the acute stage. There may be associated scrotal fluid (hydrocele)
- An abnormal (horizontal) position of the testis is more frequent in testicular torsion than epididymitis [197]. Looking for absence of the cremasteric reflex is a simple method with 100% sensitivity and 66% specificity for testicular torsion [222, 227] (LE: 3). Elevation of the scrotum may reduce complaints in epididymitis, but not in testicular torsion. Fever occurs more often in epididymitis (11-19%). The classical sign of a “blue dot” was found only in 10-23% of patients with torsion of the appendix testis [196, 197, 222, 229]. In many cases, it is not easy to determine the cause of acute scrotum based on history and physical examination alone [195-200, 222, 229]. A positive urine culture is only found in a few patients with epididymitis [199, 222, 229, 230]. It should be remembered that a normal urinalysis does not exclude epididymitis. Similarly, an abnormal urinalysis does not exclude testicular torsion.
- A clinical decision tool, determining the risk, thus decreasing the indication for ultrasound
- Doppler US is useful to evaluate acute scrotum, with 63.6-100% sensitivity and 97-100% specificity, a positive predictive value of 100% and negative predictive value of 97.5% [231-236] (LE: 3). The use of Doppler US may reduce the number of patients with acute scrotum undergoing scrotal exploration, but it is operator-dependent and can be difficult to perform in pre-pubertal patients [233, 237]. It may also show a misleading arterial flow in the early phases of torsion and in partial or intermittent torsion. Of key importance, persistent arterial flow does not exclude testicular torsion. In a multicentre study of 208 boys with torsion of the testis, 24% had normal or increased testicular vascularisation [233]. A comparison with the other side should always be done.
- Manual detorsion of the testis is done without anaesthesia, and should be attempted in all patients if possible, because it is associated with improved surgical salvage rates [247]. It should initially be done by outward rotation of the testis - like opening a book -, unless the pain increases or if there is obvious resistance. Success is defined as the immediate relief of all symptoms and normal findings at physical examination [248] (LE: 3;). Doppler US may be used for guidance [249]. Bilateral orchiopexy is still required after successful detorsion. This should not be done as an elective procedure, but rather immediately following detorsion. One study reported residual torsion during exploration in 17 out of 53 patients, including eleven patients who had reported pain relief after manual detorsion [248, 250]. External cooling before exploration may be effective in reducing ischaemia reperfusion injury and preserving the viability of the torsed and the contralateral testis [251]. Medical treatments aimed at limiting such injury remain experimental [252-255]. Torsion of the appendix testis can be managed non-operatively with the use of anti-inflammatory analgesics (LE: 4). During the six-week follow-up, clinically and with US, no testicular atrophy was revealed. Surgical exploration is done in equivocal cases and in patients with persistent pain [236]. Although metachronous torsion of the appendix testis may occur in up to 8.5%, it is not necessary to explore the contralateral side, given the benign nature ot the problem. Besides it has been demonstrated that the NNT is 24 [256].
- Bilateral orchiopexy is still required after successful detorsion. This should not be done as an elective procedure, but rather immediately following detorsion. One study reported residual torsion during exploration in 17 out of 53 patients, including eleven patients who had reported pain relief after manual detorsion [172, 174]. Severe testicular atrophy occurred after torsion for as little as four hours when the turn was > 360°. In cases of incomplete torsion (180-360°), with symptom duration up to twelve hours, no atrophy was observed. However, an absent or severely atrophied testis was found in all cases of torsion > 360° and symptom duration > 24 hours [176]. Early surgical intervention with detorsion (mean torsion time less than thirteen hours) was found to preserve fertility [177]. Urgent surgical exploration is mandatory in all cases of testicular torsion within 24 hours of symptom onset. In patients with testicular torsion > 24 hours, semi-elective exploration is necessary [175, 176] (LE: 3). There is still controversy on whether to carry out detorsion and to preserve the ipsilateral testis, or to perform an orchiectomy, in order to preserve contralateral function and fertility after testicular torsion of long duration (> 24 hours). A study found that sperm quality was preserved after orchiectomy and orchidopexy in comparison to normal control men, although orchiectomy resulted in better sperm morphology [178]. During exploration, fixation of the contralateral testis is also performed. Recurrence after orchidopexy is rare (4.5%) and may occur several years later
- Incision can be median raphe or on ipsilateral hemiscrotum After skin incision dissection of Dartos until Tunica Vaginalis of affected side, expose the testis for viability and spermatic cord direction and degree of torsion. Performed detorsion to release torsion respectively Assesment of testicular viability: if still blueish and congested after detorsion, wrap in warm saline gauze and continue to orchidopexy of contralateral side reevaluate testis for color changes. Short incision of tunica albugenia deep through medulla and observe for 10 minutes if no bleeding, testis is likely nonviable and need to be removed and continue with orchidopexy of contralateral testis. If bleeding occurs, orchidopexy is treatment of choice for affected side of testis and contralateral testis.
- Testicular torsion is an urgent condition which requires prompt surgical treatment. The two most important determinants of early salvage rate of the testis are the time between onset of symptoms and detorsion, and the degree of cord twisting [257]. Severe testicular atrophy occurred after torsion for as little as four hours when the turn was > 360°. In cases of incomplete torsion (180-360°), with symptom duration up to twelve hours, no atrophy was observed. However, a necrotic or severely atrophied testis was found in all cases of torsion > 360° and symptom duration > 24 hours [258]. Early surgical intervention with detorsion (mean torsion time less than thirteen hours) was found to preserve fertility [259]. Urgent surgical exploration is mandatory in all cases of testicular torsion within 24 hours of symptom onset. In patients with testicular torsion > 24 hours, exploration may be performed as a semi-elective exploration procedure [257, 258] (LE: 3), unless there is a clear history of torsion-detorsion in which urgent exploration should still be considered. In case of prolonged torsion (> 24 hours) it is still subject to debate whether the surgically detorsed testis should be preserved. An alternative to detorsion and fixation may be to perform orchiectomy. A study found that sperm quality was preserved after both orchiectomy and orchidopexy in comparison to normal control men, although orchiectomy resulted in better sperm morphology [260]. Incision of the tunica albuginea with tunica vaginalis graft to prevent or treat compartment syndrome has also been suggested [261]. In neonates with signs of testicular torsion at birth the duration of symptoms will not be clear. The decision to perform surgical exploration should be weighed against the general condition of the child. In this age group the operation can safely be done under spinal anesthesia. New onset of symptoms of testicular torsion in neonates should be considered a surgical emergency similar to older boys. During exploration, fixation of the contralateral testis is also performed. It is good clinical practice to also perform fixation of the contralateral testis in prenatal and neonatal torsion, although there is no literature to support this, and to remove an atrophied testicle [262]. Recurrence after orchidopexy is rare (4.5%) and may occur several years later. There is no consensus recommendation about the preferred type of fixation and suture material [260, 261, 264].