Testicular torsion is a surgical emergency that requires prompt recognition and intervention. This condition occurs when the spermatic cord, which provides blood supply to the testicle, becomes twisted, leading to compromised blood flow and potentially irreversible damage. It can happen in any age group but is most commonly seen in 12-18-year-olds.
Risk factors
Testicular torsion can result from the abnormal mobility of the testicles within the scrotum, creating a predisposition for the spermatic cord to twist. While it can occur spontaneously, certain factors may increase the risk, including the following:
- Increased testicular size
- Testicular tumour
- Congenital abnormality of processus vaginalis (‘bell-clapper deformity’)
- Trauma
- Previous history of torsion
- Family history of torsion
Clinical presentation
The typical presentation is with an acutely painful, swollen testis and abdominal pain. This is often accompanied by nausea and vomiting. There is sometimes a preceding history of minor testicular trauma or of prior episodes of testicular pain caused by torsion that has untwisted itself. The abdominal pain seen in testicular torsion occurs because the testis retains its embryological nerve supply, primarily derived from the T10 sympathetic pathway.
History points that would favour testicular torsion as the diagnosis include:
- Sudden onset
- Severe pain
- Accompanied by vomiting
- Occurred during sleep (half of torsions occur during sleep)
- Previous history of torsion to the other testis
- Previous history of less severe episodes that have resolved in recent the past
- History of undescended testis
Examination points that would favour testicular torsion as the diagnosis include:
- Testis lies high in the scrotum
- Testis too tender to touch
- Opposite testis lies horizontally (Angell’s sign)
- Pain not relieved by elevating testis (negative Prehn’s sign)
- Absence of cremasteric reflex
Investigations
The diagnosis of testicular torsion relies on a combination of clinical evaluation and imaging studies. Doppler ultrasound can assess blood flow to the testicle, aiding in the confirmation or exclusion of testicular torsion. However, UK guidelines from the Royal College of Surgeons state that ‘in patients with a history and physical examination suggestive of torsion, imaging studies should NOT be performed as they may delay treatment, therefore prolonging the ischaemic time’.
While Doppler ultrasound is noted for its high sensitivity and specificity, it may provide false reassurance during the early phase of torsion or in cases of partial or intermittent torsion, as the presence of arterial flow does not rule out testicular torsion. The preference is for negative surgical exploration over a missed diagnosis, given the false-negative rate associated with all imaging studies.
In specific situations, such as late presenters or those with atypical features, imaging may be considered under the guidance of a senior clinician for a limited number of children.
Management
Following a swift clinical assessment, an urgent scrotal exploration is recommended. There should be an urgent referral to the emergency urology or surgical team. Recognising the urgency of testicular torsion is crucial, as prompt intervention is necessary to restore blood flow and salvage the testis.
The time sensitivity of testicular torsion is evident in the salvage rates. If treated within six hours, there is a 90% chance of saving the testicle. However, this rate decreases to 50% at 12 hours, 10% at 24 hours, and approaches zero after 24 hours. Approximately 40% of cases may result in the loss of the testicle.
The management approach involves immediate surgical detorsion and bilateral orchidopexy. Acting promptly within the critical time window is essential to maximise the chances of testicular salvage. Timely recognition and intervention are pivotal in preserving testicular function and preventing irreversible damage.
Header image used on licence from Shutterstock
Thank you to the joint editorial team of www.mrcemexamprep.net for this article.
