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Testicular Torsion

Testicular Torsion -Causes, Diagnosis and its Treatment

 

Introduction

Testicular torsion is a condition wherein the spermatic cord twists on itself. The spermatic cord supports the testis in the scrotum and any anomaly in the positioning of the cord can result in twisting. As a result, the blood supply to the testicles is cut off and causes acute testicular pain. Congenital malformation can cause testicular torsion when testis are not adequately attached or affixed to the scrotum, allowing for free movement. This increases the risk of spermatic cord and surrounding vessels getting twisted under varied circumstances. Testicular torsion can be found quite commonly in pre-pubescent and young adult males. 1 in every 4000 men experience testicular torsion before the age of 25.

Risk factors

As testicular torsion cuts off the blood supply to testicles, severe damage can be done to the testicles if the disorder is left undiagnosed and untreated. Blood loss can cause shrinkage of testis even days or months after testicular torsion has been corrected. The ‘bell clapper deformity’ is a congenital condition wherein testis can internally rotate and become increasingly susceptible to torsion. This mechanical twisting can also happen in pre-natal stages causing neo-natal torsion. As a result a male baby can be born with a single testis.

Causes

Testicular torsion happens due to a mechanical twisting of the spermatic cord and therefore, there are rarely any external factors that contribute to the onset of this disorder. Some studies do indicate that warm and humid temperatures increase the risk of testicular torsion, but men living in all climatic conditions are at equitable risk of this disorder. The most prominently recognized causes of testicular torsion are –

  • Variation in the size of testis: If one of the testicles is significantly larger than the other, the chances of imbalance in the anatomy are much higher. This can increase the vulnerability of the testis and make them prone to twisting within the scrotum.
  • Tumorous growth on testis: If there is a tumorous growth on one of the testicles, then the chances of twisting of spermatic cord and surrounding vessels increases because of anatomical imbalance.
  • Injury to the scrotum: In the event of an injury and subsequent swelling on the scrotum, testicular torsion may also occur.
  • Physical duress: During early phase of puberty and in older men, heavy exercise can also lead to onset of testicular torsion.

Diagnosis

Diagnosis of testicular torsion can be conducted by taking into account the patient history and conducting physical exams. In order to rule out other similar testicular or epididymis related disorders; Doppler ultrasound is also used for differential diagnosis. The commonly observed symptoms of testicular torsion are –

  • Swelling in one of the testis
  • An unprecedented, sudden and severe pain in one of the testis without any external injury
  • A visible lumpy formation on one of the testis
  • Blood in semen
  • Lightheadedness, nausea and vomiting

In addition to taking stock of the symptoms, clinical examination also includes a test for cremasteric reflex, which is typically absent in case of a true torsion. In normal cremasteric reflex, upon stroking of the inner thigh, the cremaster muscles contract and result in lifting up of testis. But in the twisted cord condition of testicular torsion, testis can’t lift up at all, failing to manifest cremasteric reflex.

The Doppler ultrasound test is 90% accurate as it confirms the absence of blood flow in the testicle experiencing torsion. As the disorder requires urgent surgical treatment, Doppler ultrasound is the fastest diagnostic confirmation which can enable physicians to distinguish between testicular torsion and epididymitis.

Treatment for Testicular Torsion

At the onset of testicular torsion, the affected testicle twists towards the midline of the body and away from the thigh. In some cases, this torsion can be fixed manually by twisting the testicle back in position, towards the thigh. But this is a very unreliable way of correcting the disorder. As testicular torsion is accompanied by severe testicular pain and nausea, a patient can easily acknowledge the need of medical attention. Surgical assistance is essential in case of testicular torsion and if taken within 6 hours of the onset of pain, the chances of saving the affected testicle from shrinkage remain as high as 90%. As time passes without treatment, the risk of testicular shrinkage due to torsion increases significantly and beyond 24% it can be almost impossible to save the affected testicle. When children suffer from testicular torsion, the preferred treatment is surgically sewing up the testicle to the scrotum, to avoid recurrence of the disorder. It is a common practice to also set the alternate testicle during surgical procedure as the risk of torsion is high in future for the unaffected testis.