Testicular torsion is an inversion of the spermatic cord, leading to infringement of its constituent elements and disruption of the blood supply to the testicle. Testicular torsion is accompanied by sudden acute pain syndrome, nausea, vomiting, collapse; local symptoms – unilateral swelling, hyperemia or pallor of the scrotum. For diagnostic purposes, if a testicular torsion is suspected, diaphanoscopy, ultrasound and ultrasound of the vessels of the scrotum organs, puncture of the testicular membranes are performed. In the first hours, external manual unwinding of the testicle can be undertaken to eliminate testicular torsion; in other cases, surgical intervention is indicated. In case of necrosis of the testicle, its removal is performed (orchiectomy).
Testicular torsion is a twist, twisting of the spermatic cord around the vertical axis, accompanied by ischemia, and in severe cases, necrosis of the testicle. The spermatic cord is an anatomical formation, which includes the vas deferens, testicular arteries and veins, lymphatic vessels and nerves surrounded by the membranes of the spermatic cord. When the testicle is twisted, a sudden sharp violation of the blood supply to the testicle develops, which in a matter of hours can lead to its irreversible damage and even death. These circumstances make it possible to attribute testicular torsion to the category of urgent conditions found in clinical urology and andrology. Testicular torsion occurs in 1 out of 4000 men or in every 500th urological patient. The pathology most often develops in adolescent children aged 10-16 years, but it can also occur in newborn children and adult men.
The prerequisite for the torsion of the testicle is its excessive mobility, due to the lack of normal attachment of the organ to the bottom of the scrotum. A number of anatomical and topographic features that occur in some men can contribute to increased displacement of the testicle: aplasia or hypoplasia of the testicular guide ligament, congenital elongation of the spermatic cord, inversion of the testicles, inguinal-scrotal hernia, separation of the elements of the spermatic cord (neurovascular bundle and vas deferens), etc. A testicle that has not descended into the scrotum (with cryptorchidism) can be twisted. In children, testicular torsion is often associated with prematurity, morphofunctional immaturity of the reproductive system and disproportionate growth of the genitals.
The immediate factors provoking testicular torsion are usually scrotal injuries, active movements, outdoor games, physical exertion, increased intra-abdominal pressure, wearing tight underwear and clothing, sexual intercourse, as well as other moments that entail a cremaster reflex – contraction of the muscle that raises the testicle. The twist of the spermatic cord is accompanied by the rotation of the testicle around its vertical axis. When the testicle is rotated by more than 180 °, a sharp violation of blood circulation in the genital gland develops, thrombosis of the veins of the spermatic cord occurs, serous-hemorrhagic transudate accumulates in the cavity of the testicle’s own shell – a secondary hydrocele develops.
More often, testicular torsion is unilateral; bilateral pathology is diagnosed extremely rarely. According to the mechanism of development, extravaginal and intravaginal testicular torsion are distinguished. In case of extravaginal (supravaginal) torsion of the testicle, the twisting of the spermatic cord is performed together with its membranes. This form of pathology is usually observed in children under 1 year of age and is associated with morphological immaturity of the structures of the spermatic cord, hypertonicity of the cremaster muscle, short and wide inguinal canal, looseness of the fusion of membranes, etc.
In the case of intravaginal (intracellular) testicular torsion, the spermatic cord is twisted inside its own vaginal sheath. This variant of testicular torsion is typical for children older than 3 years and adults. The mechanism of intravaginal testicular torsion is as follows. With a reflex contraction of the cremaster muscle, the testicle is pulled up and begins to make a rotational movement. The longer the mesentery of the testicle, the higher its mobility, and the stronger the force of muscle contraction and the greater the mass of the testis, the more pronounced the degree of testicular torsion.
Testicular torsion symptoms
The earliest signal indicating the accomplished torsion of the testicle is an acute, sharp and sudden pain in the scrotum, which radiates into the inguinal region and perineum. The pain syndrome is so pronounced that it is accompanied by reflex nausea, vomiting, sharp arterial hypotension (collapse). An exception to the general rule is cases of testicular torsion in newborns, which proceed painlessly and are usually detected on the basis of an increase in one half of the scrotum.
Local changes in testicular torsion include hyperemia (cyanosis) or pallor of the scrotum skin, its increased sensitivity to touch. Due to the development of dropsy of the testicular membranes, the scrotum looks swollen and edematous. The twisted testicle is located much higher than its usual location and above the second testicle. Dyspeptic disorders, frequent and painful urination, acute urinary retention, subfebrility are possible.
In some cases, there may be a twist of the hydatid (suspension, appendix) of the testicle – a rudimentary formation located in the area of the upper pole of the testicle. The manifestations of testicular hydatid torsion are generally similar to the symptoms of testicular torsion, with the exception of more limited swelling and hyperemia of the scrotum. Necrosis of the hydatid can cause purulent melting of the scrotum tissues and cause its amputation.
Atrophy of the spermatogenic epithelium and male infertility may result from testicular torsion. Irreversible changes in testicular tissues can develop as early as 6 hours after the spermatic cord is twisted, so this condition requires immediate treatment by a specialist – urologist, andrologist or surgeon.
During examination and palpation, the swelling and hyperemia of the scrotum is determined, the testicle tightened to the external inguinal ring and inactive on the side of the twist; the consistency of the testicle is tight-elastic, the spermatic cord is thickened. An attempt to raise the testicle even higher causes increased pain (Pren’s symptom). Additional examinations to reliably determine testicular torsion include diaphanoscopy, ultrasound of the scrotum organs and ultrasound of the scrotum vessels. An echographic sign indicating the viability of the testicle is an unchanged echo density of the organ; testicles with reduced or heterogeneous echogenicity, as a rule, are not viable.
Diagnostic puncture of the scrotum allows you to determine the nature of the contents of the membranes (exudate, blood, pus). Differential diagnosis of testicular torsion is carried out with inflammatory diseases of the scrotum (orchitis and epididymitis), hydrocele, Quincke’s edema.
Testicular torsion treatment
Treatment of testicular torsion should be initiated immediately after diagnosis. In the first hours after the development of the disease, a conservative solution to the problem is possible with the help of external manual detorsion (unwinding) of the testicle. Testicular detorsion is performed in the position of the patient lying on his back; at the same time, the tissues of the scrotum together with the testicle are grasped by hand and rotated 180 ° in the direction opposite to the median suture of the scrotum, with simultaneous light traction of the testicle down. This manipulation is performed several times. Indicators of successful elimination of testicular torsion are a significant reduction or disappearance of pain in the scrotum, the mobility of the testicle and its occupation of the usual place in the scrotum. If several attempts at external detorsion are unsuccessful, conservative tactics should be abandoned and surgical treatment of testicular torsion should be carried out.
The operation for the torsion of the spermatic cord is performed through inguinal (with extravaginal form) or scrotal (with intravaginal form of testicular torsion) access. During surgery, the most important stage is the correct assessment of the viability of the testicle after its intraoperative detorsion. If, after the restoration of blood circulation, the testicle acquires a normal color, the testicle is repositioned and fixed to the tissues of the scrotum. When diagnosing testicular necrosis, its removal is indicated – orchiectomy followed by implantation of an artificial testicle to correct a cosmetic defect. If, during the revision of the scrotum, a twist of the testicular hydatid is detected, its leg is bandaged at the base, after which the hydatid is cut off and removed. In the postoperative period, novocaine blockades of the spermatic cord, physiotherapy, and drug therapy aimed at improving microcirculation in the damaged organ are carried out.
Prognosis and prevention
Only in 2-3% of patients, testicular torsion can be eliminated conservatively, in other cases surgical intervention is inevitable. If less than 6 hours have passed since the twisting of the testicle, the probability of viability of the organ is 90-100%; after 12-24 hours – 50-20%. There is evidence that men who have previously suffered a torsion of the spermatic cord are more likely to develop testicular cancer in the future.
Prevention of testicular torsion allows the prevention of injuries to the scrotum organs, the use of protection during sports, wearing loose clothing. Patients who have suffered testicular torsion are routinely recommended to perform preventive orchipexy from the opposite side, which allows to prevent torsion of the collateral testicle in the future. If pain and swelling appear in the scrotum, you should immediately consult a doctor to exclude testicular torsion.