Testicular Torsion

TESTICULAR TORSION

Any child or young man who presents with acute testicular pain is considered to have testicular torsion, until proven otherwise.  The etiological factor seems to be a congenital predisposition of the testis to a horizontal lie rather than the normal vertical lie.  The testis is twisted upon itself, giving rise to vascular strangulation. Depending on the degree of torsion, the torsion has to be relieved, usually within 6 hours to avoid testicular infarct. In real life practice, testicular torsion is often missed and often a subject of medico-legal negligence against the attending doctor and the surgeon.

Emergency surgery consists of scrotal exploration, untwisting the torsion and fixing the testicle with 3 sutures.  The fixation also has to be done for the contralateral testis.  However, if the testis is infarcted, the testis is best removed and consent has to be taken preoperatively for this as well.

However, only 50% of children and young men presenting with acute testicular pain are due to torsion.  The differential diagnosis is often that of inflammation e.g. epididymo-orchitis from viral infection especially mumps.  Urinary tract infection (in children with underlying UTI, urogenital tract abnormalities) and in young adults with other infections (e.g. TB, STD) can also present acutely with testicular pain.  However, upon taking a detailed history, they may be found to have an insidious onset, including constitutional symptoms e.g. fever, mumps in a close family member or in the school.

Emergency investigations can occasionally help to rule out torsion and this includes emergency Doppler ultrasound of the testis, epididymis and spermatic cord to trace the blood supply. In some medical centres, emergency isotope study can also confirm the vascularity of the testis.  When in doubt, it is always better to list the patient for emergency exploration.

Dr Clarence Lei Chang Moh, FRCS Urol

Consultant Urologist

email: clarencelei@gmail.com

10^th September 2013

Enclosures: Two sets of operative photographs indicating (a) testicular torsion infarcted and testicle removed, (b) testicular torsion twisted intraoperatively and salvaged.