TESTICULAR TORSION

DEFINITION
Testicular torsion is an emergency in the form of rotation of the
longitudinal axis of the spermatic cord which results in blocked
testicular blood flow. Most acute cases of scrotum in children are
testicular torsion.
EPIDEMIOLOGY
Testicular torsion is the most common cause of acute scrotum. The
incidence of testicular torsion is 1 in 4000 men before the age of 25
years. Testicular torsion can occur at any age, most often at the age of
12-16 years; the left side more often. The median age of testicular
torsion patients is 15 years.
CLASSIFICATION
Testicular torsion according to the cause is divided into extravaginal and
intravaginal.
Testicular torsion is also divided according to its duration since onset. The
division is also clarified with pathological features on sonographic examination
:
- Type 1 -> Acute phase
- Type 2 -> Initial phase
- Type 3 -> Late phase
RISK FACTORS
- Season with lower and humid temperatures like spring and cold
- Pregnancy with complications such as prolonged labor, pre-eclampsia, gestational
diabetes, multiple pregnancies, large birth weight, and vaginal delivery
- family history, Cryptorchidism or undescended testicles are also said to increase 10
times the risk of testicular torsion.
PATHOPHYSIOLOGY
Intravaginal and extravaginal torsion will result in testicular ischemic
injury due to the spin of the testis in the spermatic cord pediculus.
Experimental studies show that testicular infarction begins 2 hours after
the onset of testicular torsion, irreversible damage occurs after 6 hours,
and complete infarction arises at 24 hours.
Intravaginal
The cause of intravaginal testicular torsion is an anatomical abnormality in the form of
tunica vaginalis that covers the entire testis and epididymis so that the attachment to
the scrotum is disrupted.
This deformity is better known as the "bell clapper" which is characterized by
increased testicular mobility. Intravaginal testicular torsion most often occurs during
sleep, and due to trauma.
Extravaginal
Extravaginal torsion of the testis is most common in cases of fetal and
neonatal torsion. In this type of torsion, spermatic cord twisting occurs
outside the tunica vaginalis sac in the scrotum. The external spermatic
fascia is not attached to the dartos muscle, and new spermatic cord
attaches to the scrotum in 7-10 days of life.
APPEAL DIAGNOSIS
Testicular torsion is often misdiagnosed; Testicular torsion is the 3rd most common
malpractice case in adolescents aged 12-17 years. The most common misdiagnosis is
epididymitis.
In children it is important to be distinguished from appendicitis, hematocele,
hydrocele, testicular neoplasms, and scrotal abscesses whose symptoms are similar to
torsion.
What distinguishes the torsion of the testicular appendix from the testicular torsion, in
addition to its gradual complaints, is the presence of a blue dot sign that is commonly
found in the anterosuperior region of the testis.
 DIAGNOSIS

a. Anamnesis
Severe unilateral pain that is suddenly felt at rest and is often
accompanied by nausea, vomiting. Nausea, vomiting caused by celiac
ganglion stimulation reflexes, is an important symptom of ischemic
systemic effects in the body.
b. Physical examination
On physical examination found tenderness, abnormal testicular position, and
loss of cremaster reflexes. Abnormal testicular position occurs because the
spermatic cord is shortened, twisting will pull the testis higher.
• Cremaster reflex examination
- positive results: good testicular blood flow
- negative results: there is twisting
Edema, induration, and scrotal erythema can be found in severe degrees.
• Examination of Phren's sign is important to distinguish pain caused by
torsion or orchitis.
Torsion position can be touched on physical examination. The cord knot is
palpated by identifying the top of the testis and the head of the epididymis.
Enlargement of the painful and hard left scrotum
c. Radiology Examination
The most important are Doppler ultrasound (DUS) and Radionuclide
Scrotal Imaging (RNSI) to assess testicular perfusion and whether the
testis is viable. Color DUS shows "spiraling" (whirlpool) or twisting of
vessels on the spermatic cord topography.
a) Scrotal ultrasound describes the
position of the left testicle which is
abnormally tranverse with minimal
reactive hydrocele.

b) Doppler ultrasound shows the least

blood flow to the left testis.
 TREATMENT
a. Manual Detortion : Detection manually is done by intravenous sedation or spermatic
cord anesthesia. The success of a detortion is marked by the loss of pain complaints.
Even though manual detortion is successful, operative action is required, namely
immediate orchidopexy, and biopsy examination.

b. Surgical Exploration: Surgical exploration continues in all cases of testicular torsion. In

exploration, a spermatic and testicular heavenly derotation was performed, along with
an assessment of testicular viability after detortion. Orchidectomy if the testicles are
necrotic and non-viable. Orchidectomy is performed by contralateral testicular
orchidopexy. If the testis is viable after detortion, bilateral orchidopexy is performed.
In paradise exploration, 1/3 of the torsion testis cases were found dead and had an
orchiectomy. In the saved testicles, testicular damage is still found accompanied by a
decrease in testicular size. Anti-sperm antibody examination and inhibin B can be used
as markers of testicular function after surgery. After exploration or detortion, the
testes are covered with warm gauze for 10-15 minutes and assess for signs of testicular
reperfusion.
The spermatic cord twists
on the testicular torque
 PROGNOSIS
- Infertility is a long-term consequence
- Impaired spermatogenesis due to torsion of the testes will reduce sperm
quality.
The sooner the diagnosis is established, <6 hours, the better the
prognosis can be saved of the testes. The most common cause of
orchidectomy is late diagnosis. The orchidectomy rate is 9% at <6 hours after
onset and 56% at> 6 hours. Testicular ischemia will result in testicular atrophy.
After torque, 36-39% of men will have a sperm concentration below 20 million
/ mL.
In the perinatal age group, the testes can no longer be saved, whereas
in the postnatal age group immediate paradise exploration is needed.
Recurrent torsion can occur several years after orchidectomy and orchidopexy.
CONCLUSION
Testicular torsion is an emergency case in children and adolescents. A
quick and precise diagnosis is needed because the speed of the
intervention greatly affects the safety of the testes. Doppler ultrasound
is still the choice for diagnosis of torsio testis. The only treatment is
detortion. Although the most ideal is surgical detortion, clinicians must
know the technique of manual detortion.