Aetiology and incidence
Peak incidence between 12 – 16 years, but can occur at any age younger or older.
Prevalence 1 in 4000
Extra-vaginal torsion only seen antenatally or in neonates.
All other torsion is intra-vaginal, i.e. within the tunica vaginalis.
Generally accepted aetiology is the “bell-clapper” deformity – anatomical variant with abnormally high insertion of the tunica vaginalis on to the cord, allowing increased mobility of the testis and distal parts of cord.
- Can also be described as a failure of the posterior gubernacular attachments
Presentation
Acute unilateral scrotal pain and swelling is the typical presentation, although cases can be atypical.
Vomiting and nausea is often present.
Typical examination findings are a higher riding testis with an abnormal lie, oedema, erythema, absent cremasteric reflex, tenderness.
https://pubmed.ncbi.nlm.nih.gov/32650017/
Diagnosis
Ultrasound may show alternate diagnoses. False negative rates (normal flow) can be 10 – 20 %, especially in early torsion, which is unacceptable.
Availability of urgent ultrasound is also limited, and it can be operator dependent.
Generally, ultrasound is used in lower-risk groups (pre-pubertal) in which an alternate diagnosis is suspected and can be confirmed.
If in any doubt, explore.
Management
Attempted de-torsion in emergency department – usually “open the book” laterally – may help relieve pain, but often still torsion present, and does not negate need for urgent exploration and orchidopexy.
Urgent scrotal exploration, de-torsion and bilateral fixation is the management.
I use non-absorbable prolene sutures in a 3-point.
To assess viability:
- Cover in warm packs whilst fixing other side
- Incise tunica albuginea and observe for active bleeding
If non-viable – proceed with orchidectomy.
Post-torsion
Atrophy is not uncommon following salvage and orchidopexy, especially if symptom duration was 10 hours or longer.
A proportion of men following post-pubertal torsion have circulating serum antisperm antibodies – but its significance and relevance to fertility is uncertain.
- It isn’t possible to know if these antibodies are from the torsion event itself, or from fixation and breach of the tunica albuginea.
Testicular prosthesis can be considered in patients who lose a testis to torsion.
Follow up studies have suggested reduced semen quality in men who had torsion as an adolescent – unclear aetiology – could be antisperm antibodies, pre-existing testicular dysgenesis or toxic free radicals reduced during ischaemia.
- Also unclear whether this actually affects fertility.
Endocrine function appears unchanged.
Differential diagnosis of acute painful scrotum:
- Torsion of testicular appendage
- Most common cause of pain in pre-pubertal children
- Typically less acute onset of pain, more gradual
- Appendix testis from Mullerian duct, appendix epididymis from Wolffian
- Blue dot sign – not always
- May be seen on ultrasound. If diagnosis confirmed or suspected, surgery not necessary.
- Hydrocele
- Epididymo-orchitis
- Mumps orchitis
- Idiopathic scrotal oedema
- Painless, peak incidence 5-6 years
- Usually marked oedema of scrotum, with erythema, occasionally extending to groin or perineum
- Swelling usually settles in 1-2 days. Antibiotics or antihistamines may or may not help.
- Hernia
- Henoch-Shonlein vasculitis
- 2 – 38 % of cases have scrotal involvement – tenderness, oedema, erythema, haematoma, infarction or rarely torsion
- Purpuric rash of buttocks, perineum and legs
- Tumour
- Trauma
- Ureteric stone
Intermittent torsion
30 – 50 % of patients with torsion give a history of episodic self-limiting acute scrotal pain.
If suspected, bilateral orchidopexy is appropriate in an attempt to prevent loss of testis in a future episode of unresolved torsion.
However, parents and patients should be aware that the diagnosis is essentially impossible to confirm, and that pain or issues may persist after orchidopexy.