Testicular torsion is a testicle’s rotation over its own axis, leading to a spermatic cord’s twisting, which supplies the testicle’s blood.
This disease is common in the adolescent age range while males are in their growth periods. Nonetheless, it can occur at any age. It is a urological emergency. Its early diagnosis and further treatment are vital to save the testicle and preserve its fertility. Within this article, you will find answers to some of the most common questions like what is it, is it treatable, and many more. Before reaching that point, there will be brief explanations about basic concepts to understand the disease.
By reading this article, you will obtain key insights about Testicular Torsion, its symptoms, its diagnosis, and the treatment. Therefore, please continue reading to get pearls on this specific topic at the hands of a Doctor.
What is Testicular Torsion?
Testicular torsion is a disease that is most common in adolescents and neonates (newborns). It is also the most common cause of testicular loss at this age. Nonetheless, a torsion may occur at any age, around 40-50 years old, tends also to be very common.
Now, testicular torsion refers to the twisting or torsion itself of the spermatic cord. Spermatic cord torsion leads to subsequently decreased blood flow to the testicle attached to it. But, what is inside these spermatic cords? The contents of the spermatic cords include the following:
- Ductus deferens and its associated blood vessels and nerves.
- Testicular artery.
- Pampiniform plexus, which ultimately forms the testicular vein.
- Genital branch of the genitofemoral nerve.
It is a condition that may happen spontaneously, due to exercise, or in fewer cases associated with traumatism. Testicular torsion accounts for approximately one-quarter of the scrotal pain or scrotal swelling complaints in an emergency room.
Types of Testicular Torsion
The tunica vaginalis plays a major role in this disease; it should be attached securely to the posterior lateral side of the testicle. If this happens, the spermatic cord should not be very mobile. However, suppose the attachment of the tunica vaginalis to the testicle is inappropriately high. In that case, the spermatic cord will be free to rotate within it. This freedom of movement will ultimately lead to an intravaginal torsion. It is a defect that receives the name of Bell Clapper Deformity.
Going through puberty may represent a risk factor for developing testicular torsion. Intravaginal torsion is the most common cause of torsion for adolescents. The sudden contraction of the cremasteric muscle often referred to as the cremasteric reflex, asides from the growth of the testicle after puberty. It may be the cause of an acute torsion.
The other type is the Extravaginal Torsion or neonatal testicular torsion. It is a condition that is more common in neonates. It happens because the tunica vaginalis is not attached securely yet to the spermatic cord.
In neonates, it is common to see that the testicle has not descended yet to the scrotum. Therefore, this undescended testicle predisposes the testicle to torsion due to its mobility. Thus, both structures are likely to twist as one. It is a pathology that can occur within weeks or months prior to birth. However, neonates can also present intravaginal torsion.
Who is at risk of having it?
It can be very obvious, but only men can suffer from testicular torsion. Now, certain risk factors may raise the risk of developing testicular torsion. Among the risk factors are the following:
- Age: The most important of all the risk factors. Testicular torsion is a disease that can happen while men are at adolescent ages and during puberty. That is why this is a condition that is more common in males between 12 and 18 years old.
- Previous Testicular Torsion: People who suffer from acute scrotal pain that later goes away without any treatment may suffer from intermittent testicular torsion. Intermittent torsion is more likely to repeat itself and with more frequency. These people are at risk of developing a complete testicular torsion which may lead to testicular infarction.
- The familiar history of testicular torsion: Testicular torsion can be a condition that runs in families. The defect on the tunica vaginalis may be inherited through generations within a family.
Although age and family history are the most common risk factors for testicular torsion, others may also prompt this disease. Also, there are some exceptions to age that are worth mentioning. Neonates or newborns can also be at risk of suffering from testicular torsion alongside men 40 to 50 years old.
Testicular torsion can also happen after vigorous physical activity or after a minor injury to the testicles.
What are the symptoms of Testicular Torsion?
Testicular torsion often presents as an abrupt onset of unilateral scrotal pain. This means that there is an affected testicle and an unaffected testicle. The symptoms asides from severe pain are the following:
- Swelling of the scrotum
- Abdominal pain
- Frequent urination
- A testicle in a position higher than normal or at an unusual angle
Commonly, episodes of testicular torsion happen during the night, making patients that suffer from it waking up in pain in the middle of the night. Both of the testicles should always be of the same size. However, in testicular torsion, the affected testicle can grow in size, which can be a problem.
There are also changes in the color of the scrotum. If this happens, it can be a sign of severity. The colors the scrotum can have are redness or darkening of the area. Early on, after the onset of the severe pain, there may not be the presence of redness or swelling of the scrotum. Nonetheless, shortly after, these symptoms may appear.
It is important to say that having troubles with urination are not normal signs of testicular torsion. The most affected of the testicles is the left testis. It is a condition that is more common on the left testicle than the right testicle. Nonetheless, although it is very unlikely to happen, testicular torsion can happen in both testes simultaneously.
After 6 hours of reduced blood flow, the testicle can suffer from testicular ischemia, leading to the testicular tissue’s death. If this happens, the testicle will shrink its size, and the scrotum will be very tender, red, and swollen.
How is it diagnosed?
To make an assertive diagnosis, the doctor will first make a series of questions to the patient to verify if the symptoms directly correlate to testicular torsion. Shortly after this, the doctor will perform a physical examination.
During this physical examination, the doctor will emphasize the scrotum, the testicles, the abdomen, and the groin. Also, the doctor will test the patient’s reflexes by pinching the inside of the thigh on the side with pain. On normal conditions, this pinch causes the testicles to contract. If it is testicular torsion, this reflex may not be present. After the examination, the doctor will ask for some tests to confirm the diagnosis. Among the tests are the following:
- Urine test: Doctors will ask for a urine sample to rule out urinary tract infections as the symptoms can be similar.
- Blood tests: As the urine sample, a regular blood test may show if the patient has an active infection.
- Ultrasound: Although testicular torsion is a clinical diagnosis, if there is suspicion of this pathology, a doctor may ask for a Doppler ultrasound or Doppler Ultrasonography. There are two types of Doppler ultrasound, plain ultrasonography, and spectral Doppler. The second one is more assertive for cases of testicular torsion as it shows color on the screen. The color shows the blood flow of the testicle. Plain Doppler ultrasonography may be less accurate than spectral as the gray-scale examination may show normal results.
Nonetheless, this is a clinical entity in which time is very valuable. Doctors may perform an assertive diagnosis after the physical examination. After this, the patient might go directly to emergency surgery without making further tests. Delaying the surgery may result in loss of the testicle.
What conditions may resemble testicular torsion?
Several conditions may resemble the symptoms of testicular torsion. Urologic emergencies are not so uncommon in the Emergency Room. However, doctors should perform a complete examination to rule out other pathologies.
Most of these conditions have a direct correlation to sexual intercourse or urinary tract infections. Among the pathologies or conditions that may resemble testicular torsion are the following.
- Scrotal trauma
- Testicular Choriocarcinoma
- Testicular Seminoma
- Testicular trauma
- Fournier Gangrene
- Inguinal Hernia
- Testis tumor
- Idiopathic scrotal edema
Nonetheless, the history of the patient plays a major role and the age of the patient too. Doctors are very aware that children are prone to develop testicular torsion. Children are very unlikely to have sexual intercourse at young ages. Still, there are certain cases in which this may vary.
What are the treatment options for this disease?
To correct testicular torsion, the patient in most of the cases requires surgical intervention. There are cases in which the doctor might be able to untwist the testicle through manual detorsion. Nonetheless, these patients will require surgery to attach the testicles to the scrotum and prevent another torsion event.
This surgery is a simple procedure in which the patient will be fully sedated. The doctor will perform a small incision in the scrotum to be able to untwist the spermatic cord. After untwisting the spermatic cord, the doctor will be able to attach one or both testicles to the scrotum. If the patient takes too long to visit an emergency room, he is at risk of losing the testicle. After six hours from the beginning of the symptoms, the chances of losing a testicle increases. And if the treatment has a delay of more than 12 hours, the patient is at severe risk of losing the testicle.
Detecting testicular torsion in newborns and infants can be challenging. Ultrasound might not be as effective as it should be. It will not detect the decrease in the blood flow of the testicle, which is why these patients require immediate surgery to determine testicular torsion. Nonetheless, practicing immediate surgery on infants may prevent future problems with male hormone production, fertility, and development.
What is the outlook for testicular torsion?
Measuring the immediate testicular salvage and late incidence of testicular atrophy helps determine testicular torsion management’s success. Over a third of the patients who suffer from testicular torsion undergo orchiectomy (testicle removal surgery). These are alarming numbers as children are the ones who suffer from this condition and may not be able to communicate their symptoms to their caregivers.
There is a direct correlation between the time in which the symptoms begin and the salvage rate of the testicle. The following shows the correlation between time and percentage of salvage:
- Below 6 hours: 90 to 100% salvage rate
- Between 12 to 24 hours: 20 to 50% salvage rate
- Over 24 hours: 0 to 10% salvage rate.
Many of these patients may undergo orchiopexy, a type of surgery. It is not a guarantee that the patient will not suffer a testicular torsion again. However, it reduces the odds of suffering it again. Then again, these patients can suffer from several complications like the following:
- Testicle infarction
- Loss of testicle
- Infection or sepsis
- Cosmetic deformity
Men often suffer from a condition that receives the name of contralateral disease. Men that go through testicular torsion often find that their endocrine and exocrine function becomes substandard. This means that it may exist a correlation between the length of the torsion and abnormalities in the semen. Specialists believe that there is an induction of pathologic changes in the contralateral testis by retaining the injured testis.
What complications are associated with testicular torsion?
Testicular torsion is a condition that may come with several complications. These complications are very easy and very likely to happen if the diagnosis time is wrong. Suppose patients do not go to an emergency room immediately after having severe pain in the testis. In that case, they are at risk of losing the affected testicle. Among the complications that a testicular torsion may imply are the following:
- Inability to father children or infertility: After a decrease in the blood flow to the testicles, acute and irreversible damage may happen to the testicular tissue. This is more likely to happen if the testicle suffers from complete privation of blood supply.
- Infection: If the testicle dies or is severely damaged, bacteria likely grow from this tissue. Bacterial growth leads to severe infections and gangrene, which may compromise other tissues or even become a life-threatening condition.
- Atrophy: Due to the lack of blood flow, some parts of the tissue may receive irreversible damage leading to atrophy of the testicle. This will cause the testicle to shrink in size.
- Cosmetic deformity: Although it is not a complication per se, it can be a consequence of testicular torsion. It can affect the overall self-esteem of men that undergo testicular torsion.
- Testicular infarction: Although it can be very obvious, testicular infarction is a real possibility of this condition. Lack of blood supply may lead to the death of the testicular tissue and further inability of it.
Suppose we take into account all the possible complications. In that case, patients are encouraged to visit an emergency room if they feel symptoms that may correlate to testicular torsion. Time plays a major role in this disease and may help to save the testicle.
How do you untwist testicular torsion?
Most of the time, doctors will untwist testicular torsion through a surgical procedure. Nonetheless, doctors will try to manually untwist the torsion to prevent further damage to the testes. If manual detorsion does not work, doctors will proceed to surgical intervention. Doctors will perform a small incision in the scrotum to reach the affected test and then untwist it. Later they will reattach the testes to the scrotum to prevent further twisting.
Does testicular torsion cause erectile dysfunction?
Although there are no studies that completely avail the link between testicular torsion and erectile dysfunction, researchers have their theories. Testicular torsion affects children mostly, which leads to atrophy of the testicles and further damage of the testicular tissue.
Researchers believe that there is a direct correlation between a substandard functionality of the testicles and erectile dysfunction. Testicular torsion leads to a decrease in the contralateral testis of the production of male hormone. This decrease may be the link between these two entities. However, there is no proof yet.
Should you go to the ER for testicular torsion?
Yes, suppose the severe pain is not reason enough for visiting the Emergency Room. In that case, patients should take into consideration that they might lose a testicle. Also, the risk of developing an infection if the patient takes too long to visit the hospital. If the patient develops an infection, it can lead to sepsis which can be a life-threatening condition.
Testicular torsion should always receive medical attention even if the pain goes away without treatment. Doctors should first rule out other conditions. If the diagnosis is testicular torsion, they should perform a surgical intervention to prevent further torsion events.
Do you have symptoms of this disease?
This tool is a Testicular Torsion Symptoms Checker. It gathers the most important signs, symptoms, and risk factors for the disease. Therefore, the tool will tell anybody who uses it the likelihood of their symptoms because of testicular torsion. Using the tool is free and would only take a few minutes.