Overview

Testicular torsion is a urological emergency that occurs when the spermatic cord twists, cutting off the blood supply to the testicle. This condition is most common in adolescent males but can occur at any age, including infancy and adulthood. Testicular torsion is a time-sensitive medical issue, and delayed treatment can lead to permanent testicular damage or even loss of the testicle. Prompt recognition and surgical intervention are crucial to preserving testicular function and overall reproductive health.

Causes

The primary cause of testicular torsion is the abnormal twisting of the spermatic cord, which contains the blood vessels, nerves, and vas deferens that supply the testicle. Several factors can contribute to this condition:

• Bell-Clapper Deformity: A congenital abnormality where the testicle is inadequately attached to the scrotum, allowing it to move freely and increasing the risk of twisting.
• Injury or Trauma: Direct trauma to the testicles or scrotum can trigger torsion.
• Rapid Growth: Adolescents may experience torsion during periods of rapid testicular growth, particularly around puberty.
• Exercise or Physical Activity: Sudden movements, intense exercise, or vigorous physical activity can sometimes provoke torsion.
• Cold Weather: Some studies suggest that exposure to cold can cause contraction of the scrotal muscles, potentially leading to twisting.

Symptoms

Testicular torsion typically presents with sudden and severe symptoms that require immediate medical attention. Common signs and symptoms include:

• Severe Scrotal Pain: Sudden onset of intense pain in one testicle is the hallmark symptom.
• Swelling: Rapid swelling and redness of the scrotum may be observed.
• High-Riding Testicle: The affected testicle may appear higher in the scrotum than usual or be positioned at an unusual angle.
• Nausea and Vomiting: The severe pain often causes accompanying nausea and sometimes vomiting.
• Abdominal Pain: In some cases, the pain radiates to the lower abdomen, leading to misdiagnosis.
• Frequent Urination: Some individuals may experience urinary symptoms like frequent urges to urinate.

Diagnosis

Early diagnosis of testicular torsion is critical to prevent irreversible damage. A healthcare provider will usually perform the following steps:

• Physical Examination: A thorough examination of the scrotum, testicles, and abdomen to check for tenderness, swelling, and testicle positioning.
• Cremasteric Reflex Test: The absence of this reflex (where the testicle normally rises when the inner thigh is stroked) is a clinical indicator of torsion.
• Scrotal Ultrasound: Doppler ultrasound is often used to assess blood flow to the testicles. Reduced or absent blood flow confirms the diagnosis.
• Urinalysis: This test may be done to rule out infection, though it usually appears normal in torsion cases.
• Surgical Exploration: If there is strong clinical suspicion, surgery may be performed immediately without further imaging to avoid delays.

Treatment

The treatment of testicular torsion is surgical and time-sensitive. Options include:

• Emergency Surgery (Detorsion and Orchiopexy): The twisted spermatic cord is untwisted to restore blood flow, and both testicles are secured (orchiopexy) to prevent future torsion.
• Orchiectomy: If the testicle is found to be non-viable (typically after 6-8 hours of torsion), it may be surgically removed to prevent infection or complications.
• Manual Detorsion: In rare cases and immediate settings, manual detorsion may be attempted in the emergency room but is not a substitute for surgery.

Early treatment within 6 hours of symptom onset significantly increases the chance of saving the testicle, while delays reduce the likelihood of successful recovery.

Prognosis

The prognosis of testicular torsion largely depends on the speed of intervention:

• Early Treatment: When treated within 4 to 6 hours, the testicle is typically salvageable, with full recovery expected.
• Delayed Treatment: Beyond 8-12 hours, the risk of permanent damage or loss of the testicle increases substantially.
• Fertility Outcomes: Many patients retain normal fertility if the testicle is saved. Even after orchiectomy, the remaining testicle usually maintains adequate hormone production and fertility.
• Recurrence Prevention: Orchiopexy of both testicles reduces the risk of future torsion episodes.

With prompt medical care, most individuals recover well. However, delayed treatment can lead to testicular atrophy, infertility, and emotional distress, emphasizing the need for rapid recognition and surgical management.