December 02, 2007

Testicular Torsion

Sometimes, the tissue surrounding a testicle is not well attached to the scrotum. As a result, the testicle may become twisted around the spermatic cord resulting in the blood supply being cut off. The following information should help you better understand this potentially serious health hazard.

What happens under normal conditions?

The testicle (testis) receives its blood supply through the spermatic cord, which arises in the abdomen, courses through the inguinal canal and then enters the scrotum. This cord also includes the vas deferens, which transports sperm to the urethra. While there is more than one source of arterial blood to the testicle, they all enter the testicle via the spermatic cord. Interruption of this arterial route, therefore, will result in a complete cutoff of blood supply and demise of the testicle.

The testicles are organs suspended in a pouch-like skin sac — the scrotum — below the penis. By looking at the scrotum, both the right and left testicle should be approximately equal in size. An asymmetric enlargement, especially if acute, suggests an underlying pathologic condition on one side. Similarly, the skin color on both sides of the scrotum should be identical. Any change in color, especially redness or darkening, also suggests a problem. Finally, testicles are normally not painful and any pain or discomfort should alert the individual to seek medical attention, even if there is no swelling or skin color change.

What is testicular torsion?

Testicular torsion, or twisting of the testicle resulting in a strangulation of the blood supply, occurs in men whose tissue surrounding the testicle is not well attached to the scrotum. It is important to emphasize that testicular torsion is a medical emergency. The testicle will die (infarct) and diminish in size (atrophy) if the blood supply is not restored within approximately six hours. Restoration of the blood supply requires untwisting the cord (de-torsion).

Torsion is relatively rare, occurring in approximately one in 4,000 males under the age of 25. However, it can also occur in newborns and in older men.

What causes testicular torsion?

In most individuals a testicle cannot twist because the surrounding tissue is well attached to the scrotum. The term "bell clapper" deformity is often used to describe a congenital condition in those individuals, whose testes hang within the scrotum and can "swing" like a bell clapper in a bell, allowing for easy twisting. It must be emphasized that boys and men born with the "bell clapper" deformity have no attachments around either testicle, so that torsion can potentially occur on either side. Bilateral testicular torsion, however, is an exceedingly rare event.

What are the symptoms of testicular torsion?

The hallmark of testicular torsion is sudden, severe, one-sided testicular pain. Torsion can occur at any time, while sitting or standing, or may awaken an individual from sleep. Physical activity does not cause torsion, but it may occur during sports or physical exercise. There is often associated nausea and vomiting. Slow-onset testicular pain, over several hours or days, can represent torsion, but it is less common. Problems with urination, such as burning or frequency, are not normally associated with torsion. Torsion is not a painless event, except perhaps in the newborn.

Early in the process, there may be no scrotal swelling. However very shortly thereafter, there will be swelling and redness of the scrotal skin. Testicles that have died (infarcted), after many hours of torsion, cause the greatest scrotal changes. The scrotum will be very tender, reddened and swollen. Often the individual will not be able to find a comfortable position.

How is testicular torsion diagnosed?

Clinical evaluation by the urologist, consisting of medical history and physical examination, is often sufficient to diagnose torsion. Time is of the essence, so if the urologist cannot exclude torsion or suspects it, surgical intervention must be undertaken without further delay. There are X-ray tests which may be used, especially in those individuals whose examination and history may not be characteristic. Both ultrasound and nuclear medicine techniques can be used to assess blood flow to the testicle, and therefore, can also exclude or confirm torsion.

How is testicular torsion treated?

Ultimately, all individuals with torsion require surgery. The testicle can at times be manually untwisted in the emergency room, but whether this is successful or not, surgery should follow. At surgery, the affected testicle will be untwisted and then sutures placed around both testicles to prevent future torsion. Most often this is performed through the scrotum, although an inguinal approach may be used. Unfortunately, there are individuals whose testicles cannot be saved, because it has already infarcted. This is determined at surgery. These individuals will undergo removal of the affected testicle at the time of surgery and then placement of sutures around the remaining opposite testicle to prevent future torsion.

The testicles of newborns with torsion can rarely be salvaged by untwisting, because they are almost always infarcted. Neonatal torsion is, therefore, not the same sort of surgical emergency as torsion in older boys and men. On the other hand, there have been instances of the other non-involved testicle twisting shortly after birth, leaving the baby with no testicles. In addition, there have been great improvements in pediatric anesthesia and postoperative care of even the smallest newborns. Many pediatric urologists will therefore take a newborn to surgery within the first few hours or days of life to remove the affected testicle and to place sutures around the opposite testicle to prevent future torsion.

What can be expected after treatment for testicular torsion?

Whether the testicle is removed or not, scrotal exploration results in minimal and short-lived discomfort. Oral pain medication may be necessary for a few days. Most surgeons will allow the patient to return to work or school within a few days to a week. However, strenuous physical activity or exercise might be best avoided for several weeks. The sutures that are placed around the testicles are not perceived by the patient and are not bothersome. It would be very rare for torsion to recur after the placement of fixation sutures. Patients and families should be wary of any testicular pain or swelling, however, especially if there is only one remaining testicle. In that case they should seek medical attention immediately.

If the torted testicle is left in place, it still might diminish in size slightly, since there may have been some permanent damage during the hours that the testicle was twisted. It is not possible to predict in whom this will happen, except that testicles torted for the longest time, in general, may have more size reduction. In addition, if one testicle is removed, the opposite testicle may increase in size to greater than normal, which is known as compensatory hypertrophy. Torsion of the testicle cannot be prevented by changes in activity or by taking medication. Only fixation sutures placed around the testis at surgery will prevent future torsion.

Frequently asked questions:

How will my future fertility be affected after the loss of a testicle?

Only one functioning testicle is necessary for normal fertility potential and full masculinization. A single testicle will produce normal amounts of sperm and testosterone. While there has been some experimental evidence to suggest that mechanisms might exist to diminish fertility in these patients, they do not appear to be clinically relevant in the vast majority of men who have had torsion.

How will my lifestyle be impacted if I have lost a testicle or have a weakened testicle?

Patients who have lost a testicle or who have a weakened testicle should remain cautious about the remaining testicle. They should always wear protection when engaging in contact sports. They should always seek medical attention if they have any discomfort or notice anything abnormal in the scrotum or remaining testicle.

Should I consider a testicular prosthesis?

Testicular prostheses are manufactured to replace a lost testicle. The products available include a solid, soft silicone polymer and a saline-filled silicone, which have not yet achieved full FDA approval. Most often, these prostheses are inserted when the individual is fully grown and through puberty. Placement of a smaller prosthesis in a younger boy would necessitate a second surgery to replace it with an adult sized prosthesis. Surgery for placement of a prosthetic testicle is not done at the time of removal of the infarcted testis, but may be performed some months later. The decision to place a prosthesis is highly personal and should be discussed with the urologist.

Can a newborn have testicular torsion?

Yes, although neonatal (newborn) testicular torsion is even more rare than torsion in older individuals. It is diagnosed right after birth, and may relate to prolonged or difficult labor. The torsion most often occurs prior to delivery. Its exact cause is unknown and location of the twisting of the spermatic cord is in a different location, as compared to older boys and men. They usually present with a hard scrotal mass, with some darkening of the scrotal skin. Unlike older patients, these infants most often are comfortable, without irritability. The vast majority of these testes cannot be salvaged and are already dead tissue when the baby is born.

What other torsions can occur?

Torsion of the appendix epididymis or testis deserves special mention, because in younger, prepubescent boys it is far more common than torsion of the testicle itself. This may occur in older boys and men, but is much less common in that age group. As in testicular torsion, there are no predisposing factors or activities that cause these structures to twist, and it can occur at any time. The testicular appendages are embryologic remnants that have no function in men. They are located at the upper pole of the testicle and epididymis. They have their own small blood supply and they can also twist, resulting in infarction. These individuals also present with scrotal pain, followed by swelling and redness. However, the pain is most often less severe and can gradually worsen over several hours or days. At times this diagnosis will be determined at the time of surgery, since the history and clinical findings are so similar to testicular torsion. At other times, the urologist may be able to make this diagnosis on physical examination or through the use of radiographic means, such as ultrasound or nuclear medicine scan. If the diagnosis is certain and testicular torsion is excluded, surgery might be avoided in those instances, since the pain and swelling will subside after several days. If there is any doubt at all, though, surgery will be suggested to rule out testicular torsion.

Adapted from: American Urological Association Education and Research

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