Torsion of the testicle
Torsion of the testis or strictly speaking torsion of the spermatic cord has been a recognized surgical emergency since Delasiauve first described a case affecting an undescended testicle in 1839 at Hotel Dieu in Paris. It remains one of the few true surgical emergencies, and in young men still causes an unacceptably high incidence of testicular loss, which now carries with it an increasing threat of litigation. Urgent referral and urgent exploration remain the key to preserving testicular viability. Torsion may occur at any age but is most common around puberty; it is unusual after the age of 25 years.
The usual predisposing cause of testicular torsion is a high investment of the tunica vaginialis, which allows the testicle to hang like a bell clapper inside and the testicle and spermatic cord to rotate within the tunica. This is a bilateral abnormality and it is important to fix both sides at the time of surgery. Intermittent testicular torsion is a well-recognized entity.
The diagnosis is made primarily on the history and examination. A high level of suspicion is mandatory in young men who present with acute pain and swelling, where it has been shown that testicular torsion accounts for nearly 90 percent of acutely presenting scrotal symptoms in the 13- to 21-year age group. Vomiting is often a feature. The scrotum must always be examined, as in the early stages pain may be referred to the groin or iliac fossa. The testis often has a high, horizontal lie in the scrotum. Edema and erythema of the scrotum are usual features in torsion and do not support a diagnosis of epididymo-orchitis, which is very unusual in this age group. Torsion of a testicular appendage is more common in prepubertal boys, as is orchitis and idiopathic scrotal edema. Rarely hemorrhage into a testicular tumor can present with acute scrotal pain.
Investigative techniques are usually unnecessary and delay exploration. Colour Doppler ultrasound may be helpful in the diagnosis but can be misleading, especially in cases of intermittent torsion where a hyperemia can occur after spontaneous untwisting.
Surgery within 4 h usually allows testicular preservation, some atrophy occurs between 4 and 8 h, and after 10 h ischaemic necrosis is virtually inevitable (Fig. 1). Fixation of the testicle should be bipolar with non-absorpable sutures, as there are case reports of recurrent episodes of torsion after fixation with catgut sutures. The contralateral side should be fixed at the same time unless there is severe infection secondary to ischaemic necrosis. Orchidectomy is the best course of action if the testis is non-viable. Semen quality is reduced in men following unilateral torsion, and while the mechanism remains unclear, there is some evidence to suggest that restoring the blood supply to an ischemic testis stimulates the production of antitestis and antisperm antibodies.